Every finding on record at Fairpark Health and Rehabilitation

Based on facility policy review, observation, and interview, the facility failed to maintain a clean, comfortable, homelike environment for 2 of 2 hallways observed for a clean, comfortable, homelike environment. The findings include: Review of the facility policy titled, Healthcare Specific Cleaning Steps, revised 10/2020, revealed .Patient Room - Daily .spot clean walls and partitions .clean floors . Review of the facility policy titled, Homelike Environment, revised 4/2026, revealed .in accordance with residents' rights .facility will provide a .clean .homelike environment .housekeeping services will be provided .to maintain a sanitary .environment . Review of the facility's undated policy titled, Restroom Cleaning, revealed .dust mop the room .spot clean all necessary areas .walls .Disinfect .sinks .damp mop the room . Review of the facility's undated policy titled, Daily Resident/Patient Room Cleaning, revealed .room cleaning tasks should be performed .dust mop .floor .sweep all trash .debris .to .door .pick it up with .dustpan .wet mop the room using disinfectant . Review of the facility's undated policy titled, EVS Environmental Specialist Job Description, revealed .goal .to create a clean .environment for our residents .perform .sweeping, mopping, dusting .polishing . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Pneumonia, and Polyneuropathy. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. During an interview on 6/29/2026 at 10:58 AM, Resident #26 stated, The housekeeping services at the facility used to be better, but now the staff only mop the floor and empty the trash and do not clean any other part of the room. During an observation on 6/30/2026 at 7:31 AM, in doorway of room [ROOM NUMBER], revealed a significant amount of a brown substance to both sides of the doorway. Continued observation in room [ROOM NUMBER] revealed a brown substance and debris on the floor in front of the sink. During an observation on 6/30/2026 at 7:39 AM, on the 200 hallway, revealed the baseboard to the right and left of the soiled utility door with a dark brown and black substance. During an observation on 6/30/2026 at 7:48 AM, at entrance to room [ROOM NUMBER], revealed broken tile to the left side of the doorway and a brown substance covered areas where the tile was missing. Further observation in room [ROOM NUMBER] revealed a broken vanity to the left side of the sink, a brown substance with debris on the floor under the sink, and the sink had a black substance around the drain. During an observation on 6/30/2026 at 7:54 AM, in room [ROOM NUMBER], revealed a brown substance to the right baseboard from the door to the sink. During an observation on 6/30/2026 at 7:55 AM, in the 200 hallway, revealed the linen room door to room [ROOM NUMBER] contained a brown substance on the baseboard. Further observation in room [ROOM NUMBER], revealed brown rings in the sink. Continued observation revealed a brown substance and debris on the floor under the sink. During an interview on 6/30/2026 at 7:56 AM, the Housekeeping Supervisor stated, .resident rooms and hallways are cleaned daily and resident rooms and hallways are deep cleaned monthly . During an interview and observation on 6/30/2026 at 9:59AM, the Administrator and the Housekeeping Supervisor observed the above observations, and confirmed the facility failed to provide a clean, comfortable, and home-like environment on the 100 Hallway, 200 Hallway, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER].

Based on facility policy review, medical record review, and interview, the facility failed to implement a care plan intervention related to falls for 1 resident (Resident #4) of 3 care plans reviewed for falls. The findings include: Review of the facility policy titled, Comprehensive Care Plan, revised 3/2025, revealed .facility to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, physical, mental, and psychosocial needs .participate in the development of and reviewing and revising of the Comprehensive Care Plan . Review of the facility policy titled, Falls Policy, reviewed 4/2026, revealed .Falls Management Program Guidelines .strives to maintain a hazard free environment, mitigate falls risk factors, and implement preventative measure .Should the Resident experience a fall .interventions to reduce risk of repeat episode . Review of the facility policy titled, Accidents and Supervision, revised 4/2026, revealed .resident environment will remain as free of accident hazards as it is possible .Implementing interventions to reduce hazard (s) .using specific interventions to try to reduce a resident's risks from hazards in the environment . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Hepatic Encephalopathy, and Mood Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated Resident #4 had severe cognitive impairment and had a fall with major injury. Review of a post fall investigation report dated 5/21/2026, revealed Resident #4 had an unwitnessed fall and an intervention for a fall mat to the left side of the bed. Review of a comprehensive care plan dated 5/21/2026, revealed Resident #4 was at risk for falls .fall mat to [left] side of bed . During an observation on 6/29/2026 at 10:05 AM, revealed Resident #4 was in bed and did not have a fall mat to the left side of the bed. During an observation and interview on 6/30/2026 at 9:44 AM, Certified Nursing Assistant (CNA) D confirmed Resident #4 had no fall mat to the left side of the bed. During an observation and interview on 6/30/2026 at 9:47 AM, Registered Nurse (RN) M confirmed Resident #4 had no fall mat to the left side of the bed. During an interview on 7/1/2026 at 8:01 AM, the Administrator stated it was her expectation all fall interventions care planned were to be in place.

Based on facility policy review, observation, and interview the facility failed to provide palatable temperature of meals for 2 residents (Resident #6 and Resident #26) of 5 residents reviewed for dietary services. The findings include: Based on the facility policy titled, Meal Supervision and Assistance Policy, dated 4/2026, revealed .resident will be prepared meal .that hot foods are hot . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Anxiety, and Hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an interview on 6/29/2026 at 10:32 AM, Resident #6 stated the food was served cold. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Pneumonia, and Polyneuropathy. Review of a quarterly MDS assessment dated [DATE], revealed Resident #26 scored a 15 on the BIMS assessment, which indicated the resident was cognitively intact. During an interview on 6/29/2026 at 10:58 AM, Resident #26 stated hot foods were often served cold or lukewarm. During an observation on 6/29/2026 at 12:50 PM, a meal tray was tested and revealed the meat loaf, fried potatoes, green beans, and corn bread were not served at a palatable temperature. During an observation and interview on 6/29/2026 at 12:52 PM, the Administrator confirmed the food items served on the test tray were not served hot and at a palatable temperature.

Based on review of the Certification and Survey Provider Enhanced Reporting (CASPER) Report Fiscal Year (FY) for the second Quarter of 2026 (January 1-March 31) review, daily staffing assignment review, time detail report review, and interviews the facility failed to submit accurate weekend staffing information to the Payroll Based Journal, (PBJ) for 13 of 13 weekends reviewed. The findings include: Review of the CASPER Report for the second quarter 2026 revealed, .Excessively Low Weekend Staffing .Triggered .Triggered = [equals] Submitted Weekend Staffing data is excessively low . Review of daily staffing assignment sheets and time detail reports dated 1/1/2026-3/31/2026, revealed adequate Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA) coverage. Continued review revealed the Staff Development Coordinator (SDC), Minimum Data Set (MDS) Coordinator and Director of Nursing (DON) provided direct patient care on 13 of 13 weekends reviewed from January 2026-March 2026. Review of the employee weekend working schedules dated 1/1/2026-3/31/2026 revealed the Per Patient Day (PPD-refers to nursing hours allocated to each resident per day) ratios were above 2.0 (the minimum required PPD hours) and staff were able to provide adequate care to the residents. During an interview on 7/1/2026 at 11:36 AM, the Administrator stated the facility coded their payroll data correct but Corporate Human Resource did not change the status from salaried employees to hourly employees on the weekends when the SDC Coordinator, MDS Coordinator, and the DON provided direct resident care which resulted in inaccurate data submitted on the PBJ to the Centers for Medicare and Medicaid (CMS). During review of timesheets and interview on 7/1/2026 at 12:20 PM, the Administrator confirmed the PBJ submission was inaccurate and did not accurately reflect the actual hours worked by direct care staff on the weekends for the second Quarter 2026 (January 1-March 31).

Based on facility policy review, observations, and interview, the facility failed to ensure an employee's personal food items were not stored in the kitchen reach-in cooler and failed to ensure frozen food items were stored properly, which had the potential to affect 70 of 71 residents residing in the facility. The findings include: Review of the facility's policy titled, Food Storage: Cold, dated 10/2019, revealed .frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code .all food items are to be stored properly in covered containers . During an observation and interview with the Dietary Manager (DM), on 6/29/2025 at 10:18 AM, of the back reach-in cooler, revealed one purple lunch box and (one) 20-ounce carbonated beverage stored beside the residents' food items for meal service. The DM confirmed the purple lunch box and the carbonated beverage belonged to a dietary employee and should not be stored with the residents' food items. During an observation of the reach-in freezer on 6/29/2025 at 10:20 AM, with the DM, revealed the following items: (one) 30-pound box of frozen peas (¾ full) not sealed properly which resulted in the frozen peas exposure to air and possible contamination. (one) 30-pound box of frozen california blend vegetables (½ full) not sealed properly which resulted in the frozen vegetables exposure to air and possible contamination. (one) 30-pound box of frozen sliced carrots (1/2 full) not sealed properly which resulted in the frozen carrots exposure to air and possible contamination. Further observation revealed the frozen box of peas, california blend vegetables, and carrots had visible signs of discoloration on the food's surface from direct exposure to the air inside the freezer. During an interview on 6/29/2025 at 11:24 AM, the DM stated all frozen food should be sealed and stored appropriately in the freezer. The DM confirmed the frozen peas, california vegetable blend, and carrots were not sealed and stored appropriately.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, facility policy review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Resident #68) of 20 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual Verson 19.1, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . Review of the facility's policy titled, RAI Assessment- MDS 3.0 Completion, revised 6/1/2025, revealed .Residents are assessed .using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .According to federal regulations, the facility conducts .accurate .assessment of each resident's capacity, using the RAI specified by the state . Review of a PASRR dated 4/5/2024, revealed Resident #68 had a PASRR Level 2 Outcome related to a serious mental illness (Bipolar). Further review revealed the PASRR was completed prior to admission. Review of the medical record revealed Resident #68 admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Depression, and Anxiety. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and had active diagnoses of Bipolar Disorder, Anxiety, and Depression. Further review revealed the resident was not coded for a PASRR Level 2 Outcome. Review of a Psychiatric Nurse Practitioner Progress Note for Resident #68 dated 6/18/2025, revealed .PSYCHIATRIC HISTORY & PROBLEMS ADDRESSED THIS VISIT: Anxiety .Bipolar . During a medical record review and interview on 7/1/2025 at 10:45 AM, Registered Nurse (RN) MDS Coordinator reviewed the significant change MDS assessment dated [DATE] and the Level 2 PASRR dated 4/5/2024 for Resident #68. RN MDS Coordinator confirmed the significant change MDS assessment for Resident #68 was inaccurate and did not reflect Resident #68's Level 2 PASRR status. During an interview on 7/1/2025 at 12:28 PM, the Administrator stated it was her expectation for MDS assessments to be coded accurately. The Administrator confirmed the facility failed to ensure the accuracy of the significant change MDS assessment dated [DATE] for Resident #68.

Based on facility policy review, observations, and interviews, the facility failed to ensure the residents' health information remained private and confidential on 1 medication cart (Back 100 cart) of 4 medication carts observed, which had the potential to allow unauthorized individuals access to the residents' private health information. The findings include: Review of the facility's policy titled, Confidentiality of Personal and Medical Records, dated 1/2/2020, revealed .facility honor the resident's right to secure and confidential personal and medical records .safeguarding the content of information including written documentation .computer information from unauthorized disclosure without the consent of the individual .resident's personal or medical information shall not be left unattended or viewable by unauthorized persons . During an observation on 7/1/2025 at 9:33 AM, on the 100 hall, revealed the residents' sensitive health information was present on the computer screen on the medication cart (back-100 hall). Further observation revealed there was a written shift-to-shift communication sheet which listed the residents' names and various medical conditions stored on top of the medication cart. Continued observation revealed the residents' personal and confidential medical information visible on the medication cart was left unattended by Licensed Practical Nurse (LPN) A. During an observation on 7/1/2025 at 9:35 AM, revealed LPN A returned to the medication cart to retrieve additional items and walked away from the medication cart. LPN A failed to ensure the written shift-to-shift communication sheet and computer screen was secured and covered prior to leaving the medication cart. During an observation and interview with the Assistant Director of Nursing (ADON) on 7/1/2025 at 9:36 AM, on the 100 hall, revealed the residents' sensitive health information was present on the computer screen on the medication cart (back-100 hall) with the written shift-to-shift communication sheet which listed the residents' names and various medical conditions stored on top of the medication cart. The ADON stated the nurse should ensure the residents' personal and confidential medical information was secured and covered prior to leaving the medication cart. The ADON confirmed the residents' personal health information was not protected and was available for the public to review.

