Every finding on record at Fairway Oaks Center

Based on record reviews and interviews the facility failed to maintain complete and accurately documented medical records for one (#2) of four sampled residents related to not completing the Admission/readmission evaluation in a timely manner, not completing a daily note for a resident receiving specialized services and skilled nursing. Findings included: Review of Resident #2s admission Record showed the resident was admitted on [DATE] with diagnoses not limited to other artificial openings of urinary tract status, retroperitoneal fibrosis, stage 4 (severe) chronic kidney disease, unsteadiness on feet (for therapy use), generalized muscle weakness (for therapy use), need for assistance with personal care (for therapy use), and oropharyngeal phase dysphagia (for therapy use). Review of Resident #2s assessments showed an Admission/readmission Nursing Evaluation, dated 1/30/26 at 5:41 p.m. was not completed and locked. The documentation showed sections a, l and n were unsigned by staff member. Section a (A) did not include information on how the resident was transferred to the facility (stretcher, wheelchair, (or) ambulatory), if the resident had weight bearing restrictions (yes or no), and did not document the presence of a nephrostomy tube. Section l (L) showed the staff had not evaluated the resident for a mechanical lift or if the resident could stand, pivot or transfer with no or limited assistance from staff. Section n (N) showed a medications were not reviewed and verified. Review of Resident #2s available assessments revealed the Daily Skilled Note assessment had not been accessed and/or completed for the resident. Review of Resident #2s progress notes did not reveal an admission note had been completed for the resident. The nursing progress notes included:-1/30/26 at 7:35 p.m. a general note showed Pt (patient) skin was checked pt has skin concern on coccyx. Pt emergency contact was notified that pt is at facility. (first note)- 1/31/26 at 8:49 a.m. electronic Medication Administration Record (eMAR) note showing the resident received pain medication. A follow up to the effectiveness was completed at 6:03 p.m.- 1/31/26 at 10:44 p.m. eMAR note revealed resident was administered pain medication for generalized pain with effectiveness documented on 2/1/26 at 5:39 a.m.- 2/1/26 at 8:32 p.m. eMar note revealed the administration of pain medication with effectiveness documented on 2/1/26 at 9:04 p.m.-2/2/26 at 1:04 a.m. an eMAR note showed the resident was administered pain medication and the effectiveness was documented on 2/2/26 at 6:14 a.m.- 2/2/26 at 9:34 a.m. an eMAR note showed the resident was administered pain medication and the effectiveness was documented on 2/2/26 at 3:46 p.m.- 2/2/26 at 2:24 p.m. a Skin/Wound note, Second skin check; scar tissue to sacrum, surgical site to right flank; minimal serous drainage - tx (treatment) in place. Scar tissue to abdomen.- 2/3/26 at 5:57 a.m. an eMAR revealed the resident was administered pain medication.- 2/3/26 at 6:02 a.m. an eMAR note related to a dressing change revealed pt was in pain and needed her pain med before.- 2/3/26 at 4:53 p.m. an eMAR note showed the pain medication was effective.- 2/3/26 at 8:43 p.m. an eMAR note showed topical pain ointment had been applied.- 2/3/26 at 9:21 p.m. an eMar note revealed the resident had received oral pain medication and the effectiveness was documented on 2/3/26 at 10:13 p.m.- 2/4/26 revealed no eMAR notes or other progress notes had been written by nursing regarding the wellbeing of Resident #2.- 2/5/26 at 4:18 a.m. an eMAR note revealed the resident was administered oral pain medication and the effectiveness was documented on 2/5/26 at 5:38 p.m.- 2/5/26 5:59 a.m. an eMAR note showed a dressing change treatment was completed for the resident.- 2/5/26 at 7:59 p.m. an eMAR note revealed the resident was administered oral pain medication and the effectiveness was documented on 2/5/26 at 8:45 p.m.- 2/6/26 at 5:39 a.m. an eMAR note revealed the resident was administered oral pain medication and the effectiveness was documented on 2/6/26 at 7:11 p.m.- a late entry note was documented on 2/7/26 for 2/6/26 at 9:30 a.m. revealing the nurse had been notified by administrative staff to report to the resident's room. The resident did not appear to be in respiratory distress with a family friend at bedside and family member on the phone. The family friend had informed the daughter the resident did not look well and the daughter wanted the resident go to the hospital with other concerns. Emergency Medical Services (EMS) arrived prior to staff being able to obtain vital signs. The review showed nursing staff had documented one general note regarding the resident had an issue on sacral area and the emergency contact had been notified of the resident's arrival at the facility on 1/30, one skin/wound note on 2/2/26 showed the presence of a surgical site, and one late entry note for 2/6/26 regarding the family member requesting the resident be transferred to the hospital, all other notes were regarding the administration of oral and topical pain medications. An interview was conducted on 2/21/26 at 11:31 a.m. with the Director of Rehab (DoR). The DoR stated Resident #2 had come to the facility for fatigue and hematuria and had received both physical and occupational therapy. The DoR stated the resident was treated in the resident's room as the resident had refused to go to the gym. The DoR stated physical therapy had done exercises with the resident on 2/5/26 till the pain level had increased and the resident had refused to sit on the side of the bed. The DoR stated Resident #2s evaluation showed the resident was status post nephrostomy placement. An interview was conducted on 2/21/26 at 1:19 p.m. with the Assistant Director of Nursing (ADON). The ADON stated Resident #2 was skilled so there should have been daily skilled charting notes. An interview was conducted on 2/21/26 at 12:07 p.m. with Staff C, Licensed Practical Nurse (LPN). The staff member stated Resident #2s name sounded familiar but couldn't picture the face. Staff C reviewed the resident's chart and reported not being able to tell anything specific regarding the resident. On 2/21/26 at 1:56 p.m. Staff C reported doing daily skilled assessments for all skilled residents. During an interview on 2/21/26 at 2:23 p.m. the Nursing Home Administrator (NHA) reviewed Resident #2s Admission/readmission Evaluation and stated no it was not completed. A review was conducted of the resident's other assessments and progress notes. The NHA stated there were not any daily skilled notes and the only nursing note was on 2/6/26 showing the resident had left and it was a late entry. An interview was conducted on 2/21/26 at 2:42 p.m. with the Interim Director of Nursing (DON). She stated staff should be doing daily skilled notes. Review of policy - Documentation Medical Records, revised 01/2026, revealed Services provided to the residents shall be documented in the resident's medical record. The medical records should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record: a) objective observations. b) Medications administered. c) Treatments or services performed. d) changes in the resident's condition. e) care provided.3. Documentation in the medical record is required as updates/ changes in the residence plan of care is made.4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.8. Documentation of procedures and treatments will include care-specific details, including: a) the date and time the procedure/ treatment was provided; b) the name and title of the individual(s) who provided the care;c) the assessment data and/ or any unusual findings obtained during the procedure/ treatment. d) Whether the resident refused the procedure/ treatment; The facility did not provide a policy specific to completing an admission assessment and/or completing daily skilled notes.

Based on observations interviews and record review, the facility failed to ensure dependent residents received assistance with showers for three residents (#4, #3 and #2) out of four residents reviewed.Findings included: 1. During a facility tour on 2/21/2026 at 9:40 a.m., Resident #4 was observed in her room. The resident stated had not had a shower since she was admitted to this facility. She stated she had been assisted with one bed bath, upon admission, not sure exactly. Review of Resident #4's admission record revealed the resident was admitted on [DATE] with diagnoses to include hypertensive heart disease without heart failure, unsteadiness of the feet, other gait abnormalities, need for assistance with personal care and blindness of left eye. Review of a Minimum Data Set (MDS) for Resident #4 dated 2/8/2026 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 meaning the resident was cognitively intact. Review of the Certified Nursing Assistant (CNA) task log for showers revealed there was no documentation to show the resident had received assistance with showers or baths for 13 days. 2. On 2/21/2026 at 10:02 a.m. an interview was conducted with Resident #3 observed in her room, noted scratching and itching her arms and upper body. Her skin was observed scaly with dry, rough, and large fishlike flakes. The resident stated she was supposed to see a dermatologist, but it had not been scheduled. She stated her family member had discussed this with the facility the previous Friday , on 2/13/2026. she stated she was applying regular store lotion, and it was not helping. The resident stated she had struggled with receiving assistance with showers. Resident #3 said, sometimes they just don't want to help you. The resident stated having filed a grievance that remained unresolved. She stated they, Just wash me up, late at night. The resident stated she wanted to shower. Review of Resident #3's admission record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include morbid (severe) obesity due to excess calories, Type 2 diabetes, unspecified kidney failure. Review of an MDS for Resident #3 dated 11/25/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, meaning the resident was cognitively intact. Review of a care plan for Resident #3 initiated 5/23/2024 revealed an ADLs self-care deficit r/t (related to)ADL needs. Participation varied due to chronic medical conditions, fatigue, impaired balance, and limited mobility. Interventions included to encourage and assist with ADL tasks including . bathing. Bathing – the resident is dependent on staff for bathing needs including transfer into and out of the shower. Review of the CNA task log for shower/bathing for the month of February 2026 revealed a shower/bathing schedule of Monday, Wednesday and Saturday evening on 3p.m. to 11p.m. shifts. The review showed the same time stamp was entered for all CNA task log. An interview with Staff A, CNA revealed that meant it was when the documentation was completed, not necessarily when the task was completed. Review of a grievance form for Resident #3 dated 2/11/2026 showed detail of complaint was, concerns regarding showers. The grievance official follow up documented CNA provided ADL care and gave resident a shower hair was washed, and nail care was performed. Resident satisfied with outcome no further concerns. The grievance was marked resolved on 2/13/2026. There were no other documents attached to include education or staff training. On 2/21/2026 at 12:35 p.m. an interview with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM). She stated Resident #3's family member was concerned about showers. She said, I followed up, I do not remember the day. I reviewed the book and saw she had not been showered. We gave her a shower. The LPN stated she thought the issue was resolved. She stated she had not heard the resident still had issues. On 2/21/2026 at 12:30 p.m. an interview was conducted with Staff A, CNA. Staff A stated Resident #4 was supposed to shower twice a week or as requested. She reviewed the showers binder and there were no shower sheets for this resident. She stated, It should be documented, I don't know why. On 2/21/2026 at 12:45 p.m. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated if the resident refused the shower, the CNAs should let the nurse know and if it was on-going IDT (interdisciplinary team) should be notified. The care plan should reflect refusals. The ADON stated Resident #4 was scheduled to shower today. She stated the shower logs or task logs should be documented. The ADON reviewed the electronic medical record and shower sheets and did not see anything documented. The ADON said it should be documented unless, it is her preference not to shower at all. During an interview on 2/21/2026 at 2:41 p.m., the interim Director of Nursing (DON) stated there should be shower sheets for the residents' showers and there should be documentation in the CNAs task log. The DON stated there should be documentation if the resident refuses. It should be documented that the nurse followed up if the CNAs reported concerns. Review of a care plan initiated on 2/9/2026 revealed an ADL focus, [Resident #4] has an ADL deficit r/t (related to) ADL needs and participation vary, fatigue, and chronic medical conditions. Interventions included to encourage and Educate resident with increased Independence as tolerated and assist with all ADL (activities of daily living) tasks as indicated, including .bathing, . personal/oral hygiene. Observe resident for changes in ADL capabilities. Notify nurse, therapy, and/or MD [medical director] as indicated. Bathing : The resident needs assist limited to extensive of 1-2 based on fatigue, weightbearing, weakness. 3. Review of Resident #2's showering/bathing schedule showed the resident was to receive assistance with bathing on Tuesday and Fridays during the 3 p.m. -11:00 p.m. The review revealed the resident received one shower on 2/6/26 out of three opportunities. The task documentation did not reveal the resident had refused bathing from 1/30 – 2/6/26. Review of Resident #2's admission Record revealed the resident was admitted on Friday 1/30/26. The Admission/readmission evaluation showed vital signs had been obtained on 1/30/26 at 4:38 p.m. The evaluation showed the resident required extensive assistance with bed mobility, was dependent upon staff assistance for toileting and transferring. Review of Resident #2's care plan showed the resident had a potential for Activities of Daily Living (ADL) self-care deficit related to ADL needs and participation vary, fatigue, (and) chronic medical conditions. The interventions showed the resident needs assist limited to extensive of 1-2 based on fatigue, weightbearing, and weakness for bathing. During an interview on 2/21/26 at 1:19 p.m. the Assistant Director of Nursing (ADON) state residents are scheduled for showering twice a week and per preference but at least twice a week. Review of a facility policy titled, ADL care and Services, revised 01/2024 revealed a standard- Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living ADL's. Guideline: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with, including but not limited to: (a.) hygiene bathing showers dressing grooming nail care oral care.

Based on observations, interviews and record review, the facility failed to ensure outside resources were available for two residents (#4 and #3) out of two residents sampled, related to podiatry visit for Resident #4, and dermatology services for Resident #3.Findings included: 1. During a facility tour on 2/21/2026 at 9:40 a.m., Resident #4 was observed in her room. The resident stated she had notified the nurse she had long nails and she was not able to cut them herself. She stated they were uncomfortable but not painful. Resident #4 stated the nurse said she would see a podiatrist.Review of Resident #4's admission record revealed the resident was admitted on [DATE] with diagnoses to include hypertensive heart disease without heart failure, unsteadiness of the feet, other gait abnormalities, need for assistance with personal care and blindness of left eye. Review of a Minimum Data Set (MDS) for Resident #4 dated 2/8/2026 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, meaning the resident was cognitively intact.Review of a nursing progress note for Resident #4 dated 2/16/2026 revealed, Resident nails are very long. Resident needs a referral to a podiatrist.Further review of Resident #4's medical record did not show further follow up regarding the podiatrist referral.Review of a podiatry facility visit list dated 2/18/2026 revealed resident #4's name was not on the list.On 2/21/2026 at 3:47 p.m. an interview was conducted with the Social Services Director (SSD). She stated the nursing staff would let her know if a resident needed to be seen and then she puts them on the list. She stated the doctor was here last week. The SSD reviewed the progress note dated 2/16/2026 and stated the resident would have made the list. She said the nurse should have notified the Assistant Director of Nursing (ADON) or Director of Nursing (DON) to let her know to add the resident to the list.During an interview on 2/21/2026 at 3:52 p.m., the interim (DON) stated podiatry comes to the facility monthly. The DON stated they tell the SSD if anyone needed to be seen. She stated there was no reason why she would not have been seen. She said the nurse should have notified them to add her name to the list. The DON said, That is a learning opportunity. We will educate the nurses.2. On 2/21/2026 at 10:02 a.m. an observation and interview was conducted with Resident #3. The resident was observed in her room in bed, noted scratching and itching her arms and upper body. Her skin was observed scaly with dry, rough, and small fishlike flakes. The resident stated she was supposed to see a dermatologist, but it had not been scheduled. She stated her family member had discussed this with the facility the previous Friday on 2/13/2026. She stated she was applying regular store lotion, and it was not helping. Resident #3 stated her itching had increased and no one had said anything. The resident said, It's getting worse.Review of Resident #3's admission record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include morbid (severe) obesity due to excess calories, Type 2 diabetes, unspecified kidney failure. Review of an MDS for Resident #3 dated 11/25/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, meaning the resident was cognitively intact.Review of current physician orders for Resident #3, dated 2/21/2026 revealed the following orders:Dermatology consultation, itching body, dated 2/11/2026.Follow -up with Dermatology, dated 2/20/26.Ammonium Lactate External lotion 12% (Lactic Acid Ammonium Lactate) apply to lower/upper extremities topically two times a day for dry skin, ordered 2/6/2026.Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dates 1/1/2026 to 2/7/2026 revealed Resident #4 was not receiving any treatment for the on-going itching condition.Review of a care plan for Resident #3 revealed a focus - the resident is at risk for skin impairment related to anemia, diabetes, incontinence, use of anticoagulant/antiplatelet medications, and weakness/decreased mobility. Interventions included monitor/observe skin while providing routine care. Notify nurse of any area of concern as indicated. Preventative skin treatments as ordered/indicated, as tolerated by resident. Skin checks weekly and as indicated. Report any s/s (signs/symptoms) of skin breakdown to MD (Medical Doctor)/wound team as indicated.On 2/21/2026 at 2:29 p.m. an interview was conducted with the Social Services Director (SSD). The SSD stated dermatology appointments were scheduled by nursing. She said she had not heard of any concerns or that Resident #3 needed to be seen. The SSD stated if it would have been mentioned, she would have reached out and assisted if needed. The SSD stated she was not aware of any skin concerns for this resident. The SSD stated not having been notified of the family member's concerns the previous Friday. She stated a grievance would have been initiated.On 2/21/2026 at12:35 p.m. an interview with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) revealed having visited the resident to investigate a grievance related to showers. She stated while there, I saw she has dry skin. I am not sure what the orders are, but she had some lotion on her bedside table which I applied. Staff B stated she did not review her orders to see if she was being seen by a dermatologist. Staff B said she could check. The staff member confirmed the resident had very dry, itchy, skin and was probably on the list to be seen by the in-house dermatologist. Staff B said, I have to look to see if she was seen by the in-house dermatologist. She stated it would be documented in the binder at the nurse's station.On 2/21/2026 at 12:41 p.m., review of the binder at the nurse's station with Staff B, LPN showed Resident #3 was scheduled to be seen on 2/19/2026, however there were no other entries to confirm if the appointment occurred. She stated she could not confirm if the resident was seen or not. She stated she would reach out to the dermatologist office.On 2/21/2026 at 1:33 p.m. an interview was conducted with the Assistant Director of Nursing (ADON). She stated not being aware of skin issues for Resident #3.During an interview on 2/21/2026 at 2:41 p.m., the interim Director of Nursing (DON) stated Resident #3 had on-going skin issues which had been long lasting. She stated she would have to check if the resident was frequently followed by the dermatologist. She stated if there were renewed issues, the physician would be notified, and it would be documented. She stated dermatology notes would be scanned in the resident's record.Review of the record showed there were no documented visits or physician notes. A follow - up was conducted with Staff B, LPN on 2/21/2026 at 2:50 p.m. Staff B stated she had reached out to the dermatologist and produced an encounter note dated 1/13/2026. Staff B stated there were no other notes.Review of a facility policy titled, Consults, Revised 01/2024 revealed - Social Services personnel shall coordinate most resident referrals with contracted providers or external agencies as indicated.Guideline:1. Social Services shall coordinate most resident referrals (i.e. podiatry, dental, vision, etc.). Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff.2. Referrals for medical services should be based on physician evaluation of resident need and a related physician order.3. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.4. Social services will document the referral in the resident's medical record.5. Social services and administration will maintain a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs.6. Social services will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate.