Based on facility policy review, medical record review, and interviews, the facility failed to prevent a medication error for 1 resident (Resident #40) of 6 residents reviewed for medication administration. The findings include: Review of the facility's policy titled, Medication Administration, revised 6/1/2025, revealed .Medications are administered .as ordered by the physician and in accordance with professional standards of practice .Identify resident by photo in the MAR [Medication Administration Record] .Review MAR to identify medications to be administered .verify resident name, medication name, form, dose, route, and time . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Morbid (Severe) Obesity, and Chronic Pain Syndrome. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a Nursing Progress Note for Resident #40 dated 9/27/2024, revealed .resident [Resident #40] .was given [Resident #40's room-mate] meds [medications] instead of her [Resident #40's] .LPN [Licensed Practical Nurse] .called on call [Nurse Practitioner] [NP] at 2000 [8:00 PM] .On call stated recheck VS [vital signs] in 2 hrs [hours], do not give Lyrica [medication used to treat nerve pain] .due to getting a Gabapentin [medication used to treat nerve pain], resident could experience drowsiness .ED [Executive Director] and DON [Director of Nursing] were notified .will continue to monitor . Review of a facility document titled, Investigation Significant Medication Error, for Resident #40 dated 9/27/2024, revealed .Date error began 9/27/2024 .Date error found 9/27/2024 .Incorrect Medication .Doxepin [medication used to treat depression] 10mg [milligrams], Tylenol [medication used to treat pain or fever] 500mg, Famotidine [acid reducer] 20mg, Gabapentin 100mg, Senna [medication used to treat constipation] 8.6mg/50mg .No adverse reactions .Nurse .Re-educated on the 6 rights of med admin [administration] . During an interview on 6/29/2025 at 11:38 AM, Resident #40 stated several months ago (unable to recall the exact date) she was administered her room-mates medications (unable to recall what medications were administered). Resident #40 stated she was awakened by a nurse (unable te recall the nurses name) and handed a medication cup which contained 5 pills and the resident typically took two pills. Resident #40 questioned the nurse about the number of pills but took the medication the nurse had prepared. Resident #40 stated the nurse returned to the room after she had questined the number of pills and informed the resident she had been given the room-mate's medications. Resident #40 further stated the nursing staff checked on her frequently throughout the night and she did not experience any adverse reactions after she received the wrong medications. During a telephone interview on 6/30/2025 at 4:47 PM, Resident #40's responsible party stated in September 2024 (unsure of the exact date) a nurse (unable te recall the nurse's name) at the facility administered Resident #40 the wrong medications. The responsible party stated the staff at the facility called her every hour to give an update on Resident #40's status and the resident had no reaction after she received the wrong medications. During a telephone interview on 6/30/2025 at 5:04 PM, LPN C stated she vaguely remembered the medication error which involved Resident #40. LPN C stated she prepared Resident #40's room-mate's medications. The LPN went into Resident #40's room, verbalized Resident 40's room-mate's name and Resident #40 stated .hey . LPN C stated she administered the cup of medications (unable to recall what medications) to Resident #40 after the resident stated hey. LPN C stated Resident #40 had asked what the medications were, the LPN went to verify the medications, and identified she had administered the wrong medications to Resident #40. LPN C stated Resident #40, the Nurse Practitioner (NP), the resident's responsible party, the Administrator, and the DON were made aware of the medication error immediately. LPN C stated the staff monitored Resident #40 and her vital signs frequently throughout the night and the resident had no adverse reactions after she received the wrong medications. During an interview on 7/1/2025 at 12:28 PM, the Administrator confirmed LPN C administered Resident #40 the wrong medication on 9/27/2024. During an interview on 7/1/2025 at 1:46 PM, the NP stated she was familiar with Resident #40 and the medication error which occurred on 9/27/2024. The NP stated she was notified immediately after the medication error occurred and the resident had no adverse outcomes from the medication error.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to perform appropriate hand hygiene when serving residents' meal trays for 3 residents (Resident #55, #11, and #38), the facility failed to wear appropriate Personal Protective Equipment (PPE) when delivering the meal tray for 1 resident (Resident #69), and the facility failed to offer hand hygiene assistance prior to meals for 1 resident (Resident #50) of 18 residents observed for meal tray distribution. The findings include: Review of the facility's policy titled, Hand Hygiene, dated 6/9/2025, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection .Hand hygiene is a general term for cleaning your hands by handwashing .or antiseptic hand rub .hand hygiene is indicated and will be performed .Between resident contacts . Review of the facility's policy titled, Transmission-Based Precautions, dated 5/21/2025, revealed .take appropriate precautions to prevent transmission of infectious agents .group of infection prevention and control practices that are used in addition to standard precautions for residents who may be infected or colonized .Contact Precautions .prevent transmission .which are spread by direct or indirect contact with the resident .or resident's environment .Healthcare personnel .wear a gown and gloves for all interactions .Donning personal protective equipment (PPE) upon room entry . Review of the facility's policy titled, Infection Prevention and Control Program, reviewed 2/2/2025, revealed .facility has established and maintains .infection prevention .to provide .safe .sanitary .to .prevent .development and transmission .diseases and infection .caregivers .provide care .to residents . Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypertension, and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #55 required setup or clean-up assistance with eating and was independent with personal hygiene. Review of the comprehensive care plan for Resident #55 dated 4/26/2025, revealed .ADLs [Activities of Daily Living] Functional .has an ADL self-care performance deficit r/t [related to] dementia .osteoarthritis .personal hygiene .requires .assist . During an observation on 6/29/2025 at 12:13 PM, the Assistant Director of Nursing (ADON) delivered the lunch meal tray to Resident #55. The ADON set up the meal tray for Resident #55. The ADON exited the room and failed to perform hand hygiene. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Postpolio Syndrome, Diabetes, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further record review revealed Resident #11 was independent with eating and personal hygiene. Review of the comprehensive care plan for Resident #11 dated 4/26/2025, revealed .ADLs Functional .resident has .ADL self-care performance deficit r/t .polio syndrome .eating .set up assist .personal hygiene .set up assist . During an observation on 6/29/2025 at 12:16 PM, the ADON delivered the lunch meal tray to Resident #11. The ADON set up the meal tray for Resident #11. The ADON exited the room and failed to perform hand hygiene. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Insomnia, Hypertension, and Cirrhosis. Review of the comprehensive care plan for Resident #38 dated 6/6/2025, revealed .ADLs Functional .resident has an ADL self-care performance r/t limited mobility .weakness .Eating .requires set-up assistance .Personal hygiene .independent . Review of the quarterly MDS assessment dated [DATE], revealed Resident #38 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further record review revealed Resident #38 required setup or clean-up assistance with eating and was independent with personal hygiene. During an observation on 6/29/2025 at 12:21 PM, the ADON delivered the lunch meal tray to Resident #38. The ADON set up the tray for Resident #38 and exited the room and failed to perform hand hygiene. During an interview on 6/29/2025 at 12:24 PM, the ADON stated staff were to perform hand hygiene after serving each resident's tray. The ADON confirmed she had not performed hand hygiene after serving Resident #55, #11, and #38's lunch meal trays. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including Chronic Pain, Hypertension, and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed Resident #69 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further record review revealed Resident #69 required setup or clean-up assistance with eating and dependent with personal hygiene . Review of the comprehensive care plan for Resident #69 revised 6/28/2025, revealed .ADLs Functional .resident has an ADL self-care performance deficit r/t osteoarthritis .eating .requires setup assistance .personal hygiene .requires partial/moderate assistance .contact isolation . During an observation on 6/29/2025 at 12:19 PM, the ADON delivered the lunch meal tray to Resident #69 without donning appropriate PPE. The resident was in contact isolation. During an interview on 6/29/2025 at 12:24 PM, the ADON stated .Yes he [Resident #69] is on contact isolation . The ADON confirmed that she had not donned the appropriate PPE before delivering the lunch tray to Resident #69. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Dysphagia, and Muscle Weakness Review of the comprehensive care plan for Resident #50 revised 6/13/2025, revealed .self-care performance deficit .EATING: set up assist .PERSONAL HYGIENE .requires total assistance . Review of an annual MDS assessment dated [DATE], revealed Resident #50 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident was dependent upon staff assistance with personal hygiene. During an observation on 6/29/2025 at 12:33 PM, in Resident #50's room, revealed Licensed Practical Nurse (LPN) B delivered Resident #50's meal tray and placed the meal tray in front of the resident. Further observation revealed LPN B set up the resident's meal tray and failed to offer Resident #50 hand hygiene assistance prior to the resident eating the lunch meal. During an interview on 6/29/2025 at 12:36 PM, LPN B confirmed she failed to offer hand hygiene assistance to Resident #50 prior to serving the lunch meal. During an interview on 6/30/2025 at 1:23 PM, the Infection Preventionist (IP) confirmed staff should perform hand hygiene prior to and after delivering residents' meal trays. The IP also confirmed appropriate PPE should be donned before entering the room of a resident on contact isolation, and hand hygiene should be offered to all residents prior to meals. During an interview on 7/1/2025 at 12:00 PM, the Director of Nursing (DON) confirmed all staff should perform hand hygiene after serving each resident's meal tray, appropriate PPE should be donned before entering the room of any resident that is on contact isolation, and all residents are offered hand hygiene assistance prior to meals.

Based on facility policy review, observation, and interview the facility failed to maintain mechanical equipment in a safe operating condition in 2 of 2 dryers observed in the laundry room. The findings include: Review of the facility's undated policy titled, Next Level Hospitality Services Chapter 2 Linen Operations and Management, showed .All lint screens must be cleaned and brushed every hour and after every single load . During an observation of the laundry room on 3/20/2024 at 3:20 PM, showed the dryer lint screens of both dryers with thick layer of lint build up on the screens and lint accumulation lying on the floor under the dryers. Further observation showed the Lint Trap Clean Out Log had not been completed for 3/20/2024. During an interview on 3/20/2024 at 3:20 PM, the Environmental Services Manager (ESM) confirmed the 2 dryers had a thick layer of lint build up on the screens and lint accumulation lying on the floor under the dryers. She confirmed the cleaning of the dryer screens had not been documented for 3/20/2024. The ESM stated the person responsible for documenting the cleaning of the dryer screens had left for the day, and she could not state when they had last been cleaned.

Based on record review, facility policy review, and interview, the facility failed to ensure 1 resident (Resident # 54) of 20 sampled residents received trauma-informed care in accordance with professional standards of practice and accounting for a resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, fracture of Right Femur, Muscle Weakness, and Post Traumatic Stress Disorder. Review of the facility policy titled, Trauma Informed Care, revised 3/15/2023, showed .Trauma is defined as an event, a series of events, or set of circumstances experienced by an individual as physically or emotional .common sources of trauma may include .physical emotional .abuse at any age .each resident will be screened for a history of trauma upon admission .the facility will account for residents' experiences, preferences, and culture differences in order to eliminate or mitigate triggers that may cause re-traumatization .potential causes of re-traumatization by staff may include, but are not limited to .being unaware of the residents traumatic history . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Further review showed a diagnosis of Post Traumatic Stress Disorder (PTSD) and resident mood interview should be conducted. Review of Resident #54's comprehensive care plan initiated 1/6/2023, showed there was no identified problems or triggers listed for PTSD. Review of a Trauma- Informed Care screening dated 1/4/2023, showed .have you ever experienced, witnessed, learned about a life-threatening illness .(witnessed) .have you ever experienced, witnessed, learned about combat or war zone combat .(no) .did any of these events bother you .(no) . Review of a Psychiatric Note dated 2/21/2024, showed .following up on history of anxiety and depression .per assigned staff no change in mood status .patient appears at baseline with no acute mood issues today and appears at baseline . During an interview on 3/20/2024 at 7:15 AM, Resident #54 stated she has had PTSD for many years from being abused as a child from her mother. The resident stated her last triggered episode was prior to admission to the facility. She stated her medications had been adjusted in the past, and the current regimen had her stable. The facility did not ask the resident about the PTSD upon admission or interview her on what triggered the PTSD. Resident #54 stated there had been no triggered episodes at the facility since admission. During an interview on 3/20/2024 at 7:22 AM, Certified Nursing Assistant (CNA) #1 stated she was unaware Resident #54 had a diagnosis of PTSD and what would trigger a behavioral episode. During an interview on 3/20/2024 at 7:55 AM, Licensed Practical Nurse (LPN) #1 stated she was unaware Resident #54 had a diagnosis of PTSD and what would trigger a behavioral episode. During an interview on 3/20/2024 at 9:32 AM, Psychiatric Nurse Practitioner (NP) stated she was unaware of Resident #54's diagnosis of PTSD and what would trigger a behavioral episode. Interview showed the NP had followed Resident #54 since admission with the resident never mentioning history of PTSD or any childhood abuse. Further interview showed the NP stated she would not have changed the treatment plan if knowledge of the PTSD was known. During an Interview on 3/20/2024 at 10:04 AM, CNA #2 stated she was unaware Resident #54 had a diagnosis of PTSD and what would trigger a behavioral episode. During an Interview on 3/20/2024 at 10:08 AM, CNA #3 stated she was unaware Resident #54 had a diagnosis of PTSD and what would trigger a behavioral episode. During an interview on 3/20/2024 at 11:04 AM, the Social Services Director (SSD) stated she had completed a Trauma- Informed Screening for Resident #54 after her admission to the facility. The SSD confirmed she had knowledge of the Resident #54 had a diagnosis of PTSD but did not screen the resident for triggers or add to the resident plan of care what triggers could cause her to have an episode. During an interview on 3/20/2024 at 2:37 PM, the Administrator, Administrator in Training (AIT), and the Area Nurse Director confirmed the facility policy for trauma informed care had not been followed.

Based on facility policy review, safety data sheet review, medical record review, observations, and interviews the facility failed to ensure chemicals were secured in resident (Resident #37, #8, and #41's) bathroom. The findings include: Review of the facility's undated policy titled, Handwashing, Chemical Use, and PPE [Personal Protective Equipment], showed .Chemical Use .chemicals should be locked at all times . Review of a Safety Data Sheet, revised 6/12/2015, showed .Product Name Clorox .Regular-Bleach .Information on toxicological effects .May cause redness and tearing of eyes .May cause redness or burns to skin .Inhalation may cause coughing . Review of a Safety Data Sheet, revised 1/18/2019, showed .Ingredient Name .Benzisothiazolin-3-0ne [antimicrobial agent and preservative in products like multi-purpose cleaning agents, stain removers, and is used in water- based solutions] .Toxicological Information .Expected to be a low ingestion hazard . Resident #37 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Gastrointestinal Hemorrhage, Congestive Heart Failure, and Obesity. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Resident #8 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Repeated Falls Diabetes, and Hypertension. Review of an admission MDS assessment dated [DATE], showed Resident #8 had a BIMs score of 14 which indicated the resident was cognitively intact. Resident #41 was admitted to the facility on [DATE] with diagnoses including Hypertension, Hyperlipidemia, and Vascular Dementia. Review of a quarterly MDS assessment dated [DATE], showed Resident #41 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. During an observation on 3/18/2024 at 10:28 AM, in Resident #37, #8, and #41's bathroom showed a 32-ounce bottle with a manufacturer label which identified the contents as glass cleaner 3/4 full. Further observation showed the bottle had a handwritten label with a black marker which identified the contents as bleach. Continued observation showed a 32-ounce bottle with a manufacturer label which identified the contents as odor control (a Benzisothiazolin) 3/4 full and both bottles were on the sink unsecured. During an observation and interview on 3/18/2024 at 11:34 AM, in Resident #37, #8, and #41's bathroom with Licensed Practical Nurse (LPN) #2 showed a 32-ounce bottle with a manufacturer label which identified the contents as glass cleaner 3/4 full. Further observation showed the bottle had a handwritten label with a black marker which identified the contents as bleach. Continued observation showed a 32-ounce bottle with a manufacturer label which identified the contents as odor control (a Benzisothiazolin) 3/4 full and both bottles were on the sink unsecured. LPN #2 sprayed the contents of the 32-ounce bottle with a handwritten label of bleach and confirmed the contents in the bottle was bleach and not glass cleaner. LPN #2 confirmed both 32-ounce bottles were left unsecured. During an observation and interview on 3/18/2024 at 11:38 AM, in Resident #37, #8, and #41's bathroom with the Environmental Service Manager (ESM) showed a 32-ounce bottle with a manufacturer label which identified the contents as glass cleaner 3/4 full. Further observation showed the bottle had a handwritten label with a black marker which identified the contents as bleach. Continued observation showed a 32-ounce bottle with a manufacturer label which identified the contents as odor control (a Benzisothiazolin) 3/4 full and both bottles were on the sink unsecured. The ESM sprayed the contents of the 32-ounce bottle with a handwritten label of bleach and confirmed the contents in the bottle was bleach and not glass cleaner. The ESM confirmed both 32-ounce bottles were left unsecured and removed the bottles immediately. During an observation on 3/18/2024 at 11:45 AM, showed Resident #41 was independent with wheelchair (W/C) mobility. During an observation on 3/18/2024 at 11:51 AM, showed Resident #8 walked independently with the walker. During an observation on 3/18/2024 at 11:55 AM, showed Resident #37 was lying in the bed. During an interview on 3/19/2024 at 9:20 AM, Housekeeper #1 stated she was cleaning the bathroom in Resident #37, #8, and #41's room on 3/18/2024 and was called away. The housekeeper also stated she had left the bottles in the room briefly that morning when the bottles were found. She also stated there were no wandering residents on the 200-hallway. During an interview on 3/19/2024 at 9:45 AM, MDS Registered Nurse (RN) #1 stated Resident #37 was dependent on staff for W/C mobility. During an interview on 3/19/2024 at 9:53 AM, Certified Nursing Assistant (CNA) #4 stated Resident #37 was dependent on staff for transfers, W/C mobility and the resident was incontinent of bowel and bladder. The CNA also stated there were no residents on the 200-hallway who wandered into other resident rooms, and she had not observed chemicals left unattended in resident's rooms. During an interview on 3/19/2024 at 10:10 AM, Resident #8 was asked if she saw a bottle labeled bleach would she drink it. The resident stated NO!!! The resident also stated she had not observed bottles of chemicals in her bathroom. During an interview on 3/19/2024 at 10:13 AM, Resident #37 was asked if she saw a bottle labeled bleach would she drink it and she stated .I can see good and still have my senses so no I would not . During an interview on 3/19/2024 at 10:20 AM, Resident #41 was asked if she saw a bottle labeled bleach would she drink it. The resident stated .I might be crazy but not that crazy . During observations from 3/18/2024-3/20/2024 at various times of the day showed no wandering residents on the 200-hallway.

Based on medical record review, observation, and interview, the facility failed to follow a physician's order for 2 residents (Residents #61 and #418) of 3 residents reviewed for wounds. The findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses including Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Pressure Ulcer to Buttocks. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #61 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment, and had a Stage 1 and Stage 2 pressure ulcer upon admission. Review of a Diet Order & Communication document dated 1/25/2024, showed Resident #61 .Diet Order .Double protein portions at all meals . The document was signed by the Registered Dietician (RD). Review of a dietary Progress Note dated 1/25/2024, showed .Will add double protein portions at meals as resident had good appetite to promote wound healing . Further review showed the document was electronically signed by the RD. Review of the Physician Order Report dated 2/20/2024 - 3/20/2024, showed Resident #61 .Consistent CHO (Consistent Carbohydrate Diet) Special Instructions Double Protein Portions . During an interview on 3/19/2024 at 3:22 PM, Resident #61 stated he was not receiving double protein portions and wasn't sure how long he had not received them. During an observation on 3/20/2024 at 8:10 AM, showed the resident was served scrambled eggs and 1 slice of bacon and the portions were not doubled. Review of Resident #61's wound documentation showed the resident had 1 Stage 2 pressure ulcer on the sacrum, the wound was stable, and had not deteriorated. Resident #418 was admitted to the facility on [DATE] with diagnoses including Cellulitis of Left Lower Limb, Type 2 Diabetes with Hypoglycemia, Hypertension and Peripheral Vascular Disease. Review of a dietary progress note dated 1/25/2024, showed .double protein portions at meals . Further review showed the document was electronically signed by the RD. Review of Resident #418's wound documentation showed the resident had a surgical wound to the left foot, the wound was stable, and had not deteriorated. Review of a quarterly MDS assessment dated [DATE], showed Resident #418 had a BIMS score of 15 which indicated the resident was cognitively intact and had a surgical wound. Review of a Physician's Order dated 3/7/2024, showed .Special Instructions .Double Protein/meat at all meals . During an interview on 3/19/2024 at 3:22 PM, Resident #418 stated he did not receive double protein portions with all meals. He was unaware of how long he had not received the double protein portions. During an interview on 3/20/2024 at 8:43 AM, Dietary Aide #1 stated she prepared resident meals and utilized dietary meal tickets for specific diet orders. She also stated she was not aware Residents #66 and #418 had not been receiving double protein portions at all meals. She also stated the residents received the double protein portions prior to the new computer system (changed approximately 3 weeks ago). During an interview on 3/20/2024 at 8:45 AM, the Dietary Manager (DM) stated the facility's computer system was changed and the residents' diet orders .may not have transferred to the new system . During an interview on 3/20/2024 at 8:50 AM, the Regional Dietary Manager stated the computer system was changed .about 3 weeks ago . During an interview on 3/20/2024 at 10:20 AM, the Area Nurse Director stated the facility recently changed the electronic medical record system and the old system did not communicate the dietary orders into the new system and dietary meal tickets were inaccurate for Resident #61 and #418. The facility had to initiate a meal tracker system (initiated on 3/7/2024) to ensure the dietary orders would be crossed over into the new system. She also stated when the meal tracker was initiated all the diet order dates changed to 3/7/2024. During an interview on 3/20/2024 at 10:50 AM, the RD stated she evaluated Resident #61 and #418 on 1/25/2024. The residents were ordered double protein portions to help promote wound healing. The residents also had other protein supplements in place, the double protein was an added intervention. The RD also stated if the residents had not received the double protein portions for approximately 3 weeks it would not be a problem because the residents were on other protein supplements. During an interview on 3/20/2024 at 11:07 AM, the Nurse Practitioner (NP) stated when Residents #61and #418 did not receive double protein portions with all meals for approximately 3 weeks, it had not affected the wound healing because the residents were on other protein supplements and the residents wounds were stable. During an interview on 3/20/2024 at 3:25 PM, the Dietary Manager confirmed the dietary tickets for Residents #61 and #418 did not identify the residents were to receive double protein portions with all meals .there was a glitch in the system . 49792

Based on facility policy review, medical record review, and interview the facility failed to develop a baseline care plan for 1 resident (Resident #3) of 20 residents reviewed. The findings include: Review of the facility policy titled, Baseline Care Plan, dated 3/22/2022, showed .The facility will develop .a baseline care plan for each resident that includes the instructions needed to provide effective .person-centered care of the resident .The baseline care plan will .Be developed within 48 hours of a resident's admission . Review of the facility policy titled, Admission of a Resident, dated 3/22/2022, showed .initial/baseline plan of care will be developed during admission process . Resident #3 was admitted to the facility on [DATE] with diagnoses including Right Hip Fracture, Dementia, Dislocation of Right Hip, Depression, and Adult Failure to Thrive. Review of the medical record showed a baseline care plan had not been developed within 48 hours of admission. The initial care plan was developed on 1/2/2023 (4 days/96 hours after admission). During an interview on 3/20/2024 at 1:34 PM, the Area Nurse Director confirmed the facility failed to develop a baseline care plan for Resident #3 within 48 hours of admission to the facility.

Based on review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 residents (Resident #39, #36 and #33) related to the use of anticoagulants, hospice, and restraints of 20 residents reviewed. The findings include: Review of the RAI Version 3.0 Manual, Chapter 3, dated 10/2023 showed .Anticoagulant [medication used to prevent blood clotting] .Do not code antiplatelet medications such as .clopidogrel [also called Plavix is an antiplatelet medication used to prevent blood clotting] .Code residents identified .in a hospice program .Identify all physical restraints that were used at any time .during the 7-day look-back period .code 0, not used .if the item was not used . Resident #39 was admitted to the facility on [DATE] with diagnoses including Diabetes, End Stage Renal Disease with Dialysis, Peripheral Vascular Disease, Amputation of Left Great Toe, and Congestive Heart Failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Further review showed the resident was taking an anticoagulant medication. Review of Resident #39's current physician orders showed, .12/15/2023 .Clopidogrel 75 MG [milligram] tablet oral Once A Day . Further review showed an anticoagulant had not been ordered. During an interview on 3/19/2024 at 12:56 PM, MDS Registered Nurse (RN) #1 stated Resident #39 had not received an anticoagulant and confirmed the MDS assessment dated [DATE] was inaccurate. Resident #36 was admitted to the facility on [DATE] with diagnoses including Diabetes, End Stage Renal Disease, Hypertension, and Anemia. Review of Resident #36's current physician orders showed hospice care was ordered on 8/21/2023. Review of an annual MDS assessment dated [DATE], showed Resident #36 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. Further review showed the MDS had not been coded to indicate Resident #36 was recieving hospice services. Review of a quarterly MDS assessment dated [DATE], showed Resident #36 had a BIMS score of 14 which indicated the resident was cognitively intact. Further review showed the MDS had not been coded to indicate Resident #36 was recieving hospice services. During an interview on 3/20/2024 at 1:35 PM, MDS RN #1 stated Resident #36 had an order for hospice services effective 8/21/2023. MDS RN #1 confirmed hospice services was not captured on the annual MDS assessment dated [DATE], the quarterly MDS assessment dated [DATE], and the assessments were inaccurate. 49568 Resident #33 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Diabetes Mellitus, Functional Quadriplegia, and Hypertension. Review of a quarterly MDS assessment dated [DATE], showed .physical restraints .used in chair or out of bed (limb restraints) .1 (indicated used less than daily) . During an observation on 3/18/2024 at 11:30 AM, showed Resident #33 lying in bed without a restraint in use. During an observation on 03/19/2024 at 8:40 AM, showed Resident #33 lying in bed without a restraint in use. During an observation on 3/20/2024 at 8:20 AM, showed Resident #33 lying in bed without a restraint in use. During an interview on 3/19/2024 at 12:58 PM, RN MDS #1 confirmed Resident #33 did not have a restraint and the MDS assessment dated [DATE] was inaccurate.