Based on record reviews and interviews the facility failed to ensure one (#2) of four residents received treatment and care in accordance with professional standards of nursing, physician orders, and person-centered care plan.Findings included: Review of Resident #2's February Medication Administration Record revealed an order dated 1/30/26 instructing staff to obtain vital signs every shift for 5 days. The order ended after vital signs had been obtained on the 3 p.m. - 11 p.m. shift on 2/4/26. The review revealed the following blood pressure (bp), temperature (temp), pulse, respiration (resp), and 02 saturation (sat):2/1/26 7:00 a.m. - 3:00 p.m.: bp 115/62, temp 97.8, pulse 85, resp 20, and O2 sat 97%.2/1/26 3:00 p.m. - 11:00 p.m.: bp 115/62, temp 97.8, pulse 85, resp 20, and O2 sat 97%.2/1/26 11:00 p.m. - 7:00 a.m.: bp 121/67, temp 98, pulse 78, resp 18, O2 sat 98%.2/2/26 3:00 p.m. - 11:00 p.m.: bp 121/67, temp 98, pulse 78, resp 18, O2 sat 98%.2/3/26 3:00 p.m. - 11:00 p.m.: bp 119/88, temp 98.3, pulse 60, resp 19, O2 sat 99%.2/3/26 11:00 p.m. - 7: 00 a.m.: bp 119/88, temp 98.3, pulse 60, resp 19, O2 sat 99%.The record showed staff had documented Resident #2's vital signs were identical on two consecutive shifts on 2/1, identical on the night shift on 2/1 and the afternoon shift on 2/2, and on two consecutive shifts on 2/3/26. Review of Resident #2's care plan revealed the resident had altered cardiovascular status related to hypertension (htn). The interventions included instructions for staff to Monitor VITAL SIGNS/weights as ordered/as needed (PRN). Notify Md of significant abnormalities/changes as ordered/indicated. Review of Resident #2's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to retroperitoneal fibrosis, unspecified chronic obstructive pulmonary disease, stage 4 (severe) chronic kidney disease, unspecified anemia, atrophy of kidney (terminal), and primary hyperparathyroidism. An interview was conducted on 2/21/26 at 1:58 p.m. the Assistant Director of Nursing (ADON) reviewed Resident #2's vital sign summary and confirmed blood pressures were missing, then reviewed the resident's vital signs documented on MAR. The ADON did not reveal how likely it was to have identical vital signs on multiple shifts but did say blood pressure could rise with pain. During an interview on 2/21/26 at 2:23 p.m. the Nursing Home Administrator viewed the vital summary and confirmed missing blood pressures for Resident #2. A review of the MAR was conducted and the NHA stated it was rare for a resident to have the same vital signs on different shifts. During an interview on 2/21/26 at 2:42 p.m. the Interim Director of Nursing (DON) stated she wouldn't say it was impossible but. (regarding identical vital signs over different shifts). Review of the policy - Documentation Medical Records, revised 01/2026, showed Services provided to the residents shall be documented in the resident's medical record. Their medical records should facilitate communication between the interdisciplinary team regarding the resident's condition in response to care.4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview and record review, the facility failed to provide activities of daily living (ADLs) related to grooming and personal hygiene care for three dependent residents (#4, #6, and #7) out of three sampled residents. Findings included:Review of Resident #4 admission Record revealed an admission to the facility on [DATE] with medical diagnoses of bullous pemphigoid, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, adult failure to thrive, muscle weakness and other reduced mobility.An interview was conducted on 11/20/2025 at 9:50 am via telephone with Resident #4's family member (fm). The fm stated having raised concerns and spoke with staff at the facility about Resident #4's overgrown fingernails and residents' nails not being cut down. A grievance was filed by Resident #4's family member 7/7/2025 with the facility regarding concerns with ADL care and Resident #4's nails. The facility noted in the grievance follow-up that nails and shower were done on 7/8/25.Review of Resident # 4's Quarterly Minimum Data Set (MDS) dated [DATE], section titled, Cognitive Patterns revealed resident was rarely understood. The assessment revealed Resident #4 was severely impaired. Resident #4 was dependent for toileting hygiene, and shower/bathe care.Review of Resident #4's care plan revealed no documentation for Resident #4 needing assistance with nail trimming/care. The care plan revealed Resident #4 was dependent on staff for bathing needs.On 11/20/2025, at 3:15 p.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B stated they did not cut the residents' nails, but they cleaned them. Staff B stated CNAs are not allowed to trim resident's nails. Staff B stated that CNAs document showers and nail care on the specific resident's shower sheet. Staff B stated the residents are showered at least twice a week. Staff B stated if an unplanned event occurred and the resident requires a shower on a non-shower day, then the resident would be showered.2. During an observation and interview on 11/20/2025, at 10:40 a.m., Resident #6 was observed lying in bed on clean bed linen and wearing a clean gown, disheveled in appearance and overgrown fingernails. Resident #6 stated, concern about overgrown fingernails. Resident #6 stated preferring short fingernails. Resident #6 stated previously addressing this with staff but that no one had come to trim them down. Resident #6's fingernails were observed to be long, with dirt underneath the nails.Review of Resident #6's admission Record revealed resident was admitted to the facility on [DATE] with medical diagnoses of osteomyelitis of vertebra, lumbar region, muscle weakness, muscle wasting and atrophy, intraspinal abscess and granuloma, repeated falls.Review of Resident #6's Quarterly MDS dated [DATE], Section GG revealed Resident #6 is dependent for toileting hygiene and requires substantial/max assistance for shower/bathe care.Review of Resident #6's care plan did not reveal documentation of the resident needing assistance for nail care. An interview was conducted on 11/20/2025, at 2:50 p.m., with Staff C, CNA. Staff C stated they trim residents' nails once a week on bath days. Staff C stated they usually bathe residents two to three times a week at residents' request. She stated the nails are trimmed/cleaned during shower days.Review of Resident #6's shower sheets for the month of November 2025 revealed the following:On 11/6/25 Resident #6 did not receive a shower. There is no documentation of nails being trimmed/cleaned. Resident #6 received a bed bath. Under nails being trimmed/cleaned, it was documented the resident refused.On 11/13/25 Resident #6 did not receive a shower. There is no documentation of nails being trimmed/cleaned.3. During an observation and interview on 11/20/2025, at 11:07 a.m., Resident #7 was observed lying in bed, disheveled in appearance and overgrown fingernails. Resident #7 stated concerns about having overgrown fingernails and that preferred to have nails that are a lot shorter. The fingernails were observed to be long and with dirt underneath the nails. Resident #7 stated having previously addressing this with the facility staff, but no one had come to trim them. Resident #7 stated in the past there was someone who came regularly to conduct nail trimming but Resident #7 had not seen them in a very long time.Review of Resident #7's admission Record revealed the resident was initially admitted to the facility on [DATE] with medical diagnoses of unspecified atrial fibrillation, muscle weakness, muscle wasting and atrophy, and difficulty walking.Review of Resident #7's Quarterly MDS dated [DATE], revealed Resident #7 is dependent for toileting hygiene, and requires substantial/max assistance for shower/bathe care.Review of Resident #7's shower sheets for the month of October and November 2025 revealed the following:On 10/18/25, 10/23/25, 10/27/25, and 10/30/25, Resident #7 received a bed bath. There is no documentation of nails being trimmed/cleaned.On 11/3/25, 11/6/25, 11/11/25, 11/13/25, and 11/17/25 Resident #7 received a bed bath. There is no documentation of nails being trimmed/cleaned.An interview was conducted on 11/20/2025, at 12:25 p.m., with Staff D, CNA who stated the residents do not have a specific timeframe to ensure nails are cut due to how fast the residents' nails grow. Staff D stated not everyone's nails grow at the same rate. Staff D stated she bathed the residents that are assigned to them. Staff D did not address nail care concerns for the residents she bathed.An interview was conducted on 11/20/2025, at 3:40 p.m., with Staff A, Registered Nurse/Unit Manager (RN/UM). She stated the process to trim residents' nails was to consider if the patient was diabetic, which must be done by podiatry, but if they are not diabetic, the staff cuts the residents' nails. Staff A stated the staff members are required to check residents' nails when they are performing care or at least once a week.A review of the facility's policy titled ADL care dated 4/2020 stated their standard was that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Guideline that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure is that residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) are met. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with, including but not limited to: Hygiene (bathing/showers, dressing, grooming, nail care, oral care); mobility( transfer, ambulation, wheelchair, splint/brace); elimination (toileting, catheter, ostomy); dining (meals, hydration, snacks); and communication (speech, language, and any functional communication system).

Based on record review, observations, and interviews the facility failed to maintain complete clinical records for one resident (#5) of five sampled residents which were accurately documented, readily accessible, and systematically organized.Findings included:Review of Resident #5's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia following cerebral infarction, unspecified systemic lupus erythematosus, not having achieved remission myeloid leukemia, and need for assistance with personal care. The record showed the resident's family member was an emergency contact proxy.Review of Resident #5's 5-day Minimum Data Set (MDS), dated [DATE], showed the resident scored 3 of 15 on a Brief Interview of Mental Status (BIMS) indicating a severe cognitive impairment.Review of the facility incident log showed Resident #5 had falls on 10/15/25 at 11:30 a.m. and 10/22/25 at 4:00 a.m.A record review of Resident #5 revealed the resident was discharged to the community with a family member on 11/3/25.Review of Resident #5's Situation, Background, Appearance, and Review/Notify (SBAR) summary effective 10/15/25 at 12:47 p.m. showed the resident had suffered a fall with no changes observed in mental status and functional status was fall. The nursing observations, evaluation, and recommendation were Patient was observed on the floor. The recommendation from the primary care provider was to Initiate Neuro Checks and monitor for further changes. The note did not reveal any further information on the resident's fall or if the family member had been notified of the incident.Review of Resident #5's progress notes for 10/15/25 included:- Advance Directive follow up note, effective 10/15/25 at 1:29 p.m. revealed pt was observed on the floor. no new injury noted will continue to monitor. No note did not contain any further documentation.- Fall Evaluation, effective 10/15/25 at 1:30 p.m. revealed the resident was re-oriented to the call light and the fall risk evaluation was reviewed, and education was provided with the resident. The outcome of the education provided was unsuccessful.- A late entry SBAR effective 10/15/25 at 5:31 p.m. revealed the resident had a fall and did not show either the primary care provider or family member was notified.- No progress note on 10/15/25 showed the emergency contact or proxy of Resident #5 had been notified of the fall.Review of Resident #5's electronic record did not include documentation of the neuro checks recommended by the physician after the resident's fall on 10/15/25.Review of an Interdisciplinary note (IDT), effective 10/16/25 at 9:45 a.m. showed Resident #5's fall was reviewed with the IDT. The facility-initiated use of a communication board due to expressive aphasia and slurred speech. The note did not contain any other information regarding where the resident fell, was the fall witnessed or unwitnessed, who found the resident, or how the resident was found.Review of Resident #5's change in condition progress note, effective 10/22/25, at 6:51 a.m. showed the change in condition was Falls. The blood pressure, pulse, respiration rate, temperature, and pulse oximetry was taken on 10/22/25, at 4:00 a.m. The nursing observations, evaluation, and recommendations were Patient able to communexpesionicate with body and facial expression. The note showed the physician was called with no answer and a message was left. The note did not show the emergency contact/proxy was notified of the fall.Review of Resident #5's SBAR evaluation showed a fall had occurred on 10/22/25 and the condition, symptom, or sign had not occurred before. The evaluation showed the physician was notified on 10/22/25, at 6:45 a.m. with other recommendations which did not describe other. The nursing note for additional information was blank and did not describe the resident's fall. The evaluation showed the emergency contact/proxy was notified 10/29/25, at 6:43 a.m. (7 days after the incident).Review of Resident #5's IDT note, 10/22/25 at 9:18 a.m. showed the resident's fall was reviewed and no injury was noted. The resident was to be assisted with toileting upon rising, before and after meals, and at bedtime. The note did not reveal any specific details on the resident's fall.Review of Resident #5's progress notes showed on 10/22/25 at 2:46 p.m. the nurse called the emergency contact regarding of a clinical situation. The notes showed on 10/22/25 at 1:47 p.m. a Certified Nursing Assistant (CNA) had called the nurse to the resident's room to alarm the nurse of a bruise on right hip and due to facial expression of minor distress x-ray of right hip was ordered.An interview was conducted with the Director of Nursing (DON) on 11/20/25 at 12:35 p.m. The DON stated the facility did not have hard (physical) charts, everything was uploaded unless the document was in Medical Records waiting to be uploaded. The interview was in response to the request for Resident #5's neuro check evaluations from 10/15/25.An interview and observation was conducted on 11/20/25, at 1:05 p.m. with the Nursing Home Administrator (NHA) of the Medical Records office. The NHA reported Medical Records clerk works from 5 p.m. to 9 p.m. The observation showed multiple stacks of resident(s) documentation on file cabinets, boxes, and desks. The stacks ranged from a couple of inches in height, to approximately 18 inches. The NHA acknowledged the multitude stacks of documentation inside the Medical Records office, and the documents need to be uploaded to specific resident(s) accordingly.An interview was conducted with the DON and Assistant DON (ADON) on 11/20/25, at 3:18 p.m. The DON acknowledged Resident #5 had a few falls which were discussed in the Utilization Review meeting. The DON stated staff were to document a change in condition note (regarding fall) and notify the physician and family. The note should include what happened and where the resident was found. The DON reviewed the progress notes from 10/15/25 and confirmed family had not been notified of the fall and the change in condition note described the resident had been found on floor. The DON reported on 10/22/25 the resident had been found unclothed on floor in room. The DON reviewed progress notes and confirmed the note did not reveal any of the information regarding the fall nor that the family had been notified. The DON stated she had the neuro check evaluations (from 10/15 fall) on her desk. A request was made to receive the neuro check evaluations. An interview was conducted with the NHA on 11/20/25 at approximately 5:30 p.m. The NHA stated they were looking for Resident #5's neuro check evaluations in the Medical Record office, and the writer knew the condition of the office. The NHA stated it looked like a paper tornado in the medical records office. The facility was unable to produce the neuro check evaluations as requested prior to the survey exit.Review of the policy titled Change in Resident Condition or Status-Resident Rights, revised 6/2023, revealed: Facility shall notify the resident, his or her attending physician, and representative of changes in the residence medical/ mental condition and/ or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Guideline: To Ensure the facility provides timely notification in accordance with State and Federal Regulations as it pertains to residents' rights. Procedure: . 5. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of the policy titled Documentation, revised 1/2024, revealed: Guideline: Services provided to the resident shall be documented in the residence medical record. The medical record shall facilitate communication between the interdisciplinary team regarding the residence condition and response to care. Procedure: . 2. The following information was to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; . 4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 8. Documentation of procedures and treatments will include care-specific details, including: a. The date and time of procedure/ treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/ or any unusual findings obtained during the procedure/ treatment; d. Whether the resident refused the procedure/ treatment; e. Notification of family, physician, or other staff, if indicated; .

Based on interview and record review the facility failed to ensure the resident representative was notified prior to the resident's transfer for one resident (#2) of three residents reviewed for discharge.Findings Included: Review of Resident #2's Minimum Data Set (MDS), with a target date of 7/23/25, Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 00. This BIMS score indicated severe cognitive impairment. The resident's representative was a family member.On 11/20/2025 at 12:51 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated there is no discharge note or documentation notifying the representative. She said consent was not provided by the representative.On 11/20/2025 at 1:31 p.m., an interview was conducted with the NHA. He confirmed he does not have any paperwork showing the representative gave consent.Review of the Nursing Home Transfer and Discharge Notice with a notice date of 7/21/2025 and an effective date of 8/19/2025, revealed the form did not list the transfer location for the resident. The notice did not have the signature at the bottom of the page showing that the resident's representative signed before the resident was transferred to another facility.

Based on observation and interview, the facility failed to ensure two of two community shower rooms were cleaned and maintained. Findings included: On 09/08/2024 at 8:55 a.m. an observation was made of the community shower room at the end of the hall between the 100-200 rooms hallway. Entry into the shower room revealed the door to the shower room was not locked. Upon entry into the shower room an observation was made of spots of a brown substance on the floor in front of the sink vanity. Observation was made of spots of the same brown substance in the middle of the floor of the shower room and in the doorway which led into the stall with the toilet. A yellow dirty linen bin was observed inside of the shower room to the left of the door. The lid to the dirty linen bin was on the floor beside the bin. In the stall with the toilet a cabinet was observed on the wall and inside of the cabinet was a spray bottle with a label indicating it was a bottle filled with a cleaning solution. The cabinet had a lock on it, but the cabinet was not locked and a key for the cabinet was not observed. Two shower chairs were observed inside one of the three shower stalls. One of the shower chairs was observed to have a comb with hair in it laying on top of the chair seat. On the same chair there was a yellowish-brown substance on top of the chair seat to the right of the opening in the chair. Another shower chair was observed with a brown substance on top of the seat of the chair towards the back right side of the opening of the chair. An observation was made of the drain in one of the shower stalls showing hair in the drain and gauze with two pieces of tape attached. (Photographic Evidence Obtained) On 09/09/2024 at 8:20 a.m. an observation was made of the community shower room at the end of the hall between the 100-200 rooms hallway. Upon entry into the shower room an observation was made of spots of a brown substance in the middle of the floor of the shower room. An observation was made of the drain in one of the shower stalls showing hair in the drain. A shower chair was observed with a brown substance on top of the seat of the chair towards the back right side of the opening of the chair. An observation was made underneath the mat on top of the shower bed revealing spots of a reddish-brown substance on the mesh. (Photographic Evidence Obtained) On 09/09/2024 at 8:35 a.m. an observation was made of the community shower room located on the 400 rooms hallway. An observation was made underneath the mat on top of the shower bed revealing spots of a thick, odoriferous, brown-black substance on the mesh. (Photographic Evidence Obtained) During an interview on 09/10/2024 at 10:12 a.m. with Staff P, Housekeeper, she said the Certified Nursing Assistants (CNA) were supposed to clean up the shower area after they gave resident showers. Housekeeping was responsible for cleaning floors, disinfecting, and cleaning the shower area on their usual cleaning rounds. The CNA's were responsible for cleaning in between routine housekeeping cleanings. An interview was conducted with Staff M, Housekeeping Supervisor and Staff N, Environmental Services Director on 09/10/2024 at 12:06 p.m. Staff M said the housekeeping responsibilities of the shower rooms included disinfecting, general clean-up, spraying down the showers/walls/doors/handles/mirrors and vanities with the disinfectant and wiping the areas down. Staff M said the CNA's were responsible for disinfecting the entire shower room and the equipment after each resident shower. A spray disinfectant was supposed to be located in a locked cabinet in the toilet stall in each shower room. Staff N said housekeepers and the floor technicians deep cleaned all shower room equipment weekly which included pressure washing. The equipment should be cleaned and disinfected everyday by housekeeping. Staff N said the facility has four housekeepers working in the facility every day, including weekends, from 7:00 a.m. until 3:00 p.m. One of the four housekeepers worked from 8:00 a.m. until 4:30 p.m. Staff N said if the shower rooms got really dirty and the CNA's were really busy, staff could request housekeeping to return to the shower room to clean it again. Staff N said he was not aware the cabinet in the shower room on the 100-200 hall was not locked and did not have a key attached to it. Review of the policy titled Standards and Guidelines: Shower Room issued 10/2018 and revised 01/2024 showed: The facility will ensure that the shower rooms are cleaned and regularly maintained for the safe environment for residents and staff. The implementation portion of the policy included the following: 2. Remove Debris and Waste: Clear the shower room of any visible debris such as hair, soap scum and personal items. Empty trash bins and replace liners. Remove used towels, washcloths and bath mats for laundering. 3. Surface Cleaning: Shower Walls and Floors: Use a disinfectant cleaner to wipe down the shower walls, floor, and any seating areas. 5. Mopping the Floor: Sweep the floor to remove any loose dirt or debris. Mop the floor with a disinfectant solution, starting from the farthest point in the room and moving towards the door. 7. Inspection: Inspect the shower room for cleanliness. Report any issues to maintenance through the electronic maintenance request system.