Based on review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a significant change assessment for 1 resident (Resident #36) of 20 residents reviewed. The findings include, Review of CMS's RAI Version 3.0 Manual Chapter 2 dated 10/2023 revealed .Guidelines to Assist in Deciding If a Change Is Significant or Not .When a .Resident enrolls in a hospice program .must be within 14 days from the effective date of the hospice election . Resident #36 was admitted to the facility on [DATE] with diagnosis including Diabetes, End Stage Renal Disease, Hypertension, and Anemia. Review of Resident #36's current physician orders showed hospice care was ordered on 8/21/2023. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Further review showed the MDS assessment did not indicate Resident #36 was receiving hospice services. During an interview on 3/20/2024 at 1:35 PM, MDS (Registered Nurse) RN #1 stated Resident #36 had an order for hospice services effective 8/21/2023 and confirmed a significant change assessment had not been completed within 14 days.

Based on facility policy review, medical record review, observations, and interviews the facility failed to maintain a safe, clean, homelike environment on 1 of 2 hallways, and 5 resident's (Resident #37, #418, #1, #39, and #15) rooms of 15 rooms observed. The findings include: Review of the facility's policy titled, Routine Cleaning and Disinfection, revised 2/20/2024, showed .It is the policy of this facility to ensure the provision of routine cleaning .to provide a safe, sanitary environment .Cleaning refers to the removal of visible soil from objects and surfaces . During an observation on 3/18/2024 at 10:28 AM, in Resident #37's bathroom showed a black mat under the sink visibly dirty with dust and debris. A black fan in the room on a base, the base was dusty and dirty. Further observation showed the 2 doors at the sink had chipped missing paint and the baseboard had visible dirt, dust, and dark colored debris in the creases. During an observation on 3/18/2024 at 10:35 AM, in Resident #418's room showed the floor had dark scuff marks, the area under the sink had broken pieces missing from the baseboard, and the baseboard was visibly dirty with dark colored debris in the creases. Further observation showed behind the entrance door to the room was visibly dirty with dust, and debris behind the door. During an observation on 3/18/2024 at 10:40 AM, in Resident #1's room showed the floor had dark scuff marks, the area under the sink had broken pieces missing from the baseboard, and the baseboard was visibly dirty with dark colored debris in the creases. Further observation showed behind the entrance door to the room was visibly dirty with dirt, dust, and debris. During an observation on 3/18/2024 at 10:46 AM, showed the following on the 200-hallway: baseboards down the entire hallway on both sides were visibly dirty with dirt, dust, and dark colored debris. The entrance doors to all the resident rooms (a total of 15 rooms) were visibly dirty with dirt, dust, and dark colored debris at both corners. Floors were dull and scuffed with dark lines down the hallway. A housekeeping cleaning cart had a white crusty debris covering the dustpan, a white dried substance had dripped and dried on the outside of the locked cabinet, and a black tray on the bottom of the cart was visibly dirty with multiple loose particles and a brown substance. During an observation on 3/18/2024 at 11:10 AM, in Resident #39's room showed visible dirt, dust, and debris behind the entrance door. During an observation on 3/18/2024 at 11:20 AM, showed in Resident #15's room, the floor at the bedside and under the bed had a brown substance, loose particles behind the headboard of the bed, and loose dirty debris near the chest of drawer. During an observation and interview on 3/19/2024 at 1:55 PM, with the Administrator and Environmental Service Manager (ESM) showed the following on the 200-hallway: baseboards down the entire hallway on both sides were visibly dirty with dirt, dust, and dark colored debris. The entrance doors to all the resident rooms (a total of 15 rooms) were visibly dirty with dirt, dust, and dark colored debris at both corners. Floors were dull and scuffed with dark lines down the hallway. Further observation showed the following: 1. Resident #37's bathroom showed a black mat under the sink visibly dirty with dust and debris. A black fan in the room on a base, the base was dusty and dirty. Further observation showed the 2 doors at the sink in had chipped missing paint and the baseboard had visible dirt, dust, and dark colored debris in the creases. 2. Resident #418's room showed the floor had dark scuff marks, the area under the sink in the room had broken pieces missing from the baseboard, and the baseboard was visibly dirty with dark colored debris in the creases. Further observation showed behind the entrance door to the room was visibly dirty with dust, and debris behind the door. 3. Resident #1's room showed the floor had dark scuff marks, the area under the sink had broken pieces missing from the baseboard, and the baseboard was visibly dirty with dark colored debris in the creases. Further observation showed behind the entrance door to the room was visibly dirty with dirt, dust, and debris. 4. Resident #39's room showed visible dirt, dust, and debris behind the entrance door. 5. Resident #15's room, the floor at the bedside and under the bed had a brown substance, loose particles behind the headboard of the bed, and loose dirty debris near the chest of drawer. During an interview on 3/19/2024 at 2:40 PM, the Administrator confirmed the 200-hallway and Resident #37, #418, #1, #39, and #15's rooms had not been not maintained in a clean, sanitary, and homelike environment. During an observation and interview with the ESM on 3/19/2024 at 3:50 PM, showed the 200-hallway housekeeping cart with a white crusty debris covering the dustpan, a white dried substance was on the outside of the locked cabinet, and the black tray on the bottom of the cart was visibly dirty with multiple loose particles and a brown substance. The ESM confirmed the housekeeping cart was not maintained in a clean and sanitary manner.

Based on facility policy review, medical record review, facility investigation review, facility documentation review, observation, and interview, the facility failed to ensure a female, developmentally disabled and severely cognitively impaired resident (Resident #1) was protected from sexual abuse when Resident #2, a male resident with a Brief Interview for Mental Status (BIMS) score of 12 (which indicated the resident was moderately impaired) was found with his hand inside Resident #1's brief. The facility failed to identify Resident #1 was unable to consent to sexual contact and the facility failed to identify the incident as sexual abuse for Resident #1 of 4 residents reviewed for abuse. The facility's noncompliance placed Resident #1 and other cognitively impaired residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for further sexual abuse. The Administrator, Administrator in Training (AIT), and Area Director of Clinical Services were notified of the Immediate Jeopardy for F600 and F656 on 8/9/2023 at 10:20 PM, in the conference room. A partial extended survey was conducted on 8/10/2023. The facility was cited Immediate Jeopardy at F600 (K) and F656 (K) which constitutes substandard quality of care. The Immediate Jeopardy began 5/12/2023 and was removed 8/12/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 8/11/2023 at 3:30 PM, and the corrective actions were validated on-site by the surveyors on 8/12/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 8/30/2022, revealed, .Compliance Guidelines .The purpose is to assure that the facility is doing all that is within its control to prevent occurrences .Prevention .The facility will identify, correct and intervene in situations in which abuse .is more likely to occur .Identification .Sexual Abuse is the non-consensual sexual contact of any type with a resident .Alleged violation .A situation or occurrence that is observed or reported by staff, resident .if verified could be noncompliance with the Federal requirements related to .abuse .Investigation .The facility will investigate all allegations and types of incidents .Reporting/Response .The facility will report all alleged violations .and take all necessary corrective actions .The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences . Review of the facility policy titled Abuse, Neglect and Exploitation dated 8/30/2022, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Prevention of Abuse .Establishing a safe environment .This may include identifying when, how, and by whom determination of capacity to consent to a sexual contact will be made and where this documentation will be recorded .'Sexual Abuse' is non-consensual sexual contact of any type with a resident .Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm .as well as additional abuse, during or after the investigation . Review of the facility policy titled Sexual Expression of Residents dated 3/2023, revealed, .It is the policy of this facility to respect the rights of residents to express themselves sexually, as long as it does not violate the rights of other residents .This policy applies to individuals who exhibit intact cognitive decision-making capacity .The social services and nursing staff will educate the resident about any disease processes and the residents' rights .Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/or sexual expression .Residents with decisional capacity have a right to privacy, including private space for sexual expression .Residents with decisional capacity have a right to confidentially .IDT [Interdisciplinary Team] team will meet and determine if resident can participate in Sexual Consent Capacity Assessment, if it is determined that the resident is unable to participate the facility will ensure an LCSW [Licensed Clinical Social Worker] or comparable provider will complete a cognitive evaluation to determine intact cognitive decision-making-capacity and capacity to give consent .Based on the determination of the assessment the plan of care will be updated and intimacy and sexual expression shall be permitted if both parties consent, and the risks do not exceed the benefits .The facility will ensure the resident's right to privacy, including providing a private place for intimacy and /or sexual expression .Residents who express the desire to be sexually active will receive education on the definition of abuse, sexual assault, safe sex education, and who to contact to report any issues .Sexual Expression and Capacity Review Process and Education .IDT team will meet and determine if resident can participate in Sexual Consent Capacity Assessment, if it is determined that the resident is unable to participate the facility will ensure an LCSW or comparable provider will complete a cognitive evaluation to determine intact cognitive decision-making-capacity and capacity to give consent .5 Components to look at as the IDT team .1. Awareness of with whom they are having sexual contact and what that person's relationship is to them .2. Ability to articulate the type or types of intimate sexual activity with which they are comfortable .3. Consistency of behavior with respect to their previously expressed beliefs and preferences .Ability to decline unwanted sexual activity .5. Ability to articulate what their reaction will be if the sexual activity ends .The facility shall provide initial staff orientation and ongoing staff training regarding abuse, intimacy and/or sexual expression as well as sensitivity awareness about residents' sexual rights and staff documenting and reporting responsibilities . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Unspecified Intellectual Disability, Dementia with Behavioral Disturbance, Cerebral Palsy, Post Polio Syndrome, Impulse Disorder, Generalized Anxiety, Epilepsy, Pseudobulbar Affect (a condition that is characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Restlessness and Agitation. Review of Resident #1's Order of Appointing Conservator documentation with a filed date of 6/2/2006, revealed Resident #1's mother was appointed the resident's conservator. Review revealed, . [Resident #1's brother] is also appointed Standby Conservator for the Respondent [Resident #1] in the event [Resident #1's mother] is unable to serve in that capacity .The [NAME] hereby removed from [Resident #1] and vested in [Resident #1's mother] as Conservator include the right .give or refuse consent to medical and/or mental examinations and treatment or hospitalization , and other acts necessary to manage .personal well-being of [Resident #1] . Review of Resident #1's Mother's Certificate of Death dated/signed 10/2/2019, revealed Resident #1's mother, who was appointed Resident #1's conservator, passed away and Resident #1's brother was her conservator. Review of Resident #1's care plan with a problem start date of 2/15/2023, revealed Resident #1 was care planned for cognitive loss and Dementia. Review of the care plan showed Resident #1 had impaired decision-making related to her diagnosis of an Intellectual Disability. Interventions implemented by the facility were in place and included to calm the resident if signs of distress develop during the decision-making process, and encourage Resident #1 to verbalize feelings, concerns, fears, and to clarify misconceptions. Review of Resident #1's care plan dated 2/26/2023, revealed the resident was care planned for socially inappropriate/disruptive behavioral symptoms as evidenced by yelling out, refusal of care, combative with care, and the resident had behavior of touching her privates. Interventions in place included to maintain a calm environment and approach to the resident, avoid overstimulation and remove resident from group activities when behavior is unacceptable. Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE], revealed a BIMS interview should not be conducted on the resident and a staff assessment for mental status should be completed. The MDS revealed Resident #1 had short term memory problems and long-term memory problems. Resident #1's cognitive skills for daily decision was assessed as moderately impaired. Review of facility's documentation dated 5/12/2023, revealed on 5/12/2023 Licensed Practical Nurse (LPN) #1 informed the Director of Nursing (DON) that Certified Nurse Assistant (CNA) #1 was walking down the hall and observed Resident #2 in a wheelchair in Resident #1's room at Resident #1's bedside. When CNA #1 entered the room, she noticed Resident #2's hand was in Resident #1's brief. CNA #1 informed Resident #2 to leave the room and notified LPN #1. LPN #1 entered Resident #1's room and observed Resident #2 with his hand in Resident #1's brief and Resident #1's hand was on top of Resident #2's hand. LPN #1 instructed Resident #2 to leave Resident #1's room and Resident #2 exited the room. Review of Resident #1's Nursing note dated 5/12/2023, by the AIT, who was the Director of Nursing (DON) at the time of the incident revealed .Approx [Approximately] 1625 (4:25 PM) received report from nurse that CNA had reported observation of male resident [Resident #2] in w/c [wheelchair] @[at] bedside w/ [with] his hand in Res [Resident #1's] brief .detective sent to interview, nurse present during interviews Res indicated that she had motioned male resident [Resident #2] to come into her room, that she placed his hand on her vagina . Review of CNA #1's hand written statement dated 5/12/2023, revealed .I was walking back down the hallway and passed room [Resident #1's room number] .I looked in and saw a wheelchair up beside [Resident #1's] bed, I noticed it was [Resident #2] .He [Resident #2] had his right hand under the sheet, I saw the sheet moving and I told him [Resident #2] to leave .told her [LPN #1] to go to [Resident #1's room] now . Review of LPN #1's hand written statement dated 5/12/2023, revealed .Charting Nurse [LPN #1] immediately entered room [room number] noting male patient [Resident #2] in wheelchair with his back turned towards me and his right hand inside of [Resident #1's] brief .Charting nurse stating 'Hey!' at that moment male patient [Resident #2] immediately removed his hand from patients [Resident #1's] brief .Nurse also stating, 'what are you doing' in which he did not answer and began to back out of room .Charting nurse directing male patient [Resident #2] out of the room and telling him to go to his room now .I immediately notified DON, ADON [Assistant Director of Nursing] . Review of Resident #1 Acute Progress Note dated 5/12/2023, by Resident #1's Nurse Practitioner (NP) revealed .I am seeing [Resident #1] at the request of the facility for an allegation of potential abuse .It was reported to me that today at 1625 [4:25 PM] the patient [Resident #1] was in bed and motioned for a male resident [Resident #2] to come into her room .He complied and rolled next to her bed in his wheelchair .A staff member observed him with his hand inside her brief with her hand on top of his .The male resident [Resident #2] told police during questioning that [Resident #1] placed his hand on her vagina .REVIEW OF SYSTEMS: Unable to reliably obtain secondary to cognitive status .PLAN .Continue to monitor .The above was discussed with facility administrator, the Director of Nurses, and my supervising Physician [Medical Director] as well . Review of Resident #1's care plan updated 5/13/2023, following the incident of 5/12/2023, included to assess whether the behavior endangers the resident and/or others and intervene, if necessary, divert the resident's behavior by redirecting, and obtain a psych consult/psychosocial therapy. Review of Resident #1's Observation Detail Report dated 5/15/2023, performed by Social Worker (SW) revealed a BIMS assessment should be conducted on Resident #1. The resident's BIMS score was 1 and showed Resident #1 was severely cognitively impaired. Review of Resident #1's Psychiatric Nurse Practitioner Psychiatric note dated 5/15/2023, revealed .Noted incident with another resident [Resident #2] on 5/12/2023 and related disinhibited, sexual behaviors .episode hands inside brief on 5/15/23 [5/12/2023] noted development delays at baseline which are trigger for disinhibited and impulsive behaviors .Unable to determine cognitive status related to communication deficits . During an observation and interview with Resident #1 on 7/18/2023 at 10:48 AM, revealed Resident #1 in her room in bed watching a cartoon movie on her portable DVD player and smiling. The resident was holding a doll and had several dolls and stuff animals in the bed with her. The resident was unable to state her name. She was not able to answer yes or no to questions verbally or answer by nodding or shaking her head. Resident #1 did not respond to questions about the incident between her and Resident #2 on 5/12/2023 . Medical record review revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Impulse Disorder, Restlessness and Agitation, Anxiety Disorder, Dementia, Major Depressive Disorder and Hypertension. Review of Resident #2's care plan dated 2/3/2023, revealed Resident #2 was care planned for cognitive loss and Dementia and the resident had a memory problem. Interventions in place included engage the resident in conversation, ask questions for which you can validate the answers and administer medications as ordered. Review of Resident #2's quarterly MDS dated [DATE], revealed the resident had a BIMS score of 12 which indicated the resident was moderately cognitively impaired . Review of Resident #2's Psychiatric NP note dated 5/10/2023, revealed .Patient [Resident #2] seen for .f/u [follow up] visit .AO x 4 [Resident #2 was alert and oriented to self, others, place and time] . Review of Resident #2's Nursing note dated 5/12/2023, and documented by the AIT revealed, .officer and detective dispatched to speak w/[with] Res [Resident #2] and female resident [Resident #1] .Res [Resident #2] tolerated interview well, states he was bored and coming to the front from his room when noted female resident [Resident #1] across the hall motioning for him to come into her room, observed Res [Resident #1] touching herself and he [Resident #2] asked if she [Resident #1] wanted him to help and she said yes and grabbed his hand and placed it on her vagina . Review of Resident #2's NP Acute progress note dated 5/12/2023, revealed .I am seeing the patient [Resident #2] at request of facility for an allegation of potential abuse towards another resident [Resident #1] .I am seeing [Resident #2] after a staff member reported that he was observed with his hand under a female patient's brief at 1625 today [4:25 PM] .He is calm and pleasant .He does not pose a threat to himself or other residents at this time .He does not have a history of any behaviors that would pose a threat to himself or to others .The above was discussed at length with the facility administrator, Director of Nurses, and my supervising physician [Medical Director] . Review of Resident #2's Social Service (SW) note dated 5/12/2023, revealed .SW visited resident related to recent sexual incident towards another resident [Resident #1] .Resident [Resident #2] was visibly down and depressed and looked down during the entire visit .SW asked him if he wanted to talk about the incident and he reported 'no' . Review of a Police report dated 5/12/2023, revealed .Upon my arrival I met with the complainant/administrator [Administrator's name], and she stated that a male patient [Resident #2] was found in [Resident #1's] room with his [Resident #2] hand on her vagina .She advised that both patients were asked about the situation and that it appeared consensual .[The Administrator] advised that [Resident #1] had Cerebral Palsy and questioned if she fully understood what was going on .She then had me meet with the nurse [LPN #1] who found [Resident #2] in [Resident #1's] room .Upon meeting with [LPN #1] she advised that she was walking through the halls and observed [Resident #2] inside of [Resident #1's] room with his hand under her covering and on her vagina .She advised that she observed [Resident #1's] hand on top of [Resident #2's] hand when she walked into the room .[LPN #1] and I interviewed [Resident #2] .I asked him what led him into [Resident #1's ] room and if he had visited her room before .He stated he has visited her several times in the past to help her pick up things she had dropped or to get her wheelchair free from being struck .He advised that he was bored today and went for a walk .He advised that he saw [Resident #1] wave him into her room and decided to see if she needed help with something .He advised that after walking in, he [Resident #2] observed [Resident #1] touching herself in her vaginal region .He stated that is when she grabbed his hand and then placed it on her vagina . Review of Resident #2's care plan dated 5/12/2023, revealed the resident was care planned for behavioral symptoms following the incident on 5/12/2023. Resident #2 was care planned for socially inappropriate/disruptive behavioral symptoms as evidence by documented occurrence involving female resident (Resident #1). Interventions added on 5/12/2023 included Depakote increased per Psych, hourly checks x 48 hours, remove resident from group activities when behavior is unacceptable, resident room change to promote distance from female resident indicated in noted occurrence, and when the resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs. Review of Resident #2's Social Worker Psychotherapy Progress Note dated 5/13/2023, revealed .This session was at the request of the staff .Allegedly, he was involved in an incident with a female resident [Resident #1] .My task was to see how he was handling the repercussions from that allegedly incident .He denied being upset at any of the repercussions of the incident .He did not appear to think he was mistreated in any way and he was ready to 'move on' . Review of Resident #2's Social Worker Psychotherapy Progress Note dated 5/15/2023, revealed .He still denied having any negative side effects from the events that happened last week .He did state that the incident will never occur again .He has never had any incident like this before so I do not think that this would be a problem in the future . Review of Resident #2's NP Psychiatric Note dated 5/15/2023, revealed .Noted incident with another resident [Resident #1] on 5/12/2023 and related disinhibited, sexual behaviors .Cognitive status is fully oriented and recalls episode with other resident last Friday [5/12/2023] .Noted event was one time episode .no history of sexual inappropriate behaviors . Review of Resident #2's annual MDS dated [DATE], revealed the resident had a BIMS score of 14 which indicated the resident was cognitively intact. During an interview on 7/18/2023 at 1:45 PM, CNA #1 stated she was assigned Resident #1 on 5/12/2023 and witnessed the incident between Resident #1 and Resident #2. CNA #1 stated Resident #2 was in Resident #1's room on the left side of Resident #1's bed in a wheelchair. CNA #1 noted Resident #2 had his hand under the sheet near the resident's right thigh area below her navel area. CNA #1 asked Resident #2 to leave Resident #1's room and Resident #2 did not leave the room as requested. The CNA then called out to LPN #1 who was in another resident's room. CNA #1 stated, .He [Resident #2] should not have been in her [Resident #1] room or touching her .He was sexually inappropriate with [Resident #1] .That should not have occurred .She could not give him [Resident #2] her permission to touch her . CNA #1 stated Resident #1 was cognitively impaired. During an interview on 7/18/2023 at 3:50 PM, the DON stated she was the Assistant Director of Nursing (ADON) at the time of the incident on 5/12/2023. The DON stated Resident #1 was alert and oriented to person and Resident #2 was alert and oriented. The DON confirmed Resident #2 placed his hand in Resident #1's brief on 5/12/2023. The DON confirmed Resident #1 had an intellectual disability. The DON confirmed Resident #1 was not able to give her consent to be touched sexually by others. During the interview the DON confirmed Resident #1 was touched sexually inappropriately by Resident #2. During an observation and interview on 7/18/2023 at 4:15 PM, Resident #2 was noted seated in a wheelchair, at the end of the hall, away from his peers. Resident #2 stated he saw Resident #1 touching herself (masturbating) in her room when he passed her room on 5/12/2023. Resident #2 stated, .I was horny that's why I went in her room [Resident #1's room] .I have not had sex since I have been here .I went into her room because I was horny. She was playing with herself . Resident #2 denied Resident #1 asked or motioned for him to enter her room on 5/12/2023. Resident #2 stated Resident #1 grabbed his hand and put his hand near her vagina. Resident #2 confirmed he touched Resident #1's vagina. Resident #2 stated, .She [Resident #1] didn't move my hand away [from her vagina area] . During a telephone interview on 7/18/2023 at 7:07 PM, LPN #1 stated on 5/12/2023, CNA #1 stated she needed me in Resident #1's room now. LPN #1 stated when she entered Resident #1's room Resident #2 was on the left side of the room near Resident #1's bed, in his wheelchair, and his right hand was in Resident #1's brief. LPN #1 stated Resident #1's brief on her right side was undone and Resident #2's hand was in the resident's brief. The LPN stated, .I said Hey, he [Resident #2] jumped back, looked at me wide eyed .I told [Resident #2] to leave the room . LPN #1 had a CNA escort Resident #2 to his room. LPN #1 stated, .He was not supposed to be in her room .She [Resident #1] has a mind of a child. She plays with Barbies and dolls, watches cartoons .What I saw he [Resident #2] was helping her masturbate . LPN #1 confirmed Resident #2 touched Resident #1 sexually inappropriately. LPN #1 stated, .He was sexually abusing her [Resident #1] by what I saw .He [Resident #2] knows right from wrong .When I caught him, he jumped back wide-eyed . LPN #1 confirmed the facility failed to prevent abuse of Resident #1. During an interview on 7/19/2023 at 9:27 AM, Social Worker (SW) #1 stated, .[Resident #1] is childlike .She at the mind of 2-3-year-old and Intellectual Disability diagnosis .Alert and oriented x [times] 1 [self] . SW #1 confirmed Resident #1 was unable to make her own decisions and stated the resident was not cognitively intact. The SW stated Resident #1 was unable to give consent to sexual interactions. The SW stated Resident #2 was alert and oriented x 3 and knew right from wrong. The SW confirmed the facility failed to prevent abuse between Resident #1 and Resident #2 and Resident #2 touched Resident #1 sexually inappropriately. During an interview on 7/19/2023 at 10:07 AM, Resident #1 and Resident #2's NP #1 stated she was notified of the incident. The NP stated Resident #1 had an Intellectual Disability and was unable to give consent or make her own decisions. The NP stated Resident #2 should not have touched Resident #1 inappropriately. The NP confirmed the facility failed to prevent Resident #2 from abusing Resident #1. During an interview on 7/19/2023 at 11:30 AM, Resident #1 and Resident #2's Psychiatric Nurse Practitioner (PNP) confirmed she assessed Resident #1 on 5/15/2023 and noted no change in Resident #1 behaviors, no mental anguish, and no signs or symptoms of emotional distress following the incident. The PNP stated, . [Resident #2] exhibited sexually inappropriate behavior with [Resident #1 on 5/12/2023] . During an interview on 7/19/2023 at 12:16 PM, the AIT confirmed she was the DON at the time of the incident on 5/12/2023. The AIT stated she was informed CNA #1 was walking by Resident #1's room and noted Resident #2 in the room with his hand in Resident #1's brief. The AIT confirmed the facility failed to prevent Resident #2 from abusing Resident #1. During an interview on 7/19/2023 at 12:23 PM, the Administrator stated she was the Abuse Coordinator. The Administrator confirmed Resident #1 was sexually abused by Resident #2 on 5/12/2023. During an interview on 8/7/2023 at 10:30 AM, SW #1 stated, .Now we just keep a look out to ensure where the resident [Resident #2] is at all times .He also expressed he [Resident#2] will not be going into another resident's room .She [Resident #1] wanted it to happen in that moment .it was beyond my scope whether she was cognitively intact .She did want sexual contact .She waved him in .She put his hand on her privates .We did not substantiate the allegation of abuse .We thought it was consensual .He [Resident #2] doesn't want to talk about it he is embarrassed . The interview confirmed the facility failed to identify the incident between Resident #1 and #2 was sexual abuse and revealed the facility changed the conclusions of their investigation from the surveyor's initial investigation in July. Interview revealed the facility failed to identify Resident #1 was unable to consent to sexual contact. Interview revealed the facility's failure to identify Resident #1 was abused on 5/12/2023 placed other cognitively impaired residents in the facility at risk for abuse. During an interview on 8/7/2023 at 11:27 AM, the DON revealed she was the ADON at the time of the incident on 5/12/2023. The DON stated, .Abuse did not occur .We did it as a group and made the decision to unsubstantiate the abuse [The incident between Resident #1 and Resident #2 on 5/12/2023] the ADON, DON, and the Administrator .We provided the facts .When we interviewed him .He was remorseful for what he had done .[Resident #1] dropped her toys and he [Resident #2] helped her .She did ask for his help with masturbation she put her hand on his hand .He had a lapse of judgement .he had remorse and she was encouraging him .She provided the temptation and he knew it was wrong . Interview revealed the facility failed to identify Resident #1 was not able to consent to sexual acts, the facility failed to identify the incident on 5/12/2023 as abuse, and the facility's failure to identify Resident #1 was abused placed other cognitively impaired residents in the facility at risk for sexual abuse. During an interview on 8/7/2023 at 1:12 PM, the AIT confirmed she was the DON at the time of the incident on 5/12/2023. The AIT stated, .We didn't substantiate abuse she [Resident#1] motioned for him [Resident #2] to come into the room and she put his hand on her private area .She [Resident #1] screams if she doesn't want something done .or smacks someone's hand away .She [Resident #1] .did not do any of that that day [5/12/2023] .She is cognitively impaired .He [Resident #2] has never said anything sexual during baths or incontinence care .The resident [Resident #2] was consistent with his report .female [Resident #1] invited him into the room [Resident #1's room] by waving him in . Interview revealed the facility failed to identify Resident #1 was not capable of consenting to sexual acts. Interview revealed the facility failed to identify the incident between Resident #1 and Resident #2 was sexual abuse which placed other cognitively impaired residents at risk for sexual abuse. During a telephone interview on 8/7/2023 at 2:09 PM, LPN #1 confirmed Resident #1 was cognitively impaired and could not consent to sexual interaction with other residents. During a telephone interview on 8/7/2023 at 2:25 PM, CNA #1 stated, . [Resident #1] was not able to consent to sexual interaction .She has the mind of a 5-year-old . During an interview on 8/7/2023 at 2:47 PM, the Administrator (Abuse Coordinator) stated, .I didn't think it [incident on 5/12/2023 between Resident #1 and Resident #2] raised to the level of abuse .We had everyone help with interviews [interviews with staff and residents] and investigation .SW, Nurses, ADON, DON, NP .The event occurred .I thought it was consensual because [Resident #1] waved him into the room and she had her hand on top of his under the covers and she was not upset .She can clearly let you know when she is upset .She will be screaming, crying or pitch a fit .She was not doing any of that on 5/12/2023 at the time of the incident .She wasn't upset and invited him in the room [Resident #1's room] at the moment .Sexual abuse is unwanted contact . Interview revealed the facility failed to identify Resident #1 was not able to consent to sexual acts. Interview revealed the facility failed to identify Resident #1 was sexually abused on 5/12/2023. The facility's failure to identify abuse placed other cognitively impaired residents at risk for abuse. During an interview on 8/7/2023 at 4:12 PM, SW #1 stated, .Anybody [residents in the facility] that can make a decision can consent [to sexual activity] .Can [Resident #1] consent to sexual acts .I think yes she [Resident #1] can .She did consent to sexual acts .She did give consent she wanted him [Resident #2] in there [Resident #1's room] and wanted his hand on her privates .Some nonverbal and late stage Dementia patients can make a decision on sexual acts .She [Resident #1] has an intellectual disability with intellectual disability can she make decision on sex .Yes if she wants it [sexual interaction] .She [Resident #1] was not in distress .The age level she [Resident #1] functions at is low maybe at a 2 or 3 year old level . During an interview on 8/7/2023 at 4:36 PM, the ADON confirmed she was the Wound Care Nurse at the time of the incident on 5/12/2023. The ADON confirmed Resident #1 was not able to consent to sexual acts due to her low BIMS score, poor cognition, and the resident had a Power of Attorney (POA) to assist with those decisions. During an interview on 8/7/2023 at 5:00 PM, the AIT stated, .She [Resident #1] can give consent to sex .She can give consent for everything else .She motioned him to her room .Residents with BIMS of 1 they can consent [sexual interactions] it is situational .If resident can't verbalize needs .[Resident #1] it would not be ok [sexual interactions] .She [Resident #1] able to make needs known that's the difference if she drops toys, clothes .she yells .We work with the resident long enough to understand she verbalizes her wants or needs . During a telephone interview on 8/8/2023 at 9:12 AM, Resident #1's family member and conservator stated the facility notified him a male resident had his hand down Resident #1's pants in an inappropriate manner. Resident #1's family member stated, . [Resident #1] got a mind of a 3 or 4 year old .She [Resident #1] cannot put a sentence together or think rationally as an adult .She has a child-like mentality .She does not know right from wrong until scolded .I would not give permission for sexual contact with another resident because she doesn't know what it is .She lays her head on your shoulder and hugs you that's the only contact she knows .She only knows child-like affections .for someone to have sex with her is like child molestation .She cannot give consent or capable to give consent . During an interview on 8/8/2023 at 2:06 PM, the NP confirmed touching a resident in a