Based on observation, interview, and record review, the facility failed to provide quality care and services according to standards of practice related to medication administration and skin care treatment for one (#45) of three residents reviewed for wound care. Finding included: During an observation made on 09/08/24 at 02:20 p.m., Resident #45 was observed lying down in bed dressed in a hospital grown from the morning until the late in the afternoon. Resident was trying to say something but was not able to communication. During an observation made on 09/09/2024 at 11:00 a.m., Resident #45 was observed lying down in bed dressed in his hospital grown. Resident #45 legs was observed with scabs leaking with yellow fluid on his right and left legs. During an interview on 09/10/2024 at 1:00 pm with Resident #45's representative, he stated [the resident] had been at the facility for a year. He was being seen by a vascular surgeon because the facility thought he could have cancer in his legs. He said the facility never followed back up on what was going on during the time he was seen by the surgeon. He stated the facility did not follow up with him regarding the resident's care. He was supposed to have an appointment with dermatology, but the facility did not make it right. He stated when [name of office] dermatology finally called him back, they told him they had to cancel his appointment and then they rescheduled the appointment for next year. He stated he did not know why [the resident] had to wait so long to been seen. He said [the resident] really needed to be seen by a skin doctor because his skin on his legs was really bad. Review of an Admission Record showed Resident #45 was admitted to the facility with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, psoriasis vulgaria, lymphedema, not elsewhere classified. Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Review of a care plan focus showed Resident #45 had a rash related to Psoriasis and stasis dermatitis, initiated and revised on 9/10/2024. Review of the care plan goals showed Resident #45 would have no complications from rash through the review date, initiated on 9/10/2024. Review of the care plan intervention showed administer medication as ordered by the Medical Doctor ( MD), initiated on 9/10/2024. Review of the Order summary showed an order for Otezla Oral Tablet Therapy pack 10 & 20 & 30 MG, give 1 tablet by mouth one time of day for psoriasis Follow started pack instruction. Further review of the EMAR (Electronic Medication Administration Record] showed on September 2nd, 4th, 5th 6th and 8th Otezla Oral tablet was code on 12 to indicate Medication on order from pharmacy. On September 9th the EMAR showed Staff V, Registered Nurse (RN) marked medication was administered to Resident #45 when it was verified not in stock. Review of the Treatment Administration Record ( TAR ) schedule for September showed an order for Fluocinolone Acetonide External Cream 0.01% (Fluocinolone Acetonide). Apply to Bilateral legs topically every day shift for stasis dermatitis. Further review of the EMAR showed Staff V signed off that she provided treatment on September 5th, 6th, and the 9th During an interview on 09/10/2024 at 2:00 pm. with Staff V, she stated she was not Resident 45's regular assigned nurse so she was not familiar with the resident's plan of care. She stated Resident #45 was not administered his oral medication Otezla today because it was not in stock. She reached out to pharmacy to have the resident's medication reordered. He was supposed to receive this medication for his legs. He was seen by the wound care nurse today, 09/10/2024, for treatments on his legs. Staff V stated when she observed the resident's legs today, she saw he had some drainage coming from his scabs on his legs but that was normal for what he had going on with his legs. She stated the wound care nurse was responsible for doing the resident's treatment. She stated that she signed off on the resident treatments and medication records even if she was not the person doing the resident treatments. She said she did it because she assumed the treatments were being done and they were not allowed to leave holes on the medication or treatment records. During an interview on 9/10/2024 at 2:30 p.m. with Staff EE, License Practical Nurse/Wound Care Nurse, she stated Resident #45 received Fluocinolone Acetonide External Cream applied on his legs by the floor nurses once a day. She reviewed the resident's treatment record and said that it showed Resident #45 was receiving his treatment once a day. She said Resident #45 was followed by wound care for his legs in the beginning of the year, but he was no longer seen by wound care. His wounds were closed at this time, and he was getting daily treatments done by his assigned nurse on day shift. During an interview on 09/10/2024 at 2:45 pm. with the Assistant Director of Nursing (ADON), she stated she heard that Staff V said she did not give Resident #45 his medication and that she signed off on his treatments even though she was not doing the treatments. She said, when it came to treatments, the nurse knew they were responsible for their own treatments on their residents. The wound care nurse was only responsible for wounds that were being followed by the wound care team. She said she would have to discuss this situation with the Director of Nurses. During an interview on 09/10/24 at 4:45 p.m., with The Director of Nurses (DON), he stated this morning when the nurse was doing her med pass, she was not able to find the Otezla for Psoriasis - A medication for Resident #45's skin condition. He said she needed to inform the physician and then contact the pharmacy. He said he could not answer why the resident's medication was not available. Normally when a medication was missing, they contacted the pharmacy and reorder. The resident was moved from one hall to another, and the resident's medication might not have followed him over. The expectation was that the nurse should have reordered the resident's medications before the medication was out. Staff V told him she placed the order to the pharmacy and notified the physician. When it came to the facility treatment process, treatments were done by the floor nurses. The floor nurses were responsible for signing off on their own treatments. The wound care nurse had a list of residents that she saw. The wound care nurse took care of the resident's wound dressing and not the treatments. Review of the facility policy titled, Standards and Guidelines: Physician Orders, Revised date 01/2024 showed Guidelines: Orders and administration of medication and treatment will be consistent with principles of safe and effective order writing.

Based on observation, staff interview, and record review, the facility failed to provide two (#76 and #82) of forty-six sampled residents with privacy during two of four days observed. Findings included: 1. On 9/8/2024 at 10:00 a.m., the 100 hall was toured and observed. The 100/200 hall was a very high trafficked hall where staff, residents and visitors pass through. The hall was busy with housekeeping staff, direct care staff, residents ambulating/self propelling, nurses and other departmental staff. Upon reaching Resident #76's room, it was observed her room door was all the way open and she was noted lying flat in bed, on top of the bed linen and with her head over bed approximately twenty-five degrees. Further observations revealed she was wearing a hospital gown. Resident #76's hospital gown was observed pulled up all the way to her waste and she was observed totally nude. There did not appear to be any clothing on the floor, bed, nor was there any evidence of any pull up briefs at or around the bed. Resident #76 resided in the (door) bed and both the door and the privacy curtain were opened all the way. Further observations revealed a male resident seated in a wheelchair, just across from Resident #76's door and was facing her. The resident was not interviewable, but he was positioned in such a way where he could see Resident #76. Also, various staff were observed walking by the Resident's room and none stopped to either close the door or assist her with re gowning or dressing. Resident #76 was observed from the hallway totally naked from the waste down from at least 10:00 a.m. through to 10:11 a.m. with no staff intervention. On 9/8/2024 at 10:12 a.m., Resident #76's room was again approached. She moved in bed in such a manner that when she turned and the gown dropped down and covered her genitals. The resident could not respond with specific answers. She was asked if she needed or wanted any privacy and she did not answer. She was asked if staff provide her privacy when in need and she did not answer. On 9/9/2024 at 8:30 a.m., Resident #76 was again noted in her room and lying upright in bed and lying on top of the bed linen. She was observed wearing a hospital gown and the gown was pulled up to her waste. Further observations revealed she was wearing an adult brief and could be observed from the hallway. The room door and the privacy curtain were both opened all the way. The resident was asked about her day and if she needed any staff to help her. She started to sing aloud in phrases that were not understandable. The hallway was observed with high traffic from staff and visitors as the resident could be seen unrobed from the hallway. The resident was observed from the hallway in this position from 8:30 a.m. through to 8:42 a.m. with no staff intervention. An unidentified staff member walked by the resident's room and went inside to pull the resident's gown down, so she was no longer exposed. On 9/11/2024 an interview with the Resident's assigned Certified Nursing Assistant (CNA) Staff H revealed Resident #76 had cognitive impairment and though she could answer some yes and no questions, she was not able to speak to her care and services. Staff H revealed if the resident was found or seen disrobed, staff should immediately provide her with privacy by either assisting to redress, or close the door so people passing the room could not see her. Staff H revealed the resident was usually assisted with dressing right at the beginning of 7-3 shift, or she might be assisted with dressing from staff on the previous shift. Review of Resident #76's medical record, diagnosis sheet, showed she had diagnoses to include but not limited to: Cerebral Infarction, Dementia, Epilepsy, Major Depression, Schizophrenia, and Heart Failure. Review of the medical record to include nurse progress notes dated 6/25/2024 a. 6/26/2024 15:59 Summary skilled - Resident alert and confused. Review of the nurse progress notes dated from 6/25/2024 through to 9/11/2024 did not have any documented evidence of Resident #76 disrobing or having a history of disrobing. Review of the current care plans with next review date 12/4/2024 revealed the following: 1. Risk for decreased safety and independence related to cognitive communication deficit secondary to CVA, with interventions in place 2. History of exhibiting the following behaviors: Chronic/frequent refusals of care and or services, Non compliant with medications. Can be physically aggressive to staff, refuses, weight at times, with interventions in place. Note: This care plan problem area did not indicate resident has a history of removing adult briefs. 3. Resident has impaired cognitive function/impaired thought process r/t diagnosis of dementia, disease process, with interventions in place 2. On 9/9/2024 at 6:50 a.m., Resident #82 was observed seated in her wheelchair at the nurses station. She was noted dressed for the day and well groomed. She had a blanket over her lap, legs, and pulled up to her neckline. She was pleasant to speak with and had a staff member next to her and was chatting with her. On 9/9/2024 at 7:11 a.m., Resident #82 was observed seated in her wheelchair positioned in the doorway halfway in her room and halfway in the hallway. All of a sudden the resident pulled up her top and removed it all the way by pulling it up and off her head. Resident #82 was completely nude from her waste up and could be seen by all staff and visitors that walked by this area. Residents entire chest was bare and exposed. Further observations in the room revealed a Personal Care Attendant (PCA) Staff C talking with Resident #82's roommate. Staff C was observed to see Resident #82 removing her shirt and she did not say anything to her at first. At 7:14 a.m.,' Staff C called out the resident's name and said; you need to put your shirt on. However, Resident #82 did not attempt to redress. At 7:16 a.m. instead of assisting Resident #82 back in the room and closing the door, she stood at the doorway and put Resident #82's shirt back on. During the time of 7:11 a.m. and 7:16 a.m. over ten various staff and residents had passed by the area when Resident #82 was exposed. Review of Resident #82's medical record, diagnosis sheet, revealed she was admitted to the facility with diagnoses to include but not limited to: Dementia, Major Depression, Anxiety, Insomnia. Review of the current Minimum Data Set (MDS) admission assessment, dated 6/12/2024 revealed a Cognition/Brief Interview Mental Status or BIMS score 9 of 15 which indicated moderately impaired cognition ; Behavior - documented as none exhibited; Mood - None documented as exhibited Review of the nurse progress notes dated from 6/5/2024 through to 9/11/2024 did not show any documentation to support Resident #82 had a history of removing articles of clothing. On 9/10/2024 at 12:20 p.m. an interview with Resident #82's responsible party, confirmed the resident had never exhibited behaviors of removing her clothing. She would hope that staff would respond quickly to redress her if that happened. On 9/11/2024 at 9:35 a.m. an interview with the 100/200 Unit Manager Staff G revealed she did hall rounds throughout the day and if she were to see a resident nude, disrobed or unclothed, she would respond immediately and provide the resident his/her privacy by pulling closed the privacy curtain, closing the door, and attempt to redress the resident. Staff G confirmed this should be an expectation from all staff in the building. Staff G revealed she knew of both Resident #76 and #82 and neither had a history of behaviors of taking off their clothes and disrobing. She revealed she would need to speak with the assigned care aides to see if this was that happened frequently. On 9/11/2024 at 12:10 p.m., the Nursing Home Administrator revealed they did not have a specific Privacy policy and procedure, but had a Resident Rights policy they follow related to resident privacy. The policy provided revealed; Resident Rights, with a last revision date of 1/2024. The policy stated; A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. The guideline section of the policy revealed; Employees shall treat all residents with kindness, respect and dignity. The procedure section of the policy revealed; 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence; b. Be treated with respect, kindness, and dignity.

Based on observation, interview and record review, the facility failed to provide indwelling urinary catheter care and services to prevent leakage and breaks in tubing for two (#82 and #13) of ten sampled residents during two of two days observed (9/8/2024 and 9/9/2024). Findings included: 1. On 9/8/2024 at 10:45 a.m., Resident #82 was observed seated in her wheelchair and was slowly self propelling down the hall from her room. An attempt to interview the resident revealed she had cognition deficits and was only able to answer some simple yes and no questions. She kept saying, I just want to go back to my room, I want to go to bed. Passing staff told her, ok, in a minute, but we have lunch soon. Further observations revealed when the resident was self propelling in her wheelchair down the hallway, she was noted with an indwelling urinary catheter. The catheter bag was observed appropriately hanging under the seat of the wheelchair. However, the tubing from the bag to the resident was observed in excess slack, dragging on the floor with approximately six to seven inches on the floor. Further, as the rear wheelchair tires were rolling, the tubing was observed either very close to being ran over, or was touching the tire as the resident and wheelchair was moving. She remained parked near the unit station and room [ROOM NUMBER] for a period of time with staff continually passing her and saying hello. However, staff did not address the catheter on the floor. Photographic evidence was obtained. On 9/8/2024 at 10:56 a.m., Staff D, Certified Nursing Assistant (CNA) was observed to walk by the resident as the resident shouted, I just want to go get into my bed. Staff D accommodated her while pushing her back to her room, while she was in her wheelchair. While Staff D was pushing her down the hallway the catheter tubing was still observed dragging on the floor under the resident and touching the rear wheelchair tires. Staff D brought her into her room and then left as the tubing was still on the floor. On 9/8/2024 at 11:30 a.m., Resident #82 was observed in the main dining room seated in her wheelchair and positioned at a table. She had just received her lunch meal tray. Further observations revealed her indwelling catheter tubing was again dragging on the floor near her rear tire. Staff F, Registered Nurse (RN) and Staff E, RN had just repositioned the catheter up off the floor not even seven minutes prior to this observation. She remained in the main dining room until 12:13 p.m. when an unidentified staff member assisted the resident back to her room by pushing her while in her wheelchair with the tubing dragging the floor. On 9/9/2024 at 6:50 a.m., Resident #82 was observed seated in her wheelchair at the 100/200 nurse station. She was dressed for the day and well groomed. She had a blanket over her lap, legs, and pulled up to her neckline. At 6:59 a.m., she was noted to leave the area and self propelled herself down the hall, towards her room. Both of her feet were on the wheelchair foot pedals and she was using both of her hands to turn the tires to move forward. She was observed with her indwelling urinary catheter tubing dragging on the floor beneath her with approximately six inches of tubing on the floor. The rear wheelchair tire was observed brushing up against the tubing as she was moving forward. During the time she was moving towards her room, there were many staff who passed by her. Some stopped to say hello and moved on. No staff was observed to identify the tubing on the ground. Therefore, it was not reported to nursing to be readjusted. On 9/10/2024 at 12:20 p.m. an interview with Resident #82's responsible party revealed she was aware [the resident] was utilizing a urinary catheter and was made aware yesterday, 9/9/2024, of the catheter removal. The responsible party said there had been times when she had come in to visit and had seen [the resident] while in her wheelchair and with the catheter bag and tubing dragging on the floor. She said she had not thought anything about it until now during the interview. An interview with Resident #82 could not be obtained as she had cognitive deficits and could not speak specifically to her catheter care and other medical care/services. Review of Resident #82's medical record,diagnosis sheet, showed diagnoses which included but were not limited to Dementia, Neuromuscular Dysfunction of Bladder, and Presence of Urogenital Implants. Review of the current Minimum Data Set (MDS) admission assessment, dated 6/12/2024, revealed Cognition/Brief Interview Mental Status or BIMS score 9 of 15, which indicated the resident had moderate cognitive impairments; Activities of Daily Living ADL - Toileting = Dependent, Dressing = Substantial/Maximal assistance, Personal Hygiene = Dependent; Bowel and Bladder - Checked for use of Indwelling catheter and always incontinent of bowel. Review of the current Physician's Order Sheet for month 9/2024, and reviewed at 12:00 p.m. on 9/9/2024 revealed the following orders: 1. Indwelling Urinary Catheter change catheter bag and tubing every night shift staring on 18th; 2. Indwelling Urinary Catheter monitor every shift and notify the physician of changes in urinary appearance and or urinary output; 3. Indwelling Urinary Catheter change 16fr 10 ml catheter tubing, and collection bag as need when medically necessary; 4. Indwelling Urinary Catheter Encourage and assist resident to use/apply leg bag when out of bed and/or as tolerated/requested A new order on 9/9/2024 revealed to remove Foley Catheter for voiding trial one time only on 9/9/2024. On 9/11/2024 at 9:25 a.m., an interview with Staff G, 100/200 Unit Manager revealed she knew Resident #82 well and she had spoken with her responsible party at times when she visited the resident. Staff G said she usually rounded the unit multiple times a shift and looked out for resident care needs, staff delivery of care, and general resident safety. She confirmed Resident #82 utilized a urinary catheter up to the afternoon of 9/9/2024. Staff G revealed that herself, along with other nurses on the floor would observe the catheter for placement, patency, safety and infection risks. Staff G said if any resident's catheter bag and/or tubing was observed on the floor while either in bed or while in a wheelchair, the tubing and bag should be positioned safely and off the floor. 50434 2. During an interview on 09/08/2024 at 9:10 a.m., Resident #13 was observed lying in bed dressed in a hospital gown. A catheter bag was observed on the floor underneath the bed. The resident was leaning to the right of the bed hanging onto the railing of the bed. She stated when she first came to the facility, she was getting therapy to help her with her mobility but most recently she has not been going to therapy anymore and would like to start going to therapy again so she can become more independent. During an observation and interview with Resident #13 on 09/10/2024 at 1:00 p.m., she was observed lying in bed dressed in a gown and clean in appearance, there was a catheter bag located on the floor with the privacy side up. She stated she no longer had concerns about therapy because she was transferring to another facility at the end of the week so she would be closer to her family. She stated she would worry about therapy when she got to the new facility. Review of Resident #13's Admission Record showed Resident #13 was admitted to the facility with diagnoses of anxiety disorder, major depressive disorder, dementia, and neuromuscular dysfunction of bladder. Review of Resident #13's care plan dated 05/24/2024 showed, the resident has a risk for injury/infection presence of indwelling catheter secondary to a diagnosis of neurogenic bladder, start date 05/24/2024. With a goal of the resident will be free of complications catheter use through next review. With a focus of Position catheter bag and tubing so that it promotes dignity and drainage, Privacy bag/cover in place, provide catheter care per orders, Urology consult and follow up as indicated/ordered. During an interview on 09/11/2024 at 9:00 a.m., with Staff K,CNA, she stated Resident #13 was a total care resident who chose to stay in bed. She stated the resident would occasionally go to the dining room for food. She stated the resident was a 2 person [mechanical]Hoyer lift. Staff K stated she provided the resident with Peri Care, and emptied the catheter bag every shift, she stated the bag should always be placed with the privacy side out, and hanging below the bladder, she stated there was a hook on the bed they normally clipped it to. During an interview on 09/11/2024 at 9:11 a.m., with Staff L, LPN, she stated residents with catheters received perineal care to include cleaning the area. She stated residents who are mobile received a [urine collection] bag that attached to their leg, and they made sure it was covered by their clothing. She stated for residents who were in bed the catheter bag should be placed at the bottom of the bed below the bladder. She stated the catheter bags should never be placed on the floor. Review of the facilities Catheter Care, dated 10/2020, revealed Standard: The facility will maintain infection control guidelines related to catheter use and catheter care to minimize catheter associated infections. Guideline: The clinical staff will receive education and training related to providing catheter care to minimize catheter associated infections. 1. Use standard precautions when handling or manipulating the drainage system, catheter tubing, or drainage bag .3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is capped at an appropriate level to promote urine flow, and dignity is maintained. Catheter coverings are not required when drainage bags are out of sight from the public or per the residence preference.