Based on facility policy review, medical record review, facility documentation review and interview, the facility failed to develop and implement person-centered interventions for 1 resident (Resident #1), a developmentally disabled, severely cognitively impaired resident after Resident #1 was sexually abused by Resident #2 of 4 residents reviewed for abuse. The facility failed to ensure Resident #1's protection and privacy when she exhibits reported behavior of self-stimulation. Resident #1's care plan did not address the resident's inability to understand masturbation as a sexual activity and provide interventions to protect her from predatory sexual acts from others. The facility's noncompliance placed Resident #1 and other cognitively impaired residents at risk for sexual abuse. The facility's failure to develop and implement a person-centered care plan for Resident #1 placed Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Administrator in Training (AIT), and Area Director of Clinical Services were notified of the Immediate Jeopardy for F600 and F656 on 8/9/2023 at 10:20 PM in the conference room. A partial extended survey was conducted on 8/10/2023. The facility was cited Immediate Jeopardy at F600 (K) and F656 (K). The Immediate Jeopardy began on 5/12/2023 and was removed on 8/12/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 8/11/2023 at 5:02 PM, and the corrective actions were validated on-site by the surveyors on 8/12/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled Comprehensive Care Plans, revised 8/30/2022, showed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .to meet a resident's medical, nursing, mental and psychosocial needs .The care planning process will include an assessment of the resident's strengths and needs .The comprehensive care plan will describe, at a minimum .services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #1 was admitted to the facility on [DATE], with diagnoses including Unspecified Intellectual Disability, Cerebral Palsy, Post Polio Syndrome, Impulse Disorder, Dementia with Behavioral Disturbance, Pseudobulbar Affect (is a condition that is characterized by episodes of sudden uncontrollable and inappropriate laughing or crying) and Generalized Anxiety. Review of Resident #1's Pre-Admission Screening Resident Review II (PASRR Level II a state required screening conducted to determine level of services required for a resident before admission to a nursing home) conducted while in an acute hospital on 7/5/2023, showed the test for FSIQ (Full Scale Intelligence Quotient) score was 42, with 40 being the lowest score attainable. Review of Resident #1's Comprehensive Care Plan showed a date range for problems and/or interventions from 1/31/2023-5/13/2023. Review showed on 2/26/2023 the resident was care planned for socially inappropriate/disruptive behavioral symptoms as evidenced by yelling out, refusal of care, combative with care, and the behavior of touching her privates. Interventions in place included .avoid overstimulation .maintain a calm environment and approach to the resident .remove resident from group activities when behavior is unacceptable . Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE], showed no Brief Interview for Mental Status (BIMS) interview should be conducted on the resident. The resident had moderately impaired cognitive skills for daily decision-making tasks of daily life with .decisions poor, cues/supervision required . Review of the facility's documentation dated 5/12/2023, showed on 5/12/2023 Licensed Practical Nurse (LPN) #1 informed the Director of Nursing (DON) a Certified Nurse Assistant (CNA) #1 was walking down the hall and observed Resident #2 in a wheelchair, at the bedside of Resident #1. When CNA #1 entered Resident #1's room, she observed Resident #2 with his hand in Resident #1's brief. CNA #1 requested Resident #2 to leave the room and notified LPN #1. LPN #1 entered Resident #1's room and observed Resident #2 with his hand in Resident #1's brief and Resident #1's hand placed on top of Resident #2's hand. Resident #2 then exited Resident #1's room. Review of a Nursing note dated 5/12/2023, showed .Approx [Approximately] 1625 [4:25 PM] received report from nurse that CNA had reported observation of male resident in w/c [wheelchair] @ [at] bedside w/ [with] his hand in Res [resident] brief w/ her hand over his .Nurse immediately stopped interaction and removed male resident [Resident #2] from her room .Res w/o [without] any indication of distress physically or emotionally .Nurse performed skin assessment w/no [with no] abnormalities noted . Review of CNA #1's witness statement dated 5/12/2023, revealed .I was walking back down the hallway .I looked in and saw a wheelchair up beside [Resident #1's] bed, I noticed it was [Resident #2] .He [Resident #2] had his right hand under the sheets, I saw the sheet moving and I told him [Resident #2] to leave . Review of LPN #1's witness statement dated 5/12/2023, revealed .Charting Nurse [LPN #1] entered room [room number] noting male patient [Resident #2] in wheelchair with his back turned towards me and his right hand inside of [Resident #1's] brief .nurse stating 'Hey!' at that moment male patient immediately removed his hand from patient's brief .Nurse also stating, 'what are you doing' in which he did not answer and began to back out of room .I immediately notified DON, ADON [Assistant Director of Nursing] . Review of a Police report dated 5/12/2023, revealed .Upon my arrival I met with the complainant/administrator [Administrator's name], and she stated that a male patient [Resident #2] was found in [Resident #1's] room with his [Resident #2] hand on her vagina .She advised that both patients were asked about the situation and that it appeared consensual .[The Administrator] advised that [Resident #1] had Cerebral Palsy and questioned if she fully understood what was going on .She then had me meet with the nurse [LPN #1] who found [Resident #2] in [Resident #1's] room .Upon meeting with [LPN #1] she advised that she was walking through the halls and observed [Resident #2] inside of [Resident #1's] room with his hand under her covering and on her vagina .She advised that she observed [Resident #1's] hand on top of [Resident #2's] hand when she walked into the room .[LPN #1] and I interviewed [Resident #2] .I asked him what led him into [Resident #1's ] room and if he had visited her room before .He stated he has visited her several times in the past to help her pick up things she had dropped or to get her wheelchair free from being struck .He advised that he was bored today and went for a walk .He advised that he saw [Resident #1] wave him into her room and decided to see if she needed help with something .He advised that after walking in, he [Resident #2] observed [Resident #1] touching herself in her vaginal region .He stated that is when she grabbed his hand and then placed it on her vagina . Review of Resident #1's care plan updated 5/13/2023, showed interventions added after the incident on 5/12/2023 were to assess whether the behavior endangers the resident and/or others, intervene if necessary, divert resident's behavior by redirecting, and obtain psychiatric consult or psychosocial therapy. Review of a Nursing note dated 5/14/2023, revealed .CNA reported to the charting nurse that the resident [Resident #1] was observed with her pants down to her knees, right side of brief was unfastened, and the top of her brief pushed downward . Review of Nursing note dated 5/15/2023, revealed .CNA called nurse to come to the resident's room .nurse entered the room and the CNA stated that when entering the room, the resident [Resident #1] had her hand in the front of her pants and when she saw the CNA she quickly removed her hand from her pants . Review of Resident #1's Psychiatric Nurse Practitioner Psychiatric note dated 5/15/2023, revealed .Noted incident with another resident on 5/12/2023 and related disinhibited, sexual behaviors .noted development delays at baseline .Unable to determine cognitive status related to communication deficits . Review of Resident #1's Nursing note dated 6/11/2023, revealed .nurse noting resident with right hand in brief moving rapidly x2 [two times] today. Upon noticing nurse at doorway, resident would quickly remove her hand and yell at nurse to get out .would then tell resident to calm down and that she was not in trouble . Review of Resident #1's Nursing note dated 7/9/2023, revealed .Resident .has been noted lately put her hands down into clean or soiled briefs .if room is entered during this type of event, she will respond as if she is in trouble .Nursing has been assuring resident that she is not . During an observation and interview with Resident #1 on 7/18/2023 at 10:48 AM, the observation showed Resident #1 in her room, in bed watching a cartoon movie on her portable DVD player and smiling. The resident was holding a doll and had several dolls and stuffed animals in the bed with her. The resident was unable to state her name. She was not able to answer yes or no to questions verbally or answer by nodding or shaking her head. Resident #1 did not respond to questions about the incident with Resident #2 on 5/12/2023. During an interview on 7/19/2023 at 9:27 AM, Social Worker (SW) stated, .[Resident #1] is childlike .She at the mind of 2-3-year-old and Intellectual Disability diagnosis .Alert and oriented x [times] 1 . The SW confirmed Resident #1 was unable to make her own decisions and stated the resident was not cognitively intact. The SW stated Resident #1 was unable to give consent to sexual interactions. During an interview on 7/19/2023 at 10:07 AM, Resident #1's Nurse Practitioner (NP) stated she was notified of the incident. The NP stated Resident #1 had an Intellectual Disability and was unable to give consent or make her own decisions. During a telephone interview on 8/8/2023 at 4:12 PM, CNA #3 stated Resident #1 had a longstanding behavior of self-sexual expression, but it was .just in the last few months .began to be open about it . During an interview on 8/9/2023 at 10:00 AM, CNA #2 was asked about Resident #1 being care planned on 2/26/2023 for the behavior of touching her privates. CNA #2 stated .everybody has the right [to sexual expression] [Resident #1] .has no ability to understand that her [Resident #1] touching is sexual in nature . CNA #2 continued and stated the resident's privacy would need to be provided for this activity by the staff. During an interview on 8/9/2023 at 10:00 AM, LPN #2 stated the residents' care plans needed to cover all behaviors. LPN #2 stated, I'm sure sexual expression isn't understood by her [Resident #1] .should be care planned. During an interview on 8/9/2023 at 11:10 AM, LPN #1 stated .I don't know if they [the CNAs] have anything on their things they use [clarified with the LPN referring to the CNA daily assignment or the CNA software program] that would tell them about [Resident #1's] masturbation and what they should do about it . Interview continued and LPN #1 stated, .Mentally [Resident #1] does not know what sexual activity is .she was masturbating in her room weeks or months before the incident [of 5/12/2023] she has the right to masturbate .the care plan should be up to date .guide resident care . LPN #1 confirmed the care plan did not address providing safety for the resident regarding masturbation and did not provide a guide to staff on how to care for the resident during masturbation. During an interview on 8/9/2023 at 3:07 PM, the Social Worker (SW) stated the problem notated on Resident #1's care plan touching her privates was added by her and she provided the intervention of .avoid overstimulation .maintain a calm environment and approach to the resident .remove resident from group activities when behavior is unacceptable . Interview confirmed the care plan intervention .should have been updated related to masturbation and providing a safe environment . During an interview on 8/9/2023 at 3:38 PM, the Assistant Director of Nursing (ADON) stated resident care plans are updated for specific residents' behaviors .we need to take care of .care plan was updated to include her [Resident #1] behavior of touching her privates. That could mean masturbation or something else .the intervention does not address the resident's privacy and safety . Continued interview confirmed Resident #1's care plan intervention added after the 5/12/2023 incident with Resident #2 when he entered Resident #1's room and touched her vagina did not address the resident's privacy and safety during masturbation. Continued interview confirmed the intervention developed to assess whether the behavior endangers the resident and/or others did not provide a clear explanation of what behavior was being referenced and if it placed Resident #1 in danger, what interventions the facility provided to protect and provide safety for Resident #1. The ADON confirmed the intervention did not include guidance to the staff for providing resident care during masturbation and how to provide safety for a severely cognitively impaired resident, Resident #1 who did not have the decision-making capacity to consent to sexual acts with another person. During an interview on 8/9/2023 at 3:58 PM, the DON stated, .my interpretation is we updated the care plan [for Resident #1] for the behavior of touching her privates with the intervention of diverting the behavior . Continued interview confirmed there was not anything specific related to providing privacy for the resident's masturbation behavior, for providing safety, or care planning to prevent another incident similar to the incident on 5/12/2023. During an interview on 8/9/2023 at 4:14 PM, the AIT confirmed for Resident #1 the problem behavior listed as touching her privates was not specific to her known masturbation behavior and the interventions did not include guidance for the staff in order to maintain her privacy, or how to protect the resident and provide safety. Facility corrective actions included: 1. Resident #1's care plan was updated on 8/10/2023, to include pulling privacy curtain and providing privacy when resident is noted to exhibit behavior of self-stimulation. 2. On 8/11/2023, a stop sign was added to Resident #1's door to discourage other residents from entering her room. Also, on 8/11/2023, Resident #1's bed was moved to the window side of the room (furthest from the door) to facilitate privacy. 3. On 8/10/2023, 100 percent of residents with cognitive impairment and behavioral care plans were reviewed by the Social Services Director, MDS Coordinator, and Nurse leaders to ensure that interventions were appropriate and person-centered. Each resident's nurse notes, as well as CNA documentation for the past 30 days was included in the review to assure any behaviors, including sexual touching, sexual verbalization, aggression, and wandering were addressed. A total of 42 residents with cognitive impairment were reviewed. 4. On 8/10/2023, all interdisciplinary care plan team members responsible for writing care plans (MDS Coordinator, Social Services Director, Activities Director, DON) were reeducated by the Area Director of Clinical Services on the facility policy and procedure for developing Comprehensive Care Plans that are person-centered. 5. on 8/10/2023, a care plan approach was added to the cognitive impairment care plan of each resident with a BIMS of 7 or below that states Staff to monitor every shift for sexual expression. This is in alignment with the education 100 percent of staff received on 8/10/2023, regarding sexual expression. Close monitoring for sexual expression will allow staff to quickly identify a resident with sexual desires so that staff can immediately begin the facility process for determining consent. 6. Beginning 8/11/2023, the Social Services Director will review daily all nursing notes documented the day before looking for notes that pertain to behaviors, sexual conduct, and abuse. The Social Services Director will assure any new concerns are immediately addressed and care plans updated. 7. When a new behavior is identified the Social Services Director will immediately update the resident care plan utilizing person-centered interventions and will then bring a copy of the updated care plan to the morning clinical meeting to be reviewed by the interdisciplinary team to ensure the approaches are appropriate and person-centered. DON will complete daily audit tool daily for 8 weeks ensuring any newly identified behaviors have been addressed and the care plan was updated. 8. The DON will complete a random audit of 10 behavioral care plans per week for 2 weeks and then 5 behavioral care plans for 6 weeks ensuring that appropriate person-centered approaches have been developed. The surveyors validated the corrective actions implemented by the facility through a review of medical records, review of facility documentation, and interviews. The surveyors validated the review and update of all cognitively impaired residents' care plans. The surveyors validated through interviews with the interdisciplinary team members their understanding of the education received on care planning process. Interviews were conducted with CNAs and nurses on both shifts confirmed they had been educated on abuse and consent and verbalized understanding. Review of facility documentation verified nursing notes were being reviewed as documented in the removal plan and audits were completed. Noncompliance at F656 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on facility policy review, observation and interview the facility failed to ensure proper sanitation by documenting water temperatures in the dish machine; failed to ensure proper storage of milk by documenting temperatures in the milk cooler; failed to label correctly and date 1 food item stored inappropriately; and failed to store fresh fruit in a sanitary manner. The findings include: Review of the facility policy, Dishwashing Machine Use, undated revealed .A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution .after filling the dishwashing machine . Review of the facility policy, Food Receiving and Storage, undated, revealed .Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by Culinary Services Manager or designee and documented according to state-specific requirements . and .Non-refrigerated foods .will be stored in a designated dry storage unit which is .free of insects .and kept clean . Review of the dishwasher temperature logs for 7/2019 revealed no documentation of breakfast or lunch temperatures or sanitizer concentration on 7/13, 7/14, and 7/15 had been documented. Review of the Refrigerator/Freezer Temperature log for the milk cooler dated 7/2019 revealed no documentation temperatures had been documented on 7/13, 7/14, and 7/15/2019. Observation with the Certified Dietary Manager (CDM) on 7/15/19 at 9:15 AM, in the kitchen, revealed (1) 50 pound bag of thickener, in a rolling bin, labeled as sugar. Continued observation revealed 1 box which contained 5 bunches of black, dark colored bananas with a large number of small, black, flying insects on the fruit and swarming around the box. Interview with the CDM on 7/15/19 at 9:20 AM in the kitchen, confirmed the facility failed to discard spoiled fruit and failed to ensure the kitchen was free of insects. Interview with the CDM on 7/15/19 at 9:40 AM, in the kitchen, confirmed the facility failed to document dishwasher temperatures and sanitizer solution at each meal and milk cooler temperatures twice a day. Continued interview confirmed the facility failed to label 1 dry food item available for resident use correctly.

Based on medical record review, review of facility documentation, review of facility policy, and interview, the facility failed to provide supervision to prevent neglect of a cognitively impaired resident (#99), resulting in an elopement, of six residents reviewed. The facility's failure to prevent neglect and elopement for resident #99 resulted in Immediate Jeopardy to resident #99 (Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.) The Administrator and Corporate Consultant were notified of the Immediate Jeopardy on April 24, 2013, at 5:25 p.m., in the Administrator's office. The Immediate Jeopardy was effective February 2, 2013, through February 4, 2013, and was removed February 5, 2013. A corrective action plan (Allegation of Compliance) which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyor team on April 24-25, 2013. Non-compliance continues at a "D" level for F224. The facility is required to submit a Plan of Correction. The findings included: Resident #99 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Patient Nursing Evaluation dated January 31, 2013, revealed, "...1. Patient currently wanders and/or has a history of wandering...Mental Health...Behaviors: wandering...Mood: worried...agitated...restless...Ambulation...Independent...Transfer... Independent...Dressing...Independent...Functional Impairment of Range of Motion...Upper extremity...no impairment...Lower Extremity...no impairment..." Further review of the evaluation revealed the resident scored a 6 on the Nursing [MEDICAL CONDITION] Screening Scale (NuDESC) "...a score of greater than 2 on NuDESC identifies presence of [MEDICAL CONDITION]. Add interventions to care plan..." Medical record review of the Wander/Elopement Risk Evaluation dated January 31, 2013, revealed, "...1. Resident is at risk for Wandering: yes...Resident is at risk for Elopement: yes..." Medical record review of the Interim Plan of Care dated January 31, 2013, revealed, "...Other Information...Elopement Risk...Wanderguard (device placed on the ankle of a resident to alert staff of a resident's presence in an unauthorized area) in place..." Medical record review of the Resident Progress Notes dated February 2, 2013, at 8:00 a.m., revealed, "...(resident) came out of room in the middle of the NOC (night). Some restless behavior noted. Confusion over where (resident's) bedroom and bed were..." Medical record review of the Resident Progress Notes dated February 2, 2013, at 10:30 a.m., revealed, "...resident awake, alert, confused @ (at) times...resident opened dirty linen closet backing up as if it were (resident's) toilet, redirected to resident's bathroom..." Medical record review of the Resident Progress Notes dated February 2, 2013, at 12:10 p.m., revealed, "...Friend of resident came to visit. Unable to locate resident in dining area. Staff members then started to look for patient. Executive Director notified, (police department) notified...Physician here and informed...parking area and grounds checked..." Medical record review of the Resident Progress Notes dated February 2, 2013, at 1:37 p.m., revealed, "...Executive Director located resident at (resident's) house..." Review of facility documentation of a witness statement from Licensed Practical Nurse (LPN) #1 dated February 2, 2013, revealed, "...This nurse observed resident...in the service hall looking for the bathroom..." Review of facility documentation of a witness statement from Dietary Aide #1, not dated, revealed, "...saw (resident) in the service hall around 8:30 a.m...went and got a nurse and I stayed in service hall...nurse came and got (resident)..." Review of facility documentation of a witness statement from Registered Nurse (RN) #2 dated February 4, 2013, revealed, "(On February 2, 2013)...staff reported that patient was wandering service hallway...0800 (8:00 a.m.) during breakfast...Assisted patient to room. Pt (patient) stated that (resident) was trying to find bathroom...@ 1015 (10:15 a.m.) Certified Nurse Aide (CNA) reported pt tried to enter closet, thought it was bathroom. Patient was assisted to bathroom and walked to lobby and sat on sofa in front of nurse station...(resident's physician) notified of pt's confusion...Around 1115 (11:15 a.m.) patient was assessed by (resident's physician)..." Review of facility documentation of a witness statement from CNA #3 dated February 2, 2013, revealed, "...Saturday February 2nd 2013, around 10:30 a.m., I noticed (resident) had gotten confused and tried to use the linen closet as a restroom...at 11:20 a.m...went to (resident's) room and (resident) was not there...I proceeded to look in other rooms. Then the entire nursing staff started looking everywhere for (resident)..." Review of facility documentation of a witness statement from an interview with a resident conducted by the Master Social Worker, dated February 6, 2013, revealed, "...I didn't think (resident would) get out with that security guard up there..." Review of the facility policy Elopement Risk Evaluation...Policy: Accidents and Supervision to Prevent Accidents, dated April 28, 2011, and provided by the facility revealed, "...Update and/or implement care plan interventions for reducing and/or preventing attempts of elopement, examples of interventions may include, but are not limited to: a. Wandering Prevention System..." Interview with RN #3 on April 24, 2013, at 4:08 p.m., in the Dining Room, confirmed the RN had been the supervising nurse at the time of the resident's admission to the facility, and confirmed the resident was assessed as an elopement risk on the resident's admission January 31, 2013. Continued interview with the RN revealed the RN had attempted to locate a Wanderguard (wandering prevention system) for the resident, however was unable to locate one. Further interview with the RN revealed the RN had informed the oncoming third shift staff of the resident's elopement risk and the resident did not have a Wanderguard in place. Continued interview with the RN confirmed no other interventions were initiated at the time of admission to prevent elopement from the facility. Interview with LPN #2 on April 24, 2013, at 4:30 p.m., by telephone, revealed the LPN had witnessed the resident on February 2, 2013, "walking down the hall with a brief...looking for the bathroom..." Continued interview with the LPN, confirmed the resident appeared to have been confused during the LPN's care of the resident and "...it was the first time..." the LPN had cared for the resident. Further interview with the LPN revealed the LPN was not informed or aware the resident was at risk for elopement. Interview with the Administrator on April 24, 2013, at 3:00 p.m., in the Conference Room, confirmed the resident had been assessed as an elopement risk at the time of the resident's admission on January 31, 2013. Continued interview with the Administrator confirmed a Wanderguard was not placed on the resident at the time of the resident's admission to the facility, and the resident did not have a Wanderguard in place at the time of the resident's elopement from the facility on February 2, 2013. Further interview with the Administrator confirmed the resident eloped from the facility and the resident was found at the resident's apartment approximately "...4 to 5 blocks..." from the facility. Continued interview with the Administrator confirmed the resident was away from the facility for "...1 hour and 45 minutes..." The Administrator confirmed the facility did not follow policy and procedure to prevent elopement, and did not provide supervision of the resident to prevent elopement from the facility. Interviews with the Administrator and review of facility documentation provided on April 24, 2013, from 3:00 to 4:00 p.m., in the Conference Room, confirmed the facility Performance Improvement/Quality Assurance Committee convened and initiated an investigation into the root cause of the elopement. A corrective action plan was initiated on February 2, 2013. All interventions were in place, and facility wide staff reeducation was completed on February 5, 2013. Monitoring is ongoing with random chart audits completed by the Director of Nursing (DON), accuracy of identifying safety needs completed by the Administrator, and reporting to and monitoring of the corrective action plan by the Performance Improvement/Quality Assurance Committee. Interview with the DON on April 24, 2013, at 3:48 p.m., in the office, confirmed no other elopements had occurred since February 2, 2013. The corrective action plan included: 1. Returning resident #99 to the facility, following an emergency room evaluation to rule out harm or injury related to the elopement. 2. A safety device was located and placed on resident #99 upon return to the facility February 2, 2013. Additional interventions for resident #99 included one to one observations of the resident for forty-eight hours, then staff observations and documentation of the resident's status every fifteen minutes until the resident was discharged home on February 23, 2013. 3. Procuring additional safety equipment (wander guards and/or personal alarms) and ensuring additional equipment was/is available to staff at all times. The Administrator monitors the equipment drawer daily for availability and proper functioning of the safety equipment. 4. Facility wide chart audits to ensure all residents were assessed for potential elopement risk and updating assessments as needed. 5. Medication Administration Records were audited (for all residents) for current photographs of each resident and existing resident photographs were updated as needed. 6. Nurse Aid assignment sheets were reviewed and updated to reflect current elopement risk residents. 7. A notebook with current photographs and physical description of residents was placed in the nursing station and at the front desk with security personnel. 8. All facility staff was re-educated on preventing elopements, signs of potential elopement, residents at risk, and reporting procedures. 9. Daily (through the week) the Director of Nursing will review new admissions to ensure the elopement assessment has been completed. For those at risk for elopement, a care plan will be initiated and the "elopement notebook" will be updated. Wanderguards applied as required. 10. Four spare wanderguard devices (with all necessary parts) will be accessible to nursing at all times. 11. Security guards were in-serviced on elopement risk, "elopement notebook" and reporting procedures, as well as, sign in and/or out log for all visitors entering or exiting the facility. 12. Licensed Nurses who complete admission Patient Nursing Evaluations were re-educated on policies and procedures for completing care plans and initiating interventions when residents were deemed potential elopement risk. Interviews with two Registered Nurses, three Licensed Practical Nurses, six Certified Nursing Assistants, and one Security Guard on April 25, 2013, confirmed all had received education and were able to verbalize the facility's policy and procedure for residents at risk for elopement. C/O #