Based on observation, interview and record review, the facility did not ensure trauma informed care was provided for one (#39) of one resident with post-traumatic stress disorder (PTSD). The facility did not ensure PTSD triggers were on Resident #39's care plan. The facility did not ensure staff was trained annually on trauma informed care as the facility policy indicated. Findings Included: Review of Admission Record showed Resident #39 was initially admitted to the facility diagnoses which included major depressive disorder, schizoaffective disorder, unspecified psychosis, post-traumatic stress disorder, other specified persistent mood disorders, anxiety disorder, dementia. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE], Section C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Review of Resident #39's Care Plan dated revealed the following: A focus area initiated on 7/24/24 showed, the resident had experienced a traumatic event which had impacted their emotional health as evidenced by (AEB) PTSD nightmares. The goal showed, frequency or severity of the trauma-related symptoms would not increase. The interventions showed, Alert MD/designee of any significant changes in behavior. Provide a quiet, non-threatening environment as indicated. Respect resident's space and privacy. Encourage and assist the resident to have contact with family/friends as able. On 09/09/2024 at 11:50 a.m., Resident #39 was observed lying in his bed and speaking with Staff O, Licensed Practical Nurse (LPN). Resident #39 told Staff O he did not want a particular person in his room because that person tried to kill his girlfriend. The name of the person mentioned by Resident #39 was unintelligible. Resident #39 repeated his statement that he did not want a particular person in his room because that person tried to kill his girlfriend. Staff O, LPN, did not respond to the resident or acknowledge the resident's statement. An interview was conducted with Staff O, Licensed Practical Nurse (LPN) on 09/09/2024 at 11:50 a.m. Staff O said he was not aware of the care plan for Resident #39. He said he did not look at the care plans he only gave medications to the resident. Staff O, LPN said he was not aware of any psychiatric issues Resident #39 might have. An interview was conducted with The ADON (Assistant Director of Nursing) on 09/10/2024 at 10:30 a.m. The ADON she said nurses could check the care plans to see if there was anything new or different with the resident. She said they could also check the care plan if there were any new behaviors or behavior triggers on the care plan. She said the care plan was the big key for care. The nurse might put any new issues they encountered with a resident on the report/care sheet during their shift. An interview was conducted with Staff I, LPN, on 09/11/2024 at 9:54 a.m. Staff I, who was taking care of Resident #39 on this day, stated she definitely had one resident on her assignment who was diagnosed with PTSD. She stated the name of the resident whom she said has the PTSD diagnosis, however, it was not Resident #39. The resident Staff I indicated did not have a PTSD diagnosis. An interview was conducted with the DON (Director of Nursing) on 09/11/2024 at 10:15 a.m. He said the nurses on the floor should be familiar with the resident care plans. The nurses also had the task listings available for review on their assigned resident's electronic medical records. He said the staff also needed to check the [a system for organizing patient information that nursing staff use to create care plans] as well as the care plan. The DON said he believed the underlying cause of the Resident #39's PTSD was related to nightmares, but he was not sure. He said care plan interventions were monitored through feedback from the resident, social service visits, daily care and community visits. He said the facility could ensure care was consistent with the care plan through education. He said the education portion was done during the orientation process and there was no continuing education done. Changes in condition were reported to the MD and to the family. He said the care for the resident with PTSD was based on listing out the medical diagnoses and identify to see if there was PTSD and trauma. The care plan should be based on the history of trauma and the triggers. Changes in the care plan and resident's condition were communicated to the staff after care plan meetings through unit managers and MDS (Minimum Data Set) Assessments. An interview was conducted with Staff R, RN MDS Coordinator on 09/11/2024 at 2:00 p.m. He said his role in the care plan process was related to nursing. During review of the resident's care plan, he said the Focus section regarding the type of trauma the resident experienced would be based on the psychiatric evaluation. If the psychiatric evaluation did not have the specific PTSD trauma it would not be listed. He said this is the same case for the interventions, if the psychiatric evaluation does not list specific triggers they would not be listed on the care plan. Review of Resident #39's current physician's orders revealed the resident is currently taking the following medications: -Celexa oral tablet 20 MG (Citalopram Hydrobromide)/Give 1 tablet by mouth one time a day related to major depressive disorder -Trazodone HCI oral tablet 100 MG (Trazodone HCI)/Give 1 tablet by mouth in the evening for insomnia related to major depressive order -Ativan Injection Solution 2MG/ML (Lorazepam)/Inject 0.25 ml intramuscularly every 24 hours as needed for seizures Review of Resident #39's Subsequent Psychiatric Evaluation dated 05/15/2022 revealed the resident had a PTSD diagnosis related to nightmares. Review of the policy - Trauma Informed Care Issued 04/2019 and revised 01/2024 showed The facility will ensure each resident receives care and services to attain and maintain the highest practicable psycho-social well-being. The procedure included: 1. Residents will be assessed for a history of PTSD upon admission and as needed. 2. When Trauma has been identified the Social Services Director or Designee will inform the resident's attending physician and request both Psychiatry and Psychology Services for the resident. 3. Through resident interview and Psych Services, a Comprehensive Plan of Care will be developed with the interdisciplinary Team to reduce the risk of re-traumatization. 4. Residents who are trauma survivors will receive culturally competent, trauma-informed care, in accordance with professional standards of practice and accounting for residents' experiences and preferences, in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. 5. Staff will be educated on Trauma Informed Care upon hire and annually.

Based on observation, interview, and record review, the facility failed to provide residents and visitors with up to date and correct daily staffing posting information. It was determined the facility had not updated this sheet for a total of three days. Findings included: On 9/8/2024 at 8:33 a.m., an observation was made of the facility's entrance lobby. A desk in the lobby area was observed with a stand up clear plastic document holder. The holder had encased a Daily Staffing Projection sheet. The sheet had information with the date, how many nurses and how many Certified Nursing Assistants (CNAs) were working for each of the three shifts, and the resident census. The sheet showed a date of 9/5/2024, which was three days prior to the current date reviewed, 9/8/2024. The sheet had not been updated to reflect the current date, the current staffing numbers per each of the three shifts, or the current resident census. The sheet reflected a resident census of 104. An interview with the Front Desk receptionist revealed she was aware of the form because it was at her desk area. However, she was not able to explain who updated the form. An interview with the weekend supervisor, who was also the Certified Dietary Manager, revealed the current resident census was 111. At 9:02 a.m. an interview with the Nursing Home Administrator (NHA) revealed the Daily Staffing Projection sheet was updated every day and it was the Staffing Coordinator's responsibility to update and replace the sheet daily. He confirmed the front lobby desk area was the only place they posted this sheet. The NHA revealed on weekends, the assigned weekend supervisor would update and replace this sheet. He reviewed the current sheet and confirmed it had not been updated for three days. He confirmed that today, Sunday 9/8/2024, the Certified Dietary Manager was responsible for updating and posting the current day's Daily Staffing Projection sheet. On 9/9/2024 at 6:10 a.m. the building was entered. The Staffing Coordinator Staff B was met with and revealed what the Daily Staffing Projection sheet expectations were. She was observed updating the sheet as the building was entered. Staff B was asked who was responsible for changing and updating that form. She said it was her responsibility to change and update the form on a daily basis Monday through Friday. She said she was not at the facility on the weekends and it was the responsibility of the weekend supervisor to change and update it on Saturday and Sunday. Staff B was made aware from the NHA that the sheet had not been updated and changed since 9/5/2024. She said she was off on 9/6/2024 and did not know why it was not changed. On 9/11/2024 at 10:00 a.m., the Nursing Home Administrator said the facility did not have a specific policy with regards to the daily nursing assignment posting. He did say it was their standard to update and have the current nursing assignment posting available for residents and visitors to see.

Based on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5% for three (#14, #93, #498) of four sampled residents who were administered medications. This resulted in seven errors from 35 medication administration opportunities for a medication error rate of 20.00%. Findings included: 1. On 09/10/2024 at 9:55 a.m., Resident #498 was observed sitting in her room. Staff U, Licensed Practical Nurse (LPN) was observed passing medications. Verified a total of 9 medications were in the medication cup The following medications were observed as administered to Resident #498: Aspirin delayed release 81 mg (milligrams) daily for DVT prophylaxis (deep vein thrombosis) Cefuroxime Axetil 500 mg two times a day for pneumonia for 2 days Ventolin HFA inhalation Aerosol Solution 108 mcg/ACT (microgram/actuation) 1 puff three times a day for COPD (Chronic Obstructive Pulmonary Disease) Glimepiride 1 mg by mouth in the morning for Diabetes Iron 325 mg daily for supplement Lasix 40 mg give daily for CHF (Congestive Heart Failure) MiraLax 17 GM (gram)/scoop daily for constipation mix in 4-8-ounce water Duloxetine HCL delayed release 30 mg twice a day for major depression Gabapentin 300 mg give two times a day for nerve pain Pro-Stat oral liquid give 30 ml by mouth twice a day for supplement Topiramate 200 mg give 2 tablets twice a day for migraine headaches Review of the physician orders and Medication Administration Review (MAR) for September showed Azithromycin 500 mg daily for pneumonia for 2 days, not observed administered, but documented as given Flonase allergy relief Nasal Suspension 50 mcg/act (Fluticasone Propionate Nasal) 1 spray both nostrils in the morning for allergies, not observed administered, but documented as given Fluticasone-Salmeterol 250-50 mcg/act aerosol powder, 1 puff twice a day for chronic resp. failure with hypoxia Rinse mouth after use, not observed administered, but documented as given Resident #498 was admitted on [DATE] and readmitted on [DATE]. Review of admission record showed diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, heart failure, chronic respiratory failure with hypoxia, COPD, and asthma. Review of the care plans showed Resident #498 had a care plan for antibiotic therapy related to infection as of 09/09/2024. Interventions included but not limited to administer antibiotic medications as ordered by physician. The resident was at risk for altered respiratory status/difficulty breathing related to episodes of shortness of breath, pneumonia, COPD/asthma. Interventions included but not limited to administer medication/inhalers/nebulizers as ordered as of 09/09/2024. 2. On 09/10/2024 at 10:25 a.m. Resident #93 was observed sitting in her room. Staff V, Registered Nurse (RN) was observed passing medications. The following medications were observed as administered to Resident #93: Aspirin 81 mg daily for DVT prophylaxis Clopidogrel Bisulfate 75 mg daily for blood clot prevention Metoprolol Succinate ER Extended Release 24 hour 50 mg in the morning for CHF, hold for heart rate less than 60 Metformin HCL 500 mg twice a day for diabetes Midodrine HCL 5 mg three times a day, please hold for systolic over 120 Review of the physician orders and Medication Administration Review (MAR) for September showed MiraLax 17 gm give by mouth for constipation for 5 days, mix with 4-6 oz of liquid, not observed administered, but documented as given Ranolazine ER 12-hour 500 mg for chronic chest pain, not observed administered, but documented as given Sennosides 8.6 mg give 2 tablets twice a day for constipation for 5 days, not observed administered, but documented as given Review of progress notes showed on 09/10/2024 at 9:35 a.m. the Nurse Practitioner was notified that a.m. meds may be administered late this a.m. Nurse Practitioner gave ok to give meds by noon. Resident #93 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to COVID-19, diabetes, atherosclerotic heart disease, hypertension, pneumonia, history of falling, Transient Ischemic attack, muscle weakness, and reduced mobility. Review of the care plans showed Resident #93 had a care plan for altered cardiovascular status related to hyperlipidemia, hypertension as of 08/16/2024. Interventions included but not limited to administer medications per MD order. Care plan for resident was at risk for bowel irregularity related to decreased mobility, disease process as of 08/16/2024. Interventions included but not limited to administer medications as per MD orders. 3. On 09/10/2024 at 10:32 a.m. Resident #14 was observed sitting in her room. Staff W, Registered Nurse (RN) was observed passing medications The following medications were observed as administered to Resident #14 Eldertonic oral liquid give 15 ml daily for supplements House liquid protein 30 ml by mouth 100% Miralax 17 gm/scoop in the morning for constipation mix with 8 oz. of water Xeljanz XR ER 24-hour 11 mg daily for RA do not crush Advair diskus Aerosol Powder Breath Activated 250-50 mcg/dose 1 puff orally two times a day for asthma rinse mouth after use Calcium 500 mg twice a day for supplement Docusate Sodium 100 mg twice a day for constipation Eliquis 2.5 mg twice a day for blood clots prevention Ferrous Sulfate 325 mg twice a day for supplementation Senna 8.6 mg give 2 tablets twice a day for GI motility, hold for loose stool Review of the physician orders and Medication Administration Review (MAR) for September showed Calcium 600 mg twice a day for supplement was ordered on 03/11/2024 Resident #14 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to rheumatoid arthritis, disorder of lung, severe protein-calorie malnutrition, and hypertension. Review of the care plans showed Resident #14 had a care plan for at risk for alteration in nutritional status related to BMI under 18, history of significant weight loss, history of malnutrition, dependency for meals, need for nutritional supplements and diagnoses / history including: rheumatoid arthritis, history of dysphagia and hypertension. Interventions included but not limited to encourage intake of supplements and / or snacks provided. Provide supplement as ordered. Review of progress notes showed on 09/10/2024 at 10:26 a.m. the Nurse Practitioner was notified that a.m. meds may be administered late this a.m. Nurse Practitioner gave ok to give meds by noon. Assistant DON During an interview on 09/11/2024 at 10:57 a.m. the Director of Nursing (DON) reviewed the MARs for Resident's #498, #93 and #14 for medications administered. The DON stated all the medications should have been given as per orders. The DON stated the nurses should not have documented medications had been administered when they had not been administered. The DON said the missed medications were considered medication errors. The DON verified Resident #93's medical provider had been notified at 9:35 a.m., 1 hour before the resident's medication administration was given. The DON stated the notification of the nurse practitioner was a blanket statement letting them know the medications were going to be late due to scheduling. The DON stated they had schedule changes that morning due to call offs. Resident #93 was given Midodrine at 10:30 a.m. per the DON and the next dose was scheduled for 1:00 p.m. or 2 1/2 hours later. The DON verified Resident #93's Midodrine was given at 2:00 p.m. The DON verified the Calcium order for Resident #14 was for 600 mg not 500 mg as was administered. During an interview on 09/11/2024 at 12:19 p.m. the Medical Provider / APRN (Advanced Practice Registered Nurse) stated all medications should be given as ordered. The APRN stated if medications are not given, it should be documented and reported to the provider. The APRN said if the medications are given late, the provider should also be notified. She stated if a medication that was ordered three times a day was given late, the provider should be called for input into a possible order change / time change. The APRN stated it was not good for a nurse to document what had not been given. Review of the facility's policy, Medication Administration, revised 01/2024 showed medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and / or have related functions 3. Medications are administered in accordance with prescriber orders, including any required time limit. 4. Medication administration times are determined by resident need, preference, and benefit, not staff convenience. 5. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 6. Medications are administered within one hour before or after their prescribed time, unless otherwise specified. 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rationale in the residence medical record and notify the physician and responsible party if indicated. 17. As required or indicated for a a medication, the individual administering the medication records in the residence medical record: a. the date and time the medication was administered; B. The dosage; C. The route of administration; F. Any results achieved and when those results were observed if applicable, and G. The signature and title of the person administering the drug.

Based on observation, record review, and interview, the facility failed to ensure wheelchair mobility was provided for one (#7) of eight residents sampled. Finding Included: During multiple observations made on 09/08/2024, 09/09/2024, 09/10/2024 and 9/11/2024 at multiple times 10:00 a.m., 3:00 p.m., and 5:00 p.m., Resident #7 was observed lying down in bed with her call light within reach Review of an admission record showed Resident #7 was admitted to the facility with diagnoses which included but not limited to dysphagia following cerebral infarction, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance. Review of a Minimum Data Set, (MDS) dated [DATE] showed a Brief Interview for Mental Status, BIMS score of 00, which indicated interview was not able to be conducted. Further review of the MDS section GG- showed Resident # 7 used a wheelchair for mobility. Review of a care plan focus for Activity of Daily Living (ADL) initiated on 09/10/2024, showed Resident #7 had an ADL self- care deficit related to ADL needs and participation vary, chronic medical conditions, dementia, limited mobility. Review of the care plan goals showed Resident #7 would not have a decline in ADL functioning through next review date. Initiated on 09/10/2024. Review of the care plan intervention for transfer showed, The resident is dependent and is unable to assist with a transfer and will need assistance x 2 staff. Initiated on 9/10/2024. During an interview on 09/10/2024 at 3:00 p.m. with Staff Z Certified Nursing Assistant (CNA), she stated she had worked at the facility for three years. She was familiar with Resident #7 because she was assigned to her often. She gave the resident a bed bath and checked on her every 2 hours to see if she needed to be changed. She did not get Resident #7 out the bed because she did not have a wheelchair. She stated she had never seen Resident #7 out the bed. During an interview on 09/11/2024 at 10:27 a.m. with Staff W, Registered Nurse (RN), he stated he was assigned to Resident #7 and was familiar with her care. He stated Resident #7 did not get out the bed because she did not have a wheelchair. During an interview on 09/11/2024 at 1:00 p.m. with Staff AA, CNA, She stated she was assigned to Resident #7 and she did not get her out the bed. She stated she was provided with a list of residents that were assigned to get up and Resident # 7 was not on the assigned list to get out the bed. During an interview on 09/11/2024 at 11:16 a.m. with Staff BB, License Practical Nurse/Unit Manger (LPN/ Unit Manager), she stated Resident #7 was a dependent resident with limited mobility and could not walk. Therapy was working with her by providing her with bed exercise. She did not have upper extremity control. She said she had not seen the Resident #7 out the bed. The resident did not have access to a wheelchair because she needed a reclining wheelchair. During an interview on 09/11/2024 at 1:00 p.m. with the Rehab Director, she stated Resident #7 was picked up today, 09/11/2024, for therapy services. She was referred to therapy by nursing. The therapy process was that they screened all residents admitted to the facility for a mobility device. She could not answer why Resident #7 did not have a wheelchair but said they would address the issues so the resident had a wheelchair moving forward. Review of a policy titled, Standards and Guidelines: ADL Care and Services Revised dated 1/2024 showed Standards: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Gudelines: Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Including appropriate support and assistance with: b. Mobility ( Transfer and ambulation, including walking).