Based on medical record review, review of facility documentation, and interview, the facility failed to ensure safety devices were in place and functioning to prevent falls for one resident (#17) of thirty-four residents reviewed. The facility's failure to ensure safety devices were in place and functioning resulted in harm to resident #17. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired; required extensive assistance will all activities of daily living (ADLs); and was only able to stabilize with human assistance during transfers and walking. Medical record review of the resident's care plan revealed the resident was at risk for falls. Continued review of the resident's care plan revealed a "...personal alarm installed..." as an update to the care plan on September 20, 2012, and "...sensory bed pad alarm..." was added as an update on September 21, 2012. Medical record review revealed the resident had four falls between November 16, 2012, and February 25, 2013 without injury. Continued review of the medical record revealed the resident had a fall on April 4, 2013, and sustained a fracture to the left wrist as a result of the fall. Medical record review of the Post Fall Evaluation form dated November 16, 2012, revealed the resident was found "...sitting on the floor at foot of bed..." Further review of the Post Fall Evaluation revealed, "...Intervention in place at time of fall..." with a checkmark in the box for "alarm". Further review of the Post Fall Evaluation form revealed no documentation the personal alarm or sensory bed alarm were alarming at the time of the resident's fall. Further review of the form revealed, "...Immediate interventions taken to protect resident: was told to ask for assistance..." Review of facility documentation revealed the resident fell on [DATE], in the resident's bathroom, without injury. Continued review of facility documentation revealed intervention in place at the time of the fall was a checkmark in the box for "...alarm..." Continued review of facility documentation revealed no documentation the sensory pad alarm or personal alarm were in place and functioning at the time of the resident's fall. Further review of facility documentation revealed intervention "...Encourage and assist to wear proper nonslip footwear..." Medical record review of the Post Fall Evaluation form dated February 25, 2013, revealed the resident fell without injury "...resident found on floor in room next to bathroom door...resident states, 'I was coming from bathroom'..." Continued review of the Post Fall Evaluation form revealed, "...Intervention in place at time of fall..." with a checkmark in the box for alarm, and documented in section titled "...Other: (specify) Resident unhooked alarm..." Further review of the form revealed no documentation the sensory pad alarm or personal alarm were functioning at the time of the fall. Continued review of the Post Fall Evaluation revealed, "...Summary of Interdisciplinary Team: Floor Conference with CNA's (Certified Nurse Assistant)/Staff related to making certain alarms are attached and functioning properly-Placing pad alarm back to beds and chairs if they are removed temporarily..." Medical record review of the Post Fall Evaluation form dated April 4, 2013, revealed, "...heard loud noise while standing in hallway. Found pt (patient) lying in floor in RM (room) in front of bathroom door on L (left) side..." Continued review of the Post Fall Evaluation revealed checkmarks in the boxes for alarm, call bell in place, and low bed in the section titled, "...Intervention in place at time of fall..." Further review of the Post Fall Evaluation form revealed no documentation the sensory pad alarm or personal alarm were functioning at the time of the fall. Continued review of the form revealed, "...Summary of Interdisciplinary Team: encourage assisted toileting q (every) 2 hour-(known to refuse) Bolsters placed on bed to discourage unassisted attempts to get out of bed..." Medical record review of the Resident Progress Notes dated April 3, 2013, revealed, "...Pt fell this am (morning)...Roomate reported pt walking to bathroom and tried to open door and lost balance and fell . Landed on left side. Hematoma (collection of blood outside of a blood vessel)...L cheek. Laceration...left side of face...Pt removed bed alarm...sent to (hospital) for evaluation..." Medical record review of the resident's Treatment Record for the month of April, 2013, revealed, "...order date 10/01/2012 sensory bed pad alarm installed d/t (due to) fall risk..." Further review of the resident's Treatment Record revealed no documentation the resident had a personal alarm, and no documentation for monitoring placement or functioning of sensory pad alarm. Medical record review of a Radiology Report dated April 4, 2013, revealed, "...very subtle cortical breaks are present in the distal radius, suspicious for nondisplaced fractures...Conclusion: suspicious for left distal radius fractures..." Medical record review of the Physician's Progress Notes dated April 9, 2013, revealed, "...Had swelling (L) (left) wrist X-ray showed severe osteopenia (low bone density) possible fx (fracture) with 'cortical breaks seen' splint applied..." Continued review of the Physician's Progress Notes dated April 9, 2013, revealed, "...(L) wrist tender Imp (impression) (L) wrist fx..." Medical record review of the resident's care plan updated April 4, 2013, revealed, "...At risk for Musculoskeletal Problems related to Fracture (specify location) Left wrist..." Interview with Certified Nurse Assistant (CNA) #1 on April 24, 2013, at 1:21 p.m., in the 200 Hallway, confirmed the resident had a history of [REDACTED]. Interview with CNA #2 on April 24, 2013, at 1:25 p.m., in the 200 Hallway, confirmed the resident had a history of [REDACTED]. Interview with Registered Nurse (RN) #1 on April 25, 2013, at 8:25 a.m., in the Nurse's Station, confirmed the RN did not hear alarms sounding at the time of the resident's fall on April 4, 2013. Interview with CNA #2 on April 25, 2013, at 8:33 a.m., in the 200 Hallway, confirmed the CNA was working on on April 4, 2013, at the time of the resident's fall and did not hear alarms sounding at the time of the fall. Interview with the Director of Nursing (DON), and the Staff Development Nurse on April 25, 2013, at 8:00 a.m., in Nursing Administration Office, confirmed the resident had a history of [REDACTED]. on November 16, 2012, December 18, 2012, February 25, 2013, and April 4, 2013. Continued interview with the DON and the Staff Development Nurse confirmed the facility was not monitoring the placement or functional status of the resident's sensory pad alarm or personal alarm to prevent falls.