Based on record review and interview, the facility failed to provide Abuse/Neglect training to one (Staff X) of 10 employees reviewed. Findings Included: During an interview on 09/10/2024 4:30 p.m. the Director of Nursing (DON) stated Resident #100 had a lower BIMS score, and frequently wandered around the building. He stated on 03/14/2024 his Assistant Director or Nursing (ADON) and the Unit Manager (Staff G, Licensed Practical Nurse [LPN]), came and let him know that Resident #100's Resident Representative (RR) was reporting an allegation of neglect. The DON stated he went to Resident #100's room to speak with the family. He stated the family reported to him when they came in to visit Resident #100 on 03/13/2024 during the night, they found the resident in two briefs, the resident had a hospital gown on top of her clothes and was tucked in underneath her, the resident's hands were bound behind her, and that the resident's TV was not working. The DON stated once he spoke with the family, he went and notified the Nursing Home Administrator (NHA) and their regional. He stated when the Adult Protective Investigator (API) came in, they showed him pictures with a curtain with a call light and stated, There were no patient identifiers so this could have been any resident's room. He stated the API worker then showed him a picture of a brief and another brief being used as a chuck pad, and then a picture of Resident #100 with the sheets up to her arm pits and her arms outside of the sheet. The DON stated he provided a written copy of his statement to the NHA. During an interview on 09/11/2024 at 12:39 p.m. the Nursing Home Administrator (NHA) stated on 03/13/2024 Resident #100's Resident Representative (RR) came in to visit the resident around 11:45 p.m., with a female companion. During this visit, staff stated the RR was not his usual self and smelt like alcohol. He stated the RR questioned Staff X, Certified Nursing Assistant (CNA) about why the call light was clipped to the curtain and why the TV was not working. He stated the Staff X, CNA went and got Staff Y, Licensed Practical Nurse (LPN), to let her know the RR was there and that he was not acting like his usual self. Staff Y, LPN, then went to the resident's room and noticed two people in Resident #100's room, she was told by the RR that the TV was not working. Staff Y tried to fix the tv, and the RR told her he would come back the next day. He stated on 03/14/2024, the Director of Nursing (DON) was approached by the Assistant Director of Nursing (ADON) and Staff G, LPN, notifying him the RR reported that when they came to see Resident #100 on 03/13/2024 her call light was out of reach, she was wearing two briefs, and she had a hospital gown tucked around her, where she could not move. He stated after the DON spoke with the RR; the DON reported the allegation to him (NHA). He stated, he then reported the allegation of neglect for double briefing and the call light being out of reach, he then had his staff call the abuse hotline, who accepted the case, and the Police who did not proceed. He then suspended the CNA pending investigation. They evaluated the resident by completing skin sweeps, a pain evaluation, psychosocial evaluation and reported the allegation of neglect to the physician. Resident #100 was found to be in no pain, had no skin impairments and remained at her baseline. He stated they did education on Abuse, Restraints, Call Lights, and double briefing. He stated they completed education on restraints because they wanted to rule out any type of restraint, since it was reported Resident #100 was dressed in a gown that was tucked underneath her, and they wanted to do a comprehensive education. During an interview on 09/10/2024 at 3:15 p.m., Staff X, CNA stated Resident #100 was a resident under her care. She stated on 03/13/2024 she worked a double shift, and Resident #100 was known to always be talking and moving about, she stated she never sits still. She stated one night, Resident #100's Resident Representative (RR) came in and was upset that the floor was dirty, and Resident #100 was soiled. She stated she went to change Resident #100, and the RR and his family member asked if they could stay in the room while she performed the care. She stated she agreed and began providing care for the resident. She stated she moved the call bell out of the way and placed it on the curtain. She stated as she began to change the resident, the RR's noticed the liner in the resident's brief and started accusing her of double briefing Resident #100. She stated the resident liked to dig her hands in her vagina, so she added a liner to the resident's brief to keep her from getting her hands in her pants. She stated the RR began shouting at her asking her why the floor was dirty and why the TV was also turned off. She stated she went and got a towel and cleaned up the floor right away. She stated she told the RR she was not sure why the TV was not working, but she would let maintenance know first thing in the morning. She stated the RR was not willing to hear her out, so she went and got the Unit Manger. She stated the RR left after speaking with the Unit Manager. She stated the next day the RR came in and reported Resident #100 was double briefed, and she (Staff X) had touched the resident inappropriately. She stated she was immediately suspended. She stated she spoke with the State's Adult Protective Agency and the police. She stated she was suspended for three days, and she had not completed any training before returning to work and has not received any retraining or education on abuse/neglect since returning to work in mid to late March of 2024. Review of the inservice education dated 03/14/2024, revealed staff was educated on abuse allegations and reporting timely, forms of abuse can include physical restraints, residents are not to be double briefed, and call lights are to be placed with in reach, the sign in sheet did not include Staff X, CNA. Review of the facility's abuse, neglect, exploitation, misappropriation, mistreatment, and injury of unknown origin (ANEMMI) Policy dated 08/2022 revealed: Training Policy: The center will train all new and existing nursing home staff through orientation and ongoing end services in ANEMMI prevention and response. Nursing home staff includes employees, consultants, contractors, volunteers and other caregivers who provide care and services to residents on behalf of the facility. Procedure: In service training will include at a minimum: A. Regulatory requirements regarding freedom from abuse neglect and exploitation. C. What constitutes abuse neglect exploitation misappropriation mistreatment and injury of unknown origin. D. Reporting policies and procedures established by the center. E. Appropriate interventions to deal with aggressive behaviors. F. How to recognize signs of burnout frustration and stress and both residents and staff that might lead to abuse neglect exploitation misappropriation and mistreatment and how to effectively intervene. Prevention Policy: The center will provide supervision and staff support services designed to reduce the likelihood of abusive behaviors. This center will provide ongoing oversight and supervision of staff in order to assure that policies are implemented as written. Procedure only authorized staff directly involved in providing care and services for a resident should be present when care is provided unless the resident consents to other individuals being present during the delivery of care. All supervisory staff will identify inappropriate behaviors, including but not limited to the use of derogatory language; rough handling; ignoring residents while giving care; directing residents who need assistance with toileting to urinate or defecate in their beds; and will take immediate steps to correct such behaviors. Supervisors will be especially sensitive to signs and symptoms of acute frustration.

Based on record review and interview the facility failed to ensure all alleged violations of abuse to include physical restraints were reported to the State Survey Agency for 1 (#100) out of 23 residents sampled. Findings included: Review of Resident #100's Admission Record revealed she was originally admitted to the facility in 2020 with medical diagnoses of Alzheimer's disease, diabetes mellitus, non-Alzheimer's dementia, delusional disorders, chronic kidney disease, peripheral vascular disease, and depressive episodes. Review of Resident #100's Quarterly Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 showing Resident #100 was cognitively impaired. Functional Abilities and Goals, Section GG revealed Resident #100 required Partial/moderate assistance for Toileting hygiene, and Shower/bathe care, personal hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. According to the Self-Care Coding for Partial/Moderate assistance means helper does less than half the effort. A helper lifts or holds trunk or limbs and provides less than half the effort. During a phone interview on 09/10/2024 at 8:59 a.m. the Resident Representative (RR), stated he came in to see Resident #100 on 03/13/2024 around 1:00 a.m., he stated the resident was in bed with a hospital gown and sheet tucked around her. He stated his family member (FM), who was with him, removed the sheet from Resident #100 and saw that her hands were tied behind her back with a towel. He stated his FM untied Resident #100 before he was able to get a picture. He stated he and his FM removed the sheet and hospital gown from Resident #100 and saw she was double briefed and wet. He stated the call bell was also clipped to the curtain in her room and the TV was turned off. He stated he went and got Staff X, Certified Nursing Assistant (CNA) and asked her why Resident #100 was tied up in bed and in a wet brief, he stated Staff X, CNA had no explanation and exited the room and started talking to another staff member in the hallway in another language. He stated he stayed until around 3 a.m., to make sure Resident #100 was taken out of bed, given a bath and changed. He stated he came in the next morning spoke with the Director of Nursing (DON) and told him when he came in to see Resident #100, he found her in her room with a hospital gown and sheet tucked underneath her, with her hands tied behind her back, and her call light attached to the curtain. He stated after reporting the allegation to the facility no one has contacted him. During an interview on 09/10/2024 at 3:15 p.m., Staff X, CNA stated Resident #100 was a resident under her care. She stated the resident is known to always be talking and moving about, she stated she never sits still. She stated one night the resident's family came in and was upset that the floor was dirty, and Resident #100 was soiled. She stated she went to change Resident #100, and the RR and his FM asked if they could stay in the room while she performed the care. She stated she agreed and began providing care for the resident. She stated she moved the call bell out of the way and placed it on the curtain. She stated as she began to change the resident the RR's FM noticed the liner in the resident's brief and started accusing her of double briefing Resident #100. She stated the resident likes to dig her hands in her vagina so she added a liner to the resident's brief to keep her from getting her hands in her pants. She stated the RR began shouting at her asking her why the floor was dirty and why the TV was also turned off. She stated she went and got a towel and cleaned up the floor right away. She stated she told the RR she was not sure why the TV was not working but she would let maintenance know first thing in the morning. She stated RR was not willing to hear her out, so she went and got the Night Nurse assigned to Resident #100 (Staff Y, Licensed Practical Nurse [LPN]). She stated the RR left after speaking with the Staff Y, LPN. She stated the next day the RR came in and reported Resident #100 was double briefed, and she touched the resident inappropriately. She stated she was immediately suspended. She stated she spoke with the state's Adult Protective Agency and the police. She stated she was suspended for 3 days, and she had not completed any training before returning to work. During an interview on 09/10/2024 4:30 p.m. the DON stated Resident #100 had a lower BIMS score, and frequently wandered around the building. He stated on 03/14/2024 his Assistant Director or Nursing (ADON) and the Unit Manager (Staff G, Licensed Practical Nurse [LPN]), came and let him know that Resident #100's RR was reporting an allegation of neglect. He stated he went to Resident #100's room to speak with the family. He stated the family reported to him when they came in to visit Resident #100 on 03/13/2024 during the night and they found the resident in two briefs, the resident had a hospital gown on top of her clothes and was tucked in underneath her, the resident's hands were bound behind her, and that the resident's TV was not working. He stated once he spoke with the family he went and notified the Nursing Home Administrator (NHA) and their regional. He stated when the Adult Protective Investigator (API) came in, they showed him pictures with a curtain with a call light and stated, There were no patient identifiers so this could have been any resident's room. He stated the API worker then showed him a picture of a brief and another brief being used as a chuck pad, and then a picture of Resident #100 with the sheets up to her arm pits and her arms outside of the sheet. He stated he provided a written copy of his statement to the NHA. Review of the DON's statement dated 3/14/24 included the allegation of the resident in bed wrapped in a hospital gown with her clothes on under the gown so she could not move, and the residents hands being tied behind her back. A review of the federal immediate report submitted to the state agency on 3/14/24 at 4:15 PM and the federal 5 day report submitted by the facility on 3/19/24 at 1:46 PM revealed no information related to the resident being restrained with her hands bound behind her and either a hospital gown or sheets positioned in a way that could possibly restrict her movement. During an interview on 09/11/2024 at 12:39 p.m., the NHA, stated he believed this was the resident who had an allegation of being hog tied, he stated he was trying to locate the reportable because this was about the time the systems changed on where to report to and did not want to speak to anything that did not happen. He then stated on 03/13/2024 Resident #100's RR came in to see the resident around 11:45 p.m., with a female companion (the individual referred to as FM). During this visit, staff stated the RR was not his usual self and smelt like alcohol. He stated the RR questioned the CNA on why the call light was clipped to the curtain, and why the TV was not working. He stated the CNA went and got Staff Y, LPN, to let her know the RR was there and that he was not acting like his usual self. Staff Y, LPN, then went to the resident's room and noticed two people in Resident #100's room. Staff Y, LPN was told by the RR that the TV was not working. Staff Y, LPN tried to fix the TV, and the RR told her he would come back the next day. The NHA said on 03/14/2024, the DON was approached by the ADON and Staff G, LPN, notifying him that the RR reported when they came to see Resident #100 on 03/13/2024 her call light was out of reach, she was wearing two briefs, and she had a hospital gown tucked around her, where she could not move. He stated after the DON spoke with the RR; the DON reported the allegation to him. He stated, he then reported the allegation to the state agency through the online Report System, had his staff call the abuse hotline, who accepted the case, and the police who did not proceed. He then suspended the CNA pending investigation. They evaluated the resident by completing skin sweeps, a pain evaluation, psychosocial evaluation and reported the allegation of neglect to the physician. Resident #100 was found to be in no pain, had no skin impairments and remained at her baseline. He stated they did education on abuse, restraints, call lights, and double briefing. He stated they completed education on restraints because they wanted to rule out any type of restraint, since it was reported Resident #100 was dressed in a gown that was tucked underneath her, and they wanted to do a comprehensive education. He stated that he has the report now and would like to review it so that he does not speak to anything he is unsure of. He reviewed the report and stated, The resident's family did not report the restraint, it was never brought up until after the investigation. He then stated the allegation of the restraint was not added to the federal reportable because there was no skin breakdown. He then stated, We took what appeared to be coherent to us and put it in the report. He stated for allegation of abuse he has 2 hours to report it and, I would report every allegation of abuse or neglect. He stated the facility did not substantiate the complaint and when he tried to reach out to the RR he did not answer the phone or return his calls. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin (ANEMMI) Policy, dated 08/2022, and revised on 01/2024, revealed: The center will seek and accept concerns complaints or grievances from residents, resident families and staff without reprisal the right to report a concern or incident is not limited to a formal written grievance process but includes any verbalized complaint to any facility staff member, prompt efforts will be made to resolve concerns complaints or grievances Definitions: Physical Abuse Includes controlling behavior through corporal punishment or physical or chemical restraints. Reporting and Response Policy: All allegations of possible ANEMMI will be immediately reported to the abuse hotline by the administrator or designee and will be evaluated to determine the direction of the investigation Procedure: Any and all staff observing or hearing about such events must report the event immediately to the administrator immediate supervisor and one of the following directors of nursing ANEMMI prevention coordinator or risk manager so that appropriate reporting and investigation procedures take place immediately it will also be reported to other officials in accordance with state and federal regulations A. Immediate Report in accordance with CFR 483.12 (1)(C) with response to allegations of abuse neglect exploitation or mistreatment the facility must 1. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but no later than two hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury. The ANEMMI prevention coordinator will also submit to the Agency for Healthcare Administration federal immediate/5 day report.

Based on observation, record review, and interview, the facility failed to ensure timely and accurate Pre-Admission Screening and Resident Review (PASRR) for one (#73) of 23 sampled residents. Findings Included: 2. Review of the Admission Record for Resident #73 showed the resident was initially admitted to the facility on [DATE] with a re-entry admitted [DATE]. Admitting diagnoses included schizoaffective disorder bipolar type, major depressive disorder, dementia, mood disorder due to known physiological condition with depressive features. Review of Level I PASRR for Resident #73 dated 03/16/2022, revealed an incomplete PASRR with the qualifying diagnoses of depression, mood disorder and dementia not indicated. During an interview on 09/11/2024 at 9:45 a.m. with Staff S, Registered Nurse (RN) Minimum Data Set (MDS) Director, she said the facility's process for identifying a resident with a possible MD, ID or related condition prior to admission to the facility would start with the Admissions Department. Admissions got the referrals and the referral for the possible resident admission was given to either the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to look at the clinicals to see if there were any reasons to deny the admission. Based on the clinicals, they gave a decision to admit the resident or not. She said the facility identified residents with newly evident or possible serious MD, ID or a related condition after admission to the facility usually after identifying behaviors. If a behavior was identified a psychiatric consult was done and the resident was seen by psychiatric services within seven days. If any new diagnoses were indicated psychiatric services would add them into the electronic medical record. She said when she was made aware of the new diagnoses, she would update the PASRR at that point. She said she also updated the admission PASRR if it was incorrect. She was responsible for making the referral to the appropriate state-designated authority when a resident was identified as having an evident or possible MD, ID or related condition. She said it would automatically trigger the PASRR so she would do that as well. Upon viewing the PASRR for Resident #73, she agreed it was not correct and missing qualifying diagnoses. The facility has no PASRR policy. 50732

Based on observation, record review, and interview, the facility failed to develop a care plan for one (#45) of six residents sampled for skin conditions and failed to develop and implement an Activities of Daily Living care plan for two ( #44 and #51) of five residents sampled. Finding Included: 1 During an observation made on 09/08/24 at 02:20 p.m., Resident # 45 was observed lying down in bed dressed in a hospital grown from the morning until late in the afternoon. The resident was trying to say something but was not able to communicate. On 09/09/2024 at 11:00 a.m., Resident # 45 was observed lying down in bed dressed in his hospital grown. Resident #45's legs was observed with scabs leaking with yellow fluid on his right and left legs. Review of an Admission Record showed Resident # 45 was admitted to the facility with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, psoriasis vulgaria, lymphedema, not elsewhere classified. Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) score of 00, which indicated the resident had cognitive deficits. Review of a care plan focus showing Resident #45 had a rash related to Psoriasis and stasis dermatitis, initiated and revised on 9/10/2024. Review of the care plan goals showed Resident #45 will have no complications from rash through the review date, initiated on 9/10/2024. Review of the care plan intervention showed administer medication as ordered by the Medical Doctor (MD). Initiated on 9/10/2024. During an interview on 09/10/2024 at 4:00 p.m. with the Director of Minimum Data Set (MDS), she stated it was her responsibility to create the residents comprehensive care plan. She stated the Regional MDS nurse created Resident #45's skin care plan on 9/10/2024 after the surveyor asked to see his care plan related to his skin condition. She stated she should have created the skin care plan when she first identified the resident had a skin condition. 34768 2. An interview was conducted on 09/08/2024 at 09:50 a.m. with Resident #44, she was observed to be in bed, with a hospital gown on, hair was disheveled and unkempt. Resident #44 said she did not know when the last time she got a shower was, but she wanted a shower to wash her hands. Her fingernails were observed to extend past her fingertips with a dark brown, black substances under her bilateral nails. The resident said she had not had her fingernails cut and she did not like them long. Her right hand was observed to be curled into her palm and the resident pulled her fingers out and there was a red indented mark on her palm where her nail was resting in her palm. On 09/09/2024 at 10:01 a.m., Resident #44 was observed to be in her bed, hair disheveled, her bilateral fingernails were observed to extended past her fingertips. On 09/10/2024 at 9:45 a.m., Resident #44 was observed to be in her bed, hair combed. Her bilateral fingernails were observed to be extended past her fingertips. On 09/10/2024 at 5:08 p.m., the Director of Nursing (DON) observed Resident #44 eating her dinner in the dining room. The DON verified Resident #44 had long nails. The DON agreed it was a pattern of fingernails not being trimmed. The DON stated the resident's nails should be observed during care by the aide and reported to the nurse. The aide or the activities person would do the resident's nails. The DON stated if we had someone on light duty, they would do nails also. The DON stated if a resident was a diabetic, the podiatrist would do their toenails. Resident #44 was observed to have food all over the front of her clothes. She was not being assisted by any staff members at the time, even though staff members were observed in the dining room. Resident #44 did not have a clothes protector on. The DON stated that the aides were to fill out shower sheets when they gave residents a shower. The shower sheet was to be reviewed by the nurse if the resident refused, the nurse was to go speak with the resident to encourage a shower. If the resident still refused, the nurse was to document. A review of the admission record for Resident #44 showed the diagnoses included but were not limited to dementia, senile degeneration of the brain, convulsions, recurrent depressive disorder, anxiety, sarcopenia, hydronephrosis, chronic pain, overactive bladder, cancer of the brain, and a history of falling. Review of the quarterly Minimum Data Set, dated dated dated [DATE] showed a Brief Mental Interview Status (BIMS) score of 07 which indicated severe impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, substantial/maximal assistance for bathing, showering, and personal hygiene. Review of the care plans showed Resident #44 had an ADL (activities of daily living) self-care deficit related to chronic medical conditions, dementia, ADL needs and participation varies revised on 09/09/2024. Interventions included but were not limited to the resident may need dependent assistance of 1 or 2 for ADL care as of 09/09/2024. This may fluctuate with weakness, fatigue, and weight bearing status. The resident needed limited to extensive assistance of 1-2 based on fatigue, weightbearing, weakness as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident as of 05/23/2024. Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 04/29/2024. Review of the type of bathing provided to Resident #44 showed no showers from 08/13/2024 to 09/10/2024. Full bed baths were provided on 08/13/2024, 08/16/2024, 08/20/2024, 08/23/2024, 08/30/2024, 09/03/2024, 09/06/2024, 09/10/2024. A sponge bath was provided on 08/27/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does not need toenails cut, no signature by nursing 08/16/2024, refused shower, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, needs toenails cut, no signature by nursing 08/23/2024, refused shower, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, needs toenails cut, no signature by nursing 08/30/2024, skin clear, needs toenails cut, no signature by nursing 09/03/2024, refused shower, does not need toenails cut, no signature by nursing 09/06/2024, full bed bath, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:33 a.m. the DON reviewed the Skin Monitoring: Comprehensive CNA Shower Review sheets. The DON verified they showed the resident had refused showers on 08/16/2024, 08/23/2024 and 09/03/2024 and a full bed bath on 09/06/2024. The DON verified that the 08/20/2024, 8/27/2024, 08/30/2024 notes showed the resident needed her toenails cut. The DON stated the need for toenails to be cut would be subjective to the individual giving the bath. If the resident was diabetic, the aide was not expected to cut the toenails. The DON stated the nurse was to sign off on the shower sheet if the resident refused to take a shower. The DON verified the resident refused to shower based on documentation on 08/16/2024, 08/23/2024, 09/03/2024 and the nurse had not signed off on the shower sheet as had reviewed. The DON stated the aide should have taken the shower sheet to the nurse for review. The DON stated the aides needed more education. The DON stated that Resident #44 should have been offered a clothing protector during dining. The DON stated that she was in the dining room for more assistance, as needed. The DON reviewed the care plans and stated that the ADL care plan showed Resident #44 was to have supervision and cuing assistance for eating. The DON stated the ADL care plan showed to provide choice for care provisions, shower twice a week. The DON stated the care plan showed the resident was resistive to care, non-compliant with showers (which was added on 09/11/2024 during survey). 3. An observation was conducted on 09/08/2024 at 09:31 a.m. Resident #51 was observed in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. An observation was conducted on 09/09/2024 at 10:05 a.m. Resident #51 was observed in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m., Resident #51 was observed in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. During and observation and interview conducted on 09/10/2024 at 5:00 p.m. with the DON. Resident #51 was observed eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream. The resident was in her room attempting to feed herself. Resident #51's fingernails were observed to be extended past her fingers on both hands. The resident told the DON her nails were too long, and she wanted them trimmed. The resident was observed putting her fingers and nails into her cup of vanilla ice cream. The DON stated the long nails in her food including her ice cream was not acceptable and was an infection control issue. He stated his expectation was for the resident's fingernails to be cut by the nurse. After observing Resident #51 eating, the DON stated she needed more assistance with dining, more than just set-up. The DON stated he would check Resident #51's therapy evaluations. The DON stated even though the evaluations showed her weight loss was unavoidable due to Resident #51's medical conditions, they (the staff) could do better with assisting the resident to eat. Resident #51 was admitted with diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, and acute pain due to trauma. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, and personal hygiene. Review of the care plans showed Resident #51 had an ADL (activities of daily living) self-care deficit related to ADL needs and participation vary, chronic medical conditions, confusion, impaired balance, limited mobility. The care plan was updated on 09/10/2024 (after start of survey). Interventions included but were not limited to the resident was dependent on staff for bathing needs, including transfer into and out of shower as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as of 05/23/2024. Observe resident for changes in ADL capabilities. Notify nurse, therapy, and/or MD as indicated as of 05/23/2024. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. A shower refusal on 09/09/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does need toenails cut, no signature by nursing 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets did not indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. The DON reviewed the care plans for Resident #51. The DON stated he spoke with the resident's Occupational Therapist (OT) and the resident was on case load for Speech Therapy currently. The OT stated she was working with the resident but not related to eating or the need for assistance. The DON stated OT was picking the resident up today (09/11/2024). The DON stated he reviewed the resident's weight and it was actually up from admission. The DON stated the resident's weight had been fluctuating and staying steady. The DON stated the resident could use some assistance (with eating). The DON stated the aide and the floor nurse should be observing the resident's eating first and the need for eating assistance. The DON stated the resident was resistive to assistance. The DON stated the resident used to be out of her room more, but was refusing to come out of her room. During interview on 09/11/24 at 10:33 a.m. the DON stated the facility followed the RAI (Resident Assessment Instrument) for a care plan policy. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 October 2023, showed 1.1 Overview: The purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining their highest practical level of well-being. The RAI helps nursing home staff look at residents holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. Chapter 4: Care Area Assessment (CAA) Process and Care Planning 4.1 Background and Rationale: Regulations require facilities to complete a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. 4.2 Overview of the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAs) The RAI-related processes help staff identify key information about residents as a basis for identifying resident-specific issues and objectives. In accordance with 42 CFR 483.21(b) the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. 4.3 What are the Care Area Assessments (CAAs)? The completed MDS must be analyzed and combined with other relevant information to develop an individualized care plan. 4.4 What Does the CAA Process Involve? Facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs (42 CFR 483.20(d)).

Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLs) for dependent residents which included performing fingernail care and showers for two (#44 and #51) of 46 sampled residents. Findings included: 1. An interview was conducted on 09/08/2024 at 09:50 a.m. with Resident #44. She was observed to be in bed, with a hospital gown on, hair was disheveled and unkempt. Resident #44 said she did not know when the last time she got a shower was, but she wanted a shower to wash her hands. Her fingernails were observed to extend past her fingertips with a dark brown, black substances under her bilateral nails. The resident said she had not had her fingernails cut and she does not like them long. Her right hand was observed to be curled into her palm and the resident pulled her fingers out and there was a red indented mark on her palm where her nail was resting in her palm. On 09/09/2024 at 10:01 a.m. Resident #44 was observed in her bed, hair disheveled, her bilateral fingernails were observed to extended past her fingertips. On 09/10/2024 at 9:45 a.m. Resident #44 was observed in her bed, hair combed. Her bilateral fingernails were observed to be extended past her fingertips. On 09/10/2024 at 5:08 p.m. the Director of Nursing (DON) observed Resident #44 eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream in the dining room. The DON verified Resident #44 had long nails. The DON stated the resident's nails should be observed during care by the aide and reported to the nurse. The aide or the activities person would do the resident's nails. The DON stated if we had someone on light duty, they would do nails also. The DON stated if a resident was a diabetic, the podiatrist would do their toenails. Resident #44 was observed to have food all over the front of her clothes. She was not being assisted by any staff members at the time, even though staff members were observed in the dining room. Resident #44 did not have a clothes protector on. The DON stated that the aides were to fill out shower sheets when they give residents a shower. The shower sheet was to be reviewed by the nurse if the resident refused, the nurse was to go speak with the resident to encourage a shower. If the resident still refused, the nurse was to document. Resident #44 was admitted to the facility with diagnoses that included but were not limited to dementia, senile degeneration of the brain, convulsions, recurrent depressive disorder, anxiety, sarcopenia, chronic pain, and cancer of the brain. Review of the quarterly Minimum Data Set, dated dated dated [DATE] showed a Brief Interview Mental Status (BIMS) score of 07 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, substantial/maximal assistance for bathing, showering, and personal hygiene. Review of the type of bathing provided to Resident #44 showed no showers from 08/13/2024 to 09/10/2024. Full bed baths were provided on 08/13/2024, 08/16/2024, 08/20/2024, 08/23/2024, 08/30/2024, 09/03/2024, 09/06/2024, 09/10/2024. A sponge bath was provided on 08/27/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does not need toenails cut, no signature by nursing 08/16/2024, refused shower, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, needs toenails cut, no signature by nursing 08/23/2024, refused shower, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, needs toenails cut, no signature by nursing 08/30/2024, skin clear, needs toenails cut, no signature by nursing 09/03/2024, refused shower, does not need toenails cut, no signature by nursing 09/06/2024, full bed bath, does not need toenails cut, no signature by nursing Review of the care plans showed Resident #44 had an ADL (activities of daily living) self-care deficit related to chronic medical conditions, dementia, ADL needs and participation varies revised on 09/09/2024. Interventions included but were not limited to the resident may need dependent assistance of 1 or 2 for ADL care as of 09/09/2024. This may fluctuate with weakness, fatigue, and weight bearing status. The resident needed limited to extensive assistance of 1-2 based on fatigue, weight bearing, weakness as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident as of 05/23/2024. Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 04/29/2024. During an interview on 09/11/2024 at 10:33 a.m. the DON reviewed the Skin Monitoring: Comprehensive CNA Shower Review sheets. The DON verified they showed the resident had refused showers on 08/16/2024, 08/23/2024 and 09/03/2024 and a full bed bath on 09/06/2024. The DON verified that the 08/20/2024, 8/27/2024, 08/30/2024 notes showed the resident needed her toenails cut. The DON stated the need for toenails to be cut would be subjective to the individual giving the bath. If the resident was diabetic, the aide was not expected to cut the toenails. The DON stated the nurse was to sign off on the shower sheet if the resident refused to take a shower. The DON verified the resident refused to shower based on documentation on 08/16/2024, 08/23/2024, 09/03/2024 and the nurse had not signed off on the shower sheet as had reviewed. The DON stated the aide should have taken the shower sheet to the nurse for review. The DON stated the aides needed more education. The DON stated that Resident #44 should have been offered a clothing protector during dining. The DON stated that she was in the dining room for more assistance, as needed. The DON reviewed the care plans and stated that the ADL care plan showed Resident #44 was to have supervision and cuing assistance for eating. The DON stated the ADL care plan showed to provide choice for care provisions, shower twice a week. The DON stated the care plan showed the resident was resistive to care, non-compliant with showers, which was added on 09/11/2024 during survey. 2. During an observation conducted on 09/08/2024 at 09:31 a.m., Resident #51 was observed in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. During an observation conducted on 09/09/2024 at 10:05 a.m., Resident #51 was observed in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m. Resident #51 was observed in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch, barbeque sandwich, baked beans, and cauliflower. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. During and observation and interview conducted on 09/10/2024 at 5:00 p.m. with the DON, Resident #51 was observed eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream. The resident was in her room attempting to feed herself. Resident #51's fingernails were observed to be extended past her fingers on both hands. The resident told the DON her nails were too long, and she wanted them trimmed. The resident was observed putting her fingers and nails into her cup of vanilla ice cream. The DON stated the long nails in her food including her ice cream was not acceptable and was an infection control issue. He stated his expectation was for the resident's fingernails to be cut by the nurse. After observing Resident #51 eating, the DON stated she needed more assistance with dining, more than just set-up. The DON stated he would check Resident #51's therapy evaluations. The DON stated even though the evaluations showed her weight loss was unavoidable due to Resident #51's medical conditions, they (the staff) could do better with assisting the resident to eat. Resident #51 was admitted to the facility with diagnoses that included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, and acute pain. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, personal hygiene. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. A shower refusal on 09/09/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does need toenails cut, no signature by nursing 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing Review of the care plans showed Resident #51 had an ADL (activities of daily living) self-care deficit related to ADL needs and participation vary, chronic medical conditions, confusion, impaired balance, limited mobility. The care plan was updated on 09/10/2024 (after start of survey). Interventions included but were not limited to the resident was dependent on staff for bathing needs, including transfer into and out of shower as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as of 05/23/2024. Observe resident for changes in ADL capabilities. Notify nurse, therapy, and/or MD as indicated as of 05/23/2024. During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets did indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. The DON reviewed the care plans for Resident #51. The DON stated he spoke with the resident's Occupational Therapist (OT) and the resident was on case load for Speech Therapy currently. The OT stated she was working with the resident but not related to eating or the need for assistance. The DON stated OT was picking the resident up today, 09/11/2024. The DON stated he reviewed the resident's weight and it was actually up from admission. The DON stated the resident's weight had been fluctuating and staying steady. The DON stated even though, the resident could use some assistance (with eating). The DON stated the aide and the floor nurse should be observing the resident's eating first and the need for eating assistance. The DON stated the resident was resistive to assistance. The DON stated the resident used to be out of her room more, but was refusing to come out of her room. Review of the facility's policy, ADL Care and Services, revised 01/2024 showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 2. The existence of a clinical diagnosis or condition does not alone justify at decline in a resident's ability to perform ADL's. 4. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident in accordance with the plan of care, including some appropriate support and assistance with: a. hygiene parentheses bathing, dressing, grooming, nail care and oral care parentheses; d. Dining (meals, hydration, and snacks). 6. To improve or minimize a resonance functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident has the right to refuse any and all ADL care. The refusal of care will be documented in the resident's medical record with appropriate notification including the physician and resident representative. 8. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

Based on observation, interview and record review the facility failed to ensure that three (#3, #4, #5) of three residents sampled for accidents out of a total sample of 10 residents received the appropriate supervision and assistance devices to prevent falls. Resident #4 sustained a fall resulting in a right femur fracture while being transported in the facility's mini-bus without the use of a seatbelt. In addition, Resident #3 had at least 13 falls in less than 30 days and Resident #5 sustained at least 6 falls in 43 days, one which resulted in a transfer to the hospital with staples to the head. The facility failed to conduct root cause analysis and implementation of new/effective interventions to prevent continued falls for Resident #3 and #5. Findings included: 1. On 01/09/19 at 11:20 a.m., Resident #4 was observed lying in bed with the head of the bed elevated, side rails in the up position, and a foot cradle was present at the end of the bed. The resident's call light was within reach, she had books on her bedside table, and she was wearing glasses. The resident had a knee/leg immobilizer in place on the right lower extremity. Resident #4 informed the surveyor that she had broken her leg and it really hurt. She stated that she had an immobilizer on her leg after having surgery in which they had put a plate into her femur. She stated that this fracture occurred while on her first trip on the facility's mini-bus when they went to the store. She stated, the staff bolted her wheelchair to the mini-bus, but did not belt her into the wheelchair. The mini-bus stopped, she fell out of her wheelchair, and she was scrunched up into the wheelchair in front of her. She stated that the aide and recreation person put her back in her wheelchair and buckled her into her wheelchair after the fall. She stated that it did not hurt that much at first, but it started hurting later. Subsequently, when she got back to the facility, they did a portable x-ray on her leg. They found out it was broken and sent her to the hospital. She stated that there was a bus driver, an aide and an activity person on the mini-bus at the time of the event. She stated that they could have buckled her up, but they didn't. She stated that she was having therapy in her room and had been to Bingo twice since the event, but it was too painful. She had not been on anymore mini-bus trips since the incident. She reported that she was unable to walk but a few steps prior to the accident. A review of Resident #4's clinical record revealed she was originally admitted to the facility in (MONTH) of (YEAR) and was recently readmitted to the facility on [DATE] post fall. Admission record showed [DIAGNOSES REDACTED]. Record review of a significant change Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). The resident was coded to require extensive assistance of two for bed mobility, total dependence for toileting, and transferring did not occur. The resident had impairment of one lower extremity, was receiving pain medication for frequent pain of a level of 5, and she had a history of [REDACTED]. A review of the previous MDS (annual) dated 10/11/18 revealed a BIMS score of 15, extensive assistance of one for bed mobility, extensive assistance of two for transfers, and total dependence for toileting. Record review of physician orders [REDACTED]. / knee / ankle starting 12/20/18. The following new medications were ordered post fracture: [MEDICATION NAME] sulfate 15 mg every 4 hours as needed for severe pain; [MEDICATION NAME] HCL 25mg every 6 hours as needed for pruritus as of 12/24/18; and [MEDICATION NAME] Powder 17 gram by mouth daily for constipation. Record review of a Customer Transfer Form dated 11/21/18 showed Resident #4 was transferred to the hospital on [DATE] due to an acute [MEDICAL CONDITION] distal femur. Record review of a Therapy Screen dated 11/28/18 showed the following changes occurred creating impairments of self-care for the upper and lower extremities; positioning, bed mobility and increased pain. Review of the Pain Assessment performed on 11/28/18 showed changes in sleep, quality of life and mobility due to pain (post fracture). Record review of care plans showed the following care plans for Resident #4. Resident at risk for alteration in comfort related to impaired mobility and had as needed pain medication due to fracture of right distal femur revised on 11/28/18. Interventions included but not limited to administer around-the-clock medication for predictable pain; complete pain evaluation tool when pain was identified; evaluate for non-pharmacological interventions for pain; evaluate for resistance to care, decrease mobility or decrease in range of motion due to pain; immobilizer to right lower extremity due to femur fracture-on at all times; pain medications as ordered. Resident #4 was at risk for alteration in skin integrity related to decrease mobility, revised on 12/19/18. Interventions included but not limited to assist to turn and reposition frequent for comfort; foot cradle to end of bed. Resident had a documented fall prior to admission to facility initiated on 10/24/18 with a revision date of 11/25/18. Interventions included but not limited to anticipate and meet needs; Dysum to wheelchair; therapy. Record review of the hospital records revealed Resident #4 was admitted on [DATE] and discharged on [DATE] with an acute right distal femur fracture, comminuted, extra-articular. The discharge summary stated that the patient was riding a bus in her wheelchair, and she was not strapped in. The bus stopped, and the patient slid forward hitting the ground. Resident was status [REDACTED]. She underwent an ORIF and post-op was stabilized in terms of pain control and management of her chronic medical conditions. The resident was non-weight bearing on the right lower extremity, and knee immobilizer while sleeping. It was okay to remove the immobilizer for motion exercises by PT. During an interview on 01/09/19 at 1:30 p.m. Staff A/Activity Aide, stated that normally they go on outings in the mini-bus every Tuesday. They go to the store every other week and to a restaurant or something else every other week. She stated that there was always another aide on the mini-bus, which makes three staff members on the mini-bus. She stated, we can transfer some of the residents into the mini-bus seats and buckle them up. In addition to those residents, we can have up to four residents in their wheelchairs in the back. The mini-bus seats eight people plus 4 wheelchairs. She stated that the mini-bus driver and the other aide put the residents on the mini-bus. She stated that the aide latches the wheelchairs onto the mini-bus normally, while the driver mans the lift gate. She stated that they had never buckled the residents into their wheelchairs prior to the incident (involving Resident #4 on 11/20/18). She stated that Staff C, the Bus Driver/Assistant Director of Activities, had hit the brakes and Resident #4 slid out of her wheelchair onto her knees behind another resident's wheelchair. She stated that the mini-bus was not stopped. She stated that she and Staff B, a Restorative Aide, came from the front of the bus and assisted Resident #4 back into her wheelchair. The resident did not have a complaint of pain. She stated that after Resident #4 had fallen out of her wheelchair, they put a harness/strap hanging from the ceiling of the mini-bus around the resident's waist. They hooked this harness/strap onto her wheelchair for the rest of the trip to the store and back to the facility. She stated that there were three others in wheelchairs on the mini-bus at the time, but Resident #4 was the only one we seat belted in her wheelchair after the fall. We continued on to the store for shopping and eating lunch. Staff A stated, she asked Resident #4 if she was in pain and she stated no. She stated that Staff B was with the resident during the shopping trip, and she was acting fine. Staff A stated that she thought the resident started complaining of pain when she was getting out of her wheelchair and back into bed. During this time, Staff A thought that Staff C, Bus Driver, was doing a report on the incident. Staff A stated that they had been trained about a month ago (after the incident) on how to seatbelt the residents into their wheelchairs. She stated that the facility had also ordered new seatbelts for the mini-bus since the incident. The mini-bus had not gone out since the incident as they were waiting on seat belts to be put in. She stated that she did not know if there were 4 harness / straps available for the 4 wheelchairs. Staff A stated that she had never been in-serviced on buckling of the residents into their wheelchairs prior to the incident. She stated that since the incident they had been in-serviced on how to buckle the resident in their wheelchair and how to secure the wheelchair in the mini-bus. She stated that her understanding was the mini-bus will not go out again until after the seatbelts and maintenance were completed. She stated that they are supposed to be trained on how to use the new seat belts. She stated that they were trained that any time they have an incident, they were not supposed to continue on, but to call 911. They are to call the facility at the time of the incident and come back to the facility. Staff A stated that based on Resident #4's incident, they should have stopped, called 911 and the Emergency Medical Technicians (EMTs) would have evaluated the resident. We also should have called the facility at the time of the incident. During an interview on 01/09/19 at 1:55 p.m., Staff C (Bus Driver/Assistant Director of Activities) stated that he had been driving the mini-bus about 3 years with no incidents until (MONTH) (YEAR). He stated that they went out every Tuesday. Staff C reported that he puts the residents on the lift, and the aide puts the resident in the spot she wants them on the mini-bus and straps down their wheelchair to the mini-bus. Staff C stated that he was trained to strap the wheelchair to the floor of the mini-bus. Staff C stated he was never taught to use the harness / seatbelt. He stated that there was only one harness / seatbelt in the mini-bus and it was not being used. He stated that they were able to place 4 residents with wheelchairs in the back of the mini-bus but they only had one harness / seatbelt. Staff C stated that on the day of the event (11/20/18), he hit the brakes, and Resident #4 fell out of her wheelchair onto the floor. He stated that he put his flashers on (emergency hazard lights) and the aides helped her back into her wheelchair. The aides asked her if she was in any pain. He stated that the resident never complained of any pain, and he figured she was okay. He stated that the aides put the harness / strap over her onto her wheelchair. They then went on to the store and everybody shopped and ate. After the trip we brought them back to the facility and lifted them out the back of the mini-bus. Staff C stated he went to his desk and then to Staff D's office (Activity Director) to report the incident. He stated that a nurse came to him and Staff A asking about Resident #4's fall. Staff C stated that he explained the incident to Staff D, verbally. He stated that he did fill out a report as to what happened. Staff C stated that since the incident, they have been trained on how to strap the wheelchairs down and should use the strap / harness. He stated that the mini-bus had not gone out since the incident due to needing repairs. He stated that new seatbelts / harnesses were being put into the mini-bus for each wheelchair. He stated that he had training before the holidays but had not used the mini-bus with the seat belting of residents yet. He stated that if Resident #4 had been grimacing, he would have called 911 or the facility. He stated that he had not been instructed to call 911 or the facility. During an interview on 01/09/19 at 2:06 p.m., Staff B, Certified Nursing Assistant (CNA)/Restorative Aide stated that the mini-bus was used every Tuesday for outings and she had gone on the last few trips. She stated that she moves the residents into the lobby and three staff members load the residents, one by one, onto the mini-bus. The wheelchairs were in the back of the bus and there were places for 4 wheelchairs. She stated that we strap the wheelchair to the mini-bus. Staff B stated that they did not have a wheelchair seat belt. She stated that there were parts missing on the seat belts on the van so they could not be used. She stated that there was one harness / strap available at the time of this trip, but it was not being used, because it was broken. She stated that after the incident / fall we tried to tie her in the wheelchair on the way to the store and secure her in for the trip back. She stated that prior to the resident being strapped in, Staff C was coming to a stop light and stepped on the brake. The resident said uh-oh but by then, she was already down on the floor on her knees. She slid into another resident's wheelchair that was in the front of her. Staff B stated that she and Staff A went to the back and asked Resident #4 if she was okay. We asked her about her legs and she said she was not hurting. We pulled her back up into her wheelchair. She stated that the resident said she was okay. We continued on and went shopping and ate. Staff B stated that she was pushing the resident around in the store and she had no complaints. After shopping, they went back to the facility. Staff B stated that while the resident was being unloaded, she said her leg was hurting. She stated that before she could tell the nurse what happened, the resident told the nurse she had fallen out of her wheelchair on the mini-bus. The resident told the nurse she was hurting. Staff B stated that since the incident, a government agency was contacted. She stated that she had given statements to the governing agency, and Nursing Home Administrator (NHA). Staff B stated that following the incident they had been trained on how to strap the wheelchair in the mini-bus and how to use the harness / strap. She stated that the mini-bus had gone out for service and to be checked out. The mini-bus had been sent out for a complete overhaul. She stated that she had been trained twice on the seatbelts. She stated that the facility trained the restorative aides and activity aides. During an interview on 01/09/19 at 2:55 p.m. Staff D, Director of Activities, stated that he was kind of over the mini-bus trips. He stated that they got the mini-bus about 5 years ago. He stated that he and Staff C, the Bus Driver, were originally trained by the property manager. He stated that everything had stayed the same and Staff C trained the aides in (MONTH) of (YEAR). After this incident, we were all retrained by the maintenance manager and property manager. He stated that prior to this incident, he was not sure whether the harness / strap was being used or not to secure the residents in their wheelchairs. He stated that there were harnesses in bags on the sides of the mini-bus which contained harness / straps to secure the residents in their wheelchairs. Staff D stated that either the staff did not know they were there or were not using them. He did not know how long the residents had gone without being belted in their wheelchairs while on the mini-bus. He stated that the mini-bus was down now due to needed maintenance. The company decided they would install new seatbelts into the mini-bus before it goes out again. They are a more user-friendly type of seat belt. Staff D stated that from what we have been instructed now, the driver would be responsible for the safety and would do an inspection check list before and after each outing. The driver was to do a walk around and inspect the inside and make sure everyone was locked in. He stated that they trained anyone who would go on a trip to include all the restorative aides, activity staff, maintenance director, and the activities director. He stated that the mini-bus driver was ultimately responsible for the safety of the residents, but all staff was responsible. They were trained to pull the mini-bus to the side of the road, call 911 and call the supervisor or administrator at the facility if an incident occurred. They were trained that the procedure for the mini-bus was the same as if someone fell in the facility. During an interview on 01/10/19 at 1:07 p.m., Staff E (Maintenance Director) stated that it was the responsibility of the driver to report anything wrong with the mini-bus so it can be checked on. He stated that maintenance does a safety check on the mini-bus monthly. He stated that he was on vacation the weekend after the incident on 11/20/18 and checked the harness / straps when he returned on Monday. He stated that the harness / straps were in working order. He stated that the straps to hold the wheelchairs were also working. He stated that there were 3 sets of harness / straps in bags on the mini-bus that were available to be used to strap the residents into their wheelchairs. He stated that the ones that we had before did not have lap belts and only had a strap that went across the chest. The ones now were a manual tie down system. The new seatbelt system was retractable and went across the shoulder and had a lap belt. When asked why the staff that was interviewed that was on the mini-bus during the incident had not mentioned and were not aware of these harness / straps in bags on the mini-bus, he stated that he thought the Director of Activities knew how to use the chest belts. He stated, he thought the driver had been instructed when the mini-bus first came into use. When asked who was responsible to assess that the driver was using the safety devices properly, he stated, I don't know, not me. He stated that after the incident, they were trained on how to use the seat belt so they can train the others and do refreshers. He stated that there were only three working harness / straps which was why they only put three wheelchairs on the mini-bus instead of 4. He stated that currently, the mini-bus was not being used due to being serviced and to have the new seat belts put in. He stated that after the incident the aides and activity personnel were trained on how to use the seatbelts. He stated that they updated the checklist for the driver also. On 01/10/19 at 1:45 p.m., the NHA and the Maintenance Director provided Transportation Log Sheets and Inspection Sheets for (MONTH) (YEAR) through (MONTH) 20, (YEAR). They showed the seat belts not frayed, cut or torn and are in good working order for every trip taken. When asked who was responsible for ensuring the driver and staff knew about the harness / straps in the bags on the mini-bus and was a follow-up safety competency training performed after orientation? The NHA stated that he did now know and that he would have to ask the property manager. The NHA stated that the driver was under the Director of Activities. During an interview on 01/10/19 at 8:30 a.m. Resident #7 stated that she was on the mini-bus when Resident #4 fell out of her wheelchair. She stated that she had been on the mini-bus twice and the staff only strapped the wheelchair to the mini-bus. The staff did not strap her into the wheelchair or use seatbelts. She stated that the facility told her they were not going out again until the seat belts were put in the mini-bus. During an interview on 01/10/19 at 8:41 a.m., Resident #8 stated that she usually goes on the mini-bus trips twice a month. The staff had only strapped her wheelchair into the mini-bus, they had not seat belted her into her wheelchair. The resident had contractures of both of her hands. She stated that they have not gone out on the mini-bus since the incident because the mini-bus was getting fixed. During an interview on 01/10/19 at 8:42 a.m., Resident #9 stated that she goes on the mini-bus trips. She stated that the staff only strap her wheelchair in, but not her into the wheelchair. During an interview on 01/10/19 at 8:40 a.m. Resident #10 stated that he goes on excursions on the mini-bus. He stated that they only strap his wheelchair in, but he has a seatbelt on his wheelchair and doesn't need to be seat belted in. 2. On 01/10/19 at 8:25 a.m., Resident #3 was observed to be an elderly frail gentleman in a low bed with ½ side rails in the up position. He had his feet on the floor and was rocking like he was trying to get out of bed. The surveyor called the nurse, and she assisted the resident back into bed. He had an air mattress in place. He stated that he could not eat right now. Staff F, Licensed Practical Nurse (LPN) stated that he was a fall risk and had things in place. She stated that he usually stays in bed until he was fed his breakfast. After that, they get him up and place him at the nurses' station to be observed. She stated that he also went to Physical Therapy (P.T.). A review of Resident #3's clinical record revealed he was admitted on [DATE] with a readmission on 01/05/19. The admission record showed [DIAGNOSES REDACTED]. Record review of the 14-day admission MDS dated [DATE] showed a BIMS score of 03 (severe impairment). The resident was coded to require extensive assistance for bed mobility, transfers and toileting. The resident had two or more falls and required antipsychotic and hypnotic medications. Record review of physician orders [REDACTED]. Record review of the progress notes showed the following: On 12/13/18 at 2 a.m., Resident #3 was found on the floor by the bed side. His socks were on and the bed was in the lowest position. On 12/13/18 at 6:00 a.m., resident was found post fall. The resident was assessed head to toe and helped back to bed by three attendees and the Hoyer lift. On 12/13/18 at 9:45 a.m., resident was found on the floor at the bedside on his knees. He had slip resistant socks on. No signs of visible injury noted. When asked what happened, his response, I don't know what happened. Resident was removed from floor to bed via Hoyer lift machine with 2 staff members. Physician was present in facility and gave orders for safety measures, neuro checks, and blood glucose check related to history of diabetes. The side rails were in the up position. The bed was in the lowest position. Aide to make frequent rounding. Interdisciplinary Team note showed pain and skin evaluation for three days, hip savers in place and frequent rounding. On 12/13/18, PT evaluation today for therapy. On 12/14/18 at 3:10 p.m., resident found stuck. Removed foot from resident's bed rail. His pedal pulse was present. His physician was notified and an x-ray was ordered to rule out fracture. Redness and abrasions noted to side of foot. On 12/22/18 at 5:30 p.m., resident observed on the floor lying on his side facing toward the bed. No skid socks on and wrapped in blankets. Resident was assessed. He was transferred to bed. He had no complaints of pain. On 12/23/18 at 7:45 p.m., resident observed on the floor. Resident was assessed. On 12/24/18 at 8:00 a.m., resident was observed on the floor next to the bed near the window facing the back wall in sitting position. He had on hip savers and non-skid socks. He complained of general pain and was able to move all four extremities with no limitations. He was assisted off the floor onto chair and put outside in the hallway for observation. He was given as needed Tylenol for pain. Order was given for neuro checks every shift for 48 hours. On 12/24/18, an IDT note showed reviewed fall on 12/22/18; resident was alert with confusion noted; legally blind. Interventions included intentional rounding, psych consult, neuro checks for 72 hours, and skin and pain assessment for 3 days. On 12/24/18 at 2:03 p.m., psych saw resident today and recommended resident see psychiatrist. Psychiatrist increased [MEDICATION NAME] to 50 mg three times a day. On 12/26/18 at 6:42 a.m., resident was trying to get out of bed on several occasions. Resident was aggressive, violent and very combative. On 12/27/18 at 2:45 p.m., resident was observed on the floor in the hallway. He was sitting on w/c near customer room observed on the floor in the hallway. He was able to move upper extremities and was able to move bilateral lower extremities and wiggle bilateral toes. He was complaining of left ankle pain. Non-skid shoes were on. He was lifted off the floor with Hoyer lift on to the bed. No skin tears or bruising noted. Physician was called and a new order for x-ray. On 12/28/18 at 10:24 a.m., IDT reviewed fall on 12/27/18. Therapy for positioning in wheelchair. An ankle x-ray was completed. Skin and pain assessment for 3 days and neuro checks for 72 hours. On 12/28/18 at 12:05 p.m., resident observed on floor in the hallway near the dining room. He was on his right hip facing the window. He had hip savers on and non-skid socks. Resident complained of pain in left shoulder and bilateral hips. A new order for left shoulder and bilateral hip x-rays given. On 12/29/18 at 10:30 a.m., resident was observed on the floor next to his bed. Non-skid socks on. Call light within reach. He complained of bilateral hip pain. Range of Motion assessment incomplete due to complaint of pain. He was sent to the hospital for evaluation. On 12/31/18, the IDT team set up a care planning meeting with family. Pain and skin evaluations every shift for 3 days. Pain medication evaluation recommended. Activated with headphone with soft music. On 01/06/19 at 3:30 p.m., the resident appeared to have slid off the right side of the bed onto the floor. The sheets were under him and wrapped around his lower extremities. His bed was in lowest position. He had non side socks on. Hip savers had been removed by the resident. Resident was assessed with [REDACTED]. On 01/06/19 at 9:55 p.m., resident found on the floor on his left side with head beneath the sink. Resident denies pan and denies hitting his head. Resident stated that he walked over to where he was lying and laid down because the floor was warmer there. No injuries noted. Assisted back to bed. On 01/09/19 at 11:01 p.m., resident was observed crawling out of bed to lay on the floor. Resident took his covers and made a pallet and went to sleep. Nurse and aide put resident back to bed. On 01/10/19 at 1:05 a.m., resident was observed on the floor. He was assessed by the nurse and transferred back to bed by the nurse. Record review of physician progress notes [REDACTED]. Medications reviewed including anti-hypertensive, reviewed receiving several that can result in weakness and [MEDICAL CONDITION] if given simultaneously. Will obtain UA with reflex Culture and sensitivity, and ammonia level to rule out hepatic [MEDICAL CONDITION]. Add [MEDICATION NAME] 7.5 mg daily and change Losartan to evenings. Request psych review timing of psych medications and additional recommendations. Continue with fall management strategies. Record review of Resident #3's care plans showed the following: Resident had an actual fall related to unsteady gait on 12/13/18. Interventions included customer to wear hip savers initiated on 12/13/18 with update on 12/24/18; frequent rounding on 12/13/18 and update on 12/24/18; low bed when customer in bed on 12/24/18. Resident had a [DIAGNOSES REDACTED]. Intervention of Speech Therapy as of 01/07/19. Resident a risk for falls as of 12/12/18. Interventions included but not limited to anticipate and meet needs as of 12/12/18; be sure call bell is in reach at all times when in room as of 12/12/18; wearing appropriate non-slip, well-fitting footwear when indicated as of 12/12/18; maintain clutter -free environment in room as of 12/12/18; provide activities that minimize the potential for falls while providing diversion and distraction as of 12/12/18; Physical Therapy on 01/07/19; recreation to trial use of headphones with music cd's on 12/31/18; remind customer to use call light when attempting to ambulate or transfer as of 12/12/18; review pain management on 12/31/18; and meet with family to review on 12/31/18; when in bed, place all necessary personal items within reach as of 12/12/18 An interview on 01/10/19 at 2:13 P.M. with the Risk Manager (RM) revealed that a fall risk assessment was done on admission and readmission only. All falls were discussed daily during the stand-up meetings. They review each resident that has fallen, see what happened and put an intervention in place and update the care plans. During an interview on 1/10/19 at 3:33 pm., the RM reviewed Resident #3's chart and was unable to find interventions put into place at the time of the falls or a new and effective intervention for each fall. 3. Observation on 01/10/19 at 8:55 a.m. of Resident #5 revealed she was lying in bed with the head of the bed elevated. She was eating her breakfast and was unable to answer any questions. Her wheelchair was at the bedside and her call light was within reach. Interview of Staff G, LPN, revealed that Resident #5 has had some medication changes and she was not as lethargic. They adjusted her blood pressure medications as well as her [MEDICATION NAME]. She used to maneuver by herself and now she requires extensive assistance of one for dressing. She was to use non-skid socks and be up in a wheelchair. A review of Resident #5's clinical record revealed she was originally admitted in (MONTH) of (YEAR) and most recently readmitted on [DATE]. Admission record showed [DIAGNOSES REDACTED]. Record review of the significant change MDS dated [DATE] showed a BIMS score of 05 (severe impairment). Resident required limited assistance for bed mobility and transfers; and extensive assistance for toileting. Resident had two or more falls. Resident required antianxiety, antidepressants and diuretic medications Record review of the physician orders [REDACTED]. Record review of recent progress notes showed: On 11/28/18 at 2:22 p.m., on floor in bathroom between the toilet and bathroom wall in resident's room. Resident stated she was trying to sit on the toilet and missed the toilet. She was assisted back on to toilet to finish. She was assessed. She complained of pain to right knee and hip. Pain medication was ordered by physician. On 11/29/18 at 11:20 a.m., resident found on floor. Resident had full range of motion. She had no complaints of pain. Neuro checks were initiate

Based on facility record review, hospital record review, state agency reports review, and interviews the facility did not ensure treatments for a pressure ulcer were being completed, leading to an infected wound that increased in size and stage for 1 resident (#2), and the facility did not ensure treatment orders were followed for 1 resident (#1) during the wound care observation, of 3 residents reviewed for wound care. Findings included: 1. Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. Medical record review showed the following findings: On 2/6/2018, a skin assessment showed B. Are there any new areas identified 1. No A Skin report the following day, on 2/7/2018, showed a stage 2 pressure ulcer on the coccyx that was 2.5x 3.4x 0 cm. Weekly skin report dated 2/16/2018 showed the stage 2 on the coccyx was 3.7x 5.5x 0.2 cm with granulation tissue and serous (clear) drainage. On 2/20/2018, the skin report stated 'pressure ulcer on coccyx under treatment'. There was no indication of size, description, drainage, or stage. On 2/23/2018, the skin report revealed the stage 2 of the sacrum was 3.2x 5x 0.2 cm with slough (dead tissue) and serous drainage. The documentation on 3/2/2018 showed the sacral pressure ulcer, stage 2 was 3.9x 4.5x 0.2cm with slough and serous drainage. Facility staff had not completed a skin report (assessment) for 14 days, from 3/2-3/16/2018. The next skin assessment, 3/16/2018, showed the sacral wound was 5.8 x6 x 2.1 cm. Staging was not documented. There was no description of drainage or wound bed. The skin report dated 3/21/2018 showed the coccyx wound measured 2.5x 3.4x 0 cm. stage 2 with granulation tissue, no drainage. The skin report dated 3/23/2018 showed the sacral wound was 5.8 x 6x 2.1cm. The stage was not indicated. A description of the wound or any drainage present was not documented. A Medical record review of the resident's Quarterly MDS dated [DATE] showed: Wounds-1 unstagable pressure ulcer 3.7x5.5x0.2 with slough MDS dated [DATE]; Significant Change showed the wound had increased in size and depth, as indicated by the following: Section M, skin conditions M0210. Unhealed pressure ulcer (s) Does the resident have one or more unhealed pressure ulcers at stage 1 or higher. Yes M0300. Current number of unhealed pressure ulcers at each stage Stage 4 pressure ulcers, D1. 1 D2 Number of these stage 4 pressure ulcers that were present on admission/entry or reentry, 0 M0610. Dimensions of unhealed stage 3 or 4 pressure ulcers or eschar A. Stage 3 or 4 pressure ulcer longest length 05.8 B. B. Pressure ulcer width 06.0 C. C. pressure ulcer depth 02. M0700. Most severe tissue type for any pressure ulcer 3. Slough physician's orders [REDACTED]. 2/6/2018 apply dermaseptin to coccyx every shift for wound care 2/12/2018 cleanse with normal saline; apply [MEDICATION NAME]; cover with dry dressing until resolved. 2/14/2018 cleanse wound to sacrum with normal saline; apply [MEDICATION NAME]; cover with dry dressing until resolved 2/15/18 Cleanse wound to sacrum with normal saline; apply [MEDICATION NAME]; cover with dry dressing until resolved every day shift. 2/22/2018 santyl ointment 250 unit/gm ([MEDICATION NAME]) apply to sacrum topically every day shift for wound, skin prep peri-wound, cover with dry dressing, and as needed for dislodgment. 3/3/2018 santyl ointment 250 unit/gm ([MEDICATION NAME]) apply to sacrum topically every day shift for wound apply mupirocin 2% and santyl to wound bed, skin prep peri-wound skin, cover with calcium alginate and dry dressing. 3/3/2018 mupirocin ointment 2% apply to sacral ulcer topically every day shift for wound care apply mupirocin 2% and santyl to wound bed, skin prep periwound skin, cover with calcium alginate and dry dressing, and as needed for dislodgment. 3/10/2018 santyl ointment 250 unit/gm ([MEDICATION NAME]) apply to sacrum topically 2 times a day for dressing skin prep periwound, apply santyl to wound bed then pack with GCP saturated calcium alginate cover with dry absorbent bid and prn. 3/12/2018 santyl ointment to sacrum every day and evening shift for wound. Cleanse with wound cleanser pat dry start santyl to wound bed pack with GCP saturated calcium alginate, skin prep peri wound cover with dry dressing and apply to sacrum topically as needed for wound if soiling dislodgement 3/14/2018 [MEDICATION NAME] powder apply to sacrum topically every day shift for wound. Cleanse sacral wound with wound cleanser pat dry apply powdered [MEDICATION NAME] 1000 mg, then santyl to wound bed skin prep periwound skin cover with calcium alginate and dry dressing. 3/16/18 Santyl ointment 250 unit/gm ([MEDICATION NAME]) apply to sacrum topically every day and evening shift for wound, cleanse wound with wound cleanser pat dry start santyl to wound bed pack with GCP saturated calcium alginate, skin prep peri wound cover with dry dressing. Also as needed for soiling/dislodgment. Review of the Treatment Administration Records indicated treatments were not completed from 2/17-2/22/18. There were no signatures for the [MEDICATION NAME] or santyl on those dates. Additionally, treatments were not signed on 3/1/2018 or 3/2/2018, indicating the santyl was not being applied. Further review showed treatments were not signed on 3/11/2018, indicating the santyl and mupirocin ointment was not applied, and from (MONTH) 14 to (MONTH) 16, (YEAR), neither the santyl nor the [MEDICATION NAME] powder had been applied, or the GCP packed calcium alginate ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME] triple antibiotic solution). During review of the treatments in (MONTH) of (YEAR) with the DON at 11:40 p.m. on 11/14/2018, she confirmed there was no documentation that treatments were provided on the 11th, 14, 15th, and 16th of March. The Wound Consultant Provider's notes were also reviewed and the following information confirmed the resident's wound had deteriorated: On 2/16/2018 measurements at that time were 3.7x 5.5x 0.2 cm. no odor, scant serous drainage, unstagable. The Consultant saw the resident again on 2/23/2018 and measured the wound at 3.2x 5x 0.2 cm. no odor, small serous drainage, stage 3. When the consultant saw the resident again, on 3/2/2018, the sacral wound was a stage 3. It measured 3.9x 4.4x 0.2 cm. with small serous drainage, no odor. On 3/9/2018, the Consultant's assessment showed the sacral wound was now 5x 5x 0.7cm. Stage 3, with serosanguianous (bloody) moderate drainage, and an odor was present, indicating infection. The consultant debrided the wound at that time. On 3/16/2018 the consultant documented that the sacral wound was now a stage 4, measuring 5.8x 6x 2.1cm. No odor present and moderate serous drainage. On 3/23/2018, the Consultant documented a Stage 4 sacral ulcer measuring 5.5x 5.5 x1.8 cm. with undermining at 6 o'clock of 3.5cm. Moderate serous drainage and no odor. The wound was debrided again. A wound culture was collected on 3/12/2018. Results received on 3/17/2018 showed the wound was infected with Proteus Mirabealis, Morganella Morganii, and few colonies of E. Coli. On 11/15/2018 at 8:18 a.m., an interview was conducted with the acting DON at that time, who has since retired. She said orders were put in the computer and the nurses do them. When she was asked about how she ensured nurses were doing treatments, she said she doesn't remember if she ever checked treatment records. An admission record, dated 3/29/2018, from a hospitalization showed an advanced state sacral decubitus ulcer, stage 4, concern for infection and surrounding tissue [MEDICAL CONDITION]. The resident's son told the attending physician in the emergency room that the resident had a decubitus ulcer that the nursing home had been taking care of for 2 weeks, and it was recently debrided. According to a state agency report dated 3/30/2018, the initial assessment of the wound in the emergency room showed that upon removal of the dressing covering the wound, there wasn't any packing present, and the wound had yellow drainage. The last order for the wound care at the facility had included, GCP saturated calcium alginate packing. There was also undermining present. Photos obtained at that time showed the pressure ulcer was located on the coccyx, was approximately 6.0 x7.0 cm. and unstagable. There was visible slough near the top of the wound at 1:00. The surrounding tissue was excoriated - irritated and peeling. On 12/3/2018 at 12:20 p.m. in an interview with the resident's Physician she said she felt the care at the facility was good, however, because of high staff turnover with CNAs there is probably some inconsistency in continuity of care and their ability to recognize a change in someone who they may not be familiar with. She said she talks to CNAs when she makes rounds because they are with the residents more than anyone else, and if they're not familiar with the resident they may not know when there is a change. She said she did not look at the wound because there was a wound care consultant following the resident and they generally don't like it if you change their orders. They are the specialist, so she generally leaves orders and assessments up to them. The Skin Practice Guide, undated, provided by the facility showed: Evaluation and treatment of [REDACTED].>It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional ulcers or the deterioration of the pressure ulcer (s) be recognized and evaluated. Differentiate the type of ulcer (pressure related versus non-pressure related) interventions may vary depending on the type of ulcer; Determine the ulcer's stage; Describe and monitor the ulcer's characteristics; Monitor the progress toward healing and for potential complications; Evaluate, treat and monitor for pain, if present; and Monitor dressings and treatments. Staff should remain alert to potential changes in the skin condition and should evaluate and document identified changes. For example, a resident's complaint about pain or burning at a site or a nursing assistant's observation during the resident's bath that there is a change in skin condition should be reported so that the customer may be further evaluated. Ulcer Characteristics It is recommended that a facility have a system in place for monitoring skin, periodic documentation of measurements, terminology, frequency of evaluation, and documentation consistently throughout the facility. When a pressure ulcer is present, monitoring, (with accompanying documentation, when a complication or change is identified), may include: An evaluation of the ulcer if no dressing is present; An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); The status of the area surrounding the ulcer (that can be observed without removing the dressing); The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound). With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. Documentation may include the date observed and: Location and staging; Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and presence, location and extent of any undermining or tunneling/sinus tract; Exudate, if present: type (such as purulent/serous), color, odor and approximate amount; Pain if present: nature and frequency (e.g., whether episodic or continuous); Wound bed: color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar) and; Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate. 2. Record review of the care plan revealed Resident (#1) was a dependent resident. The face sheet specified the resident had [DIAGNOSES REDACTED]. Data from the Minimum Data Set (MDS) revealed -BIMS: Resident has severe impairment 0.0. Record review of the Weekly Skin Reports for Resident #1: First noted, 10/13/16, granulation tissue red, no drainage. 10/26/18: sacrum pressure-0.9 x 0.5 x 0.6, stage 2. 11/02/18: sacrum pressure ulcer-0.5x 0.5 x 0.6, Stage II, granulation tissue, no drainage, red. 11/09/18: sacrum pressure ulcer- 0.6 x 0.5 x 0.6, Stage 2, granulation tissue red, no drainage. Record review of the Physician order [REDACTED]. Wound Care- An observation of wound care with Nurse-H, RN, at 12:08 p.m. on 11/13/18, revealed: Nurse H collected Silva-Kollagen wound gel tube, a piece of foil, two skin prep pads, a medicine cup, adhesive, Island dressing 6x6, and 4x4 gauze pads stack-three fingers high. Nurse H used Disinfectant Towels with Bleach. Then collected alcohol pads stack, and 2 tongue blades. The Aide (I) was assisting Nurse H. At the med cart Nurse H put on gloves, placed all the supplies onto the piece of foil, then entered the room saying, knock, knock. Nurse H returned to the treatment cart and obtained a box of gloves and bleach wipes. Nurse H removed her gloves, rinsed her hands off, and dried. Nurse H put on gloves; took a bleach wipe and wiped off 2/3's of the bedside table. Nurse H removed her gloves. Nurse H told Resident #1 she was going to do her dressing change. Nurse H gelled her hands, allowed them to dry, and then asked Resident #1 if she had any pain. The resident #1 had no response. The Surveyor asked if Resident #1 speaks, both Aide I and Nurse H stated no. The Nurse H moved the trashcan over with her foot to bedside the bed. Aide I had uncovered Resident #1 and pulled the resident's body over to her right side, with her bottom exposed. Aide I covered the resident with a sheet. Nurse H washed her hands with soap and water, dried them and put on gloves. Nurse H dried off bedside table with paper towels, removed gloves, gelled her hands, and allowed them to dry holding hands in the air. Nurse H moved supplies on the foil from the sink, to the bedside table along with a box of gloves. Nurse H closed the blinds, washed her hands, for 10 seconds, dried her hands, and put on gloves. Aide I uncovered Resident #1 and pulled the resident onto her right side. Nurse H removed soiled dressing dated 11/12/18, and placed it into the trash. Nurse H removed her gloves, washed her hands, for10 seconds, and dried them, then put on gloves. The wound was the shape of a curved line with a pencil lead sized hole at the top of the resident's buttock crevice. The Nurse H removed her gloves, washed her hands, and dried them, put on gloves. Nurse H took wound cleanser sprayer, and sprayed onto 4x4 gauze pads and cleaned wound with one wipe, then did a second wipe, with more gauze pads wet with wound cleanser. Nurse H removed her gloves, gelled her hands, put on gloves, and took Silver-kollagen out of the box and opened. Nurse H placed some medication by squeezing tube onto the tongue blade, (dime size amount). Nurse H removed her gloves, gelled her hands, put on gloves. Nurse H took skin prep pads; skin prepped the outside perimeter skin of the wound. Then took a tongue depressor and placed Silva-kollagen gel into wound with the tongue blade. Nurse H removed her gloves, washed and dried her hands, and put on gloves. Nurse H took an island dressing, opened, and took 1- 4x4 gauze pad and placed into the gel on the coccyx wound. Nurse H covered the wound with the island dressing. Nurse H initialed dated and timed the dressing. Nurse H removed her gloves, washed her hands, and dried. Aide I turned the resident onto her back. Placed pillows into resident's back area, to put her into a right tilt. Then elevated the head of the bed. Nurse H cleaned off the bedside table trash. Washing the pen in her pocket and trashing all paper products then removed the Wound spray and hand gel. Nurse H rinsed her hands, dried and put on gloves, took bleach wipes and wiped off the bedside table again. Nurse H took the trash bag to the soiled utility room and dropped into the trash. Nurse H washed her hands. Aide I had removed her gloves and washed her hands then went out of the room to get the resident's lunch tray; bringing it into the room for Resident #1. Record review indicated a Physician order [REDACTED]. The physician orders [REDACTED]. Cover with dry dressing and border gauze dressing/change daily and prn. In an interview at 3:08 p.m. on 11/14/18, with the Director of Nurses (DON) a policy was requested for accuracy from the Director of Nurses. She said, I do not have a policy, I have guidelines. Record review of the Skin Practice Guide undated, provided by the Director of Nursing, stated on page 23, Dressing Techniques for Clean Dressing. Number 1.1-Verify the physician order; number 15.-Apply the ordered treatment to the open dressing. Do not touch the dressing in any way.

Based on resident record review, resident and staff interview and review of the facility's abuse policy, the facility failed to prevent resident to resident abuse for two ( # 11 and # 13) of 21 residents reviewed. The facility failed to provide the necessary intervention and supervision to prevent a male resident (Resident #12), who had been identified with wandering behaviors, from targeting vulnerable residents (Resident #11 and Resident #13). Resident # 12 was known to the facility as a resident who wandered into other resident rooms, yet, no interventions outside of a Wander guard to prevent elopement from the facility and a Psychiatric consult had been put in place and no care plans had been developed to address the wandering behavior and prevent access to other residents. The facility failed to ensure residents were protected from abuse after having knowledge of the actions of Resident #12 towards Residents #11 and #13. In spite of Resident # 11 expressing fear, no follow through was conducted, after [DATE] to determine the mental and psychosocial well- being of Resident # 11. In spite of Resident # 11 alleging that Resident # 13 had been touched by Resident # 12, no assessment was conducted to determine the physical, mental and psychosocial well- being of Resident # 13. In addition, the facility failed to ensure that other residents had not been impacted by the alleged actions of Resident # 12. The failure to prevent access by Resident #12 to vulnerable residents, Resident # 11 and Resident # 13, and the failure to ensure the safety of all residents after knowledge of Resident #12 ' s actions, demonstrated a lack of commitment to ensure residents were free from abuse resulting in findings of Immediate Jeopardy on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 3:26 p.m. Review of the facility's corrective action revealed that the Immediate Jeopardy was removed on [DATE] and the scope and severity was reduced to a "D" . Findings include: 1. On [DATE], at 11:43 a.m., an interview was conducted with Resident #11. Resident #11 was observed to be seated in her room in a motorized wheelchair. Her left hand was noted to be in a splint with her arm positioned on a half tray. Resident #11 stated that she was in fear of retaliation from the staff for talking to the surveyor but agreed to talk with the surveyor. The resident was asked if any facility staff had asked her if she had been inappropriately touched or abused, or seen any other residents inappropriately touched or abused. She stated that no one from the facility had ever asked her that, but she did report abuse recently. She described an incident that she stated occurred on [DATE] and she had reported it to Employee J at the time of the incident and had reported this to the Administrator the same day. She stated that on [DATE] at 3:00 a.m., she was in bed and she awoke to a man standing over her. She stated that she put her call light on and no one from the facility responded. She stated she was scared. She stated she observed the man walk over to her roommate's bed, Resident #13, and she observed him touch her roommate. She stated she couldn't see what else he was doing and she did not hear him say anything. She stated she yelled out for the nurse and the nurse (Employee J) came in the room and removed the man from her room. She stated that she told the nurse that the man was touching her roommate. She identified the man as a male resident who lived in a room across the hall from her room and who died on [DATE]. Resident #11 also indicated that she had told the Administrator about the man standing over her bed and that he told her she did not have to worry about him anymore because he had expired. A subsequent interview was held with Resident #11, on [DATE] at 12:30 p.m. to clarify information. The resident, again, stated that she felt like she would have "some trouble" for talking to the surveyors. When asked what that meant, she stated that she had to continue to live in the facility after the surveyors go home and staff might treat her badly for speaking up. The resident did, however, want to continue the conversation. The resident was asked if any staff had talked to her to inquire if she had been inappropriately touched, abused, or seen any other residents inappropriately touched or abused. She stated that no staff had come to her and asked but that she had reported abuse herself. The resident stated, again, that one night she awoke to a male resident in her room standing over her bed. The resident stated she was afraid and put her call light on. The male resident then went to her roommate ' s bed and touched her roommate, but she couldn't tell where exactly. She stated she was very frightened for herself and the roommate and because no one had responded to the call light she began screaming out for help. She stated when the nurse (Employee J) finally responded, she told her that she had awakened to the male resident standing over her bed; she also informed the nurse that he went to the roommate's bed and was touching the roommate. She stated Nurse J told her everything was okay, but she was still afraid. The resident said the administrator talked to her the next day and told her not to worry anymore because the male resident was deceased . The resident stated she could not be completely sure she told the administrator the male resident had been touching her roommate during that conversation. However, she was positive that she did tell the nurse (Employee J) the night it had happened because she was afraid he would return and do it again. The resident stated that no staff member had inquired about inappropriate touching or abuse before she reported the events of [DATE], or since she discussed it with the Administrator. Review of the record for Resident #11 revealed a Minimum Data Set (MDS) Significant Change Assessment, dated [DATE]. Review of this assessment revealed: Section B: Hearing, Speech, and Vision: B0200 Hearing - Coded as 0 - Adequate- no difficulty in normal conversation, social interaction, listening to TV. B0700 Makes Self Understood - Ability to express ideas and wants. Coded as 0 - Understood. B0800 Ability to Understand Others - Understanding verbal content. Coded as 0 - Understands - clear comprehension. B1000 Vision - Ability to see in adequate light. Coded as 0 - Adequate Section C Cognitive Patterns: Brief Interview for Mental Status (BIMS) Summary score: 15. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: cognitively intact ,[DATE]: moderately impaired ,[DATE]: severe impairment" Review of the record for Resident #11 revealed the following two entries related to the event involving Resident #12 standing over and frightening Resident #11: A progress note, dated [DATE] at 06:59, and written by Employee J, a Licensed Practical Nurse (LPN): "Customer requested her APAP then [MEDICATION NAME] for pain and given to her as ordered. Then she voiced that another customer was noted in her room and was frightened, and now she is anxious. Customer was reassurance (sic) but somehow unsatisfied with the answer. Her prn [MEDICATION NAME] was offered and refused. Call bell within reach." A progress note was reviewed, written by a mental health contractor, who had been seeing the resident for "depressed mood," with a date of [DATE]. The progress note indicated that the resident was oriented to person, place and time and had thought content with "no evidence of any perceptual disturbances, paranoia or delusional thinking." The summary stated, " Reports she has been struggling lately - Tells me that she was disturbed one night recently by a peer who came to her room and looked at her. Acknowledges that she is safe but still feels afraid." No further information was found relating to the event in Resident #11's clinical record. Review of the facility's abuse reporting log and grievance log revealed no documentation of any reports from Resident #11 in [DATE]. In addition, there was no documentation of an allegation related to inappropriate touching for Resident # 13. A phone interview was conducted with Employee J, on [DATE] at 9:24 a.m. A nursing progress note written by Employee J on [DATE] at 06:47 a.m. in Resident # 12's record was reviewed. The progress note reflected: "Customer is awakened approx. 03:00. He is alert with usual mentation. He does not voice any complaints. Staff noted customer into another customer's room once, he was removed, redirect and close supervision for the rest of the shift." The Progress note was read to Employee J and she stated she remembered the situation. She stated that she was at the nurse's station when a CNA (Certified Nursing Assistant) told her that another resident was in the room belonging to Resident #11 and #13. She identified the other resident as Resident #12. She stated that the CNA also told her that Resident #11 wanted a pain pill. Nurse J stated she went in to talk to Resident #11. Resident #11 told her there had been a man in her room and that he had been in her room many times before that night. She stated she asked the resident why she had not put her call light on the other times if he had been in her room before. She stated that Resident #11 asked her why she was being questioned and why she (the Nurse) was not questioning the man that had been in her room. Nurse J stated she asked the resident if she wanted her [MEDICATION NAME] instead of her pain pill because she was anxious. She stated that Resident #11 declined the [MEDICATION NAME] and requested the pain pill. She described Resident #11 as being "frightened and anxious but not scared." She stated that Resident #11 asked her what she should do if the man kept coming in her room, and Nurse J stated she told the resident to put the call light on and the staff would get him out. She stated that Resident #11 never said anything to her about Resident #12 touching her roommate (Resident # 13) or being over by Resident # 13's bed. Nurse J stated that she was not aware that Resident #12 was a wanderer. She stated she told the next shift nurses for both Resident #11 and Resident #12 that Resident #12 had been in Resident #11's room. Nurse J stated she did not report this incident to anyone else. Review of the clinical record for Resident # 11 revealed that she would not have been able to physically move away from the threat posed by Resident # 12 standing over her bed at 3:00 a.m. in the morning and the fright that this event caused. Resident # 11 required extensive assist of two person for bed mobility and transfer based on a significant change MDS dated [DATE] and a [DATE] care plan indicating that she was non- ambulatory, and required the assist of two persons and a mechanical lift to get out of bed. An observation of Resident #13, on [DATE] at 11:45 a.m., revealed the resident was lying in bed on her back with eyes closed. She did not respond when addressed. Resident # 11 reported, on [DATE], to two surveyors and the Administrator that she had informed Nurse J on [DATE] that Resident # 12 touched Resident # 13, yet there was no documentation found in the clinical record of Resident # 13 regarding the inappropriate touching. Review of the clinical record for Resident #13 revealed a "[DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated [DATE], revealed that the resident had short and long term memory problems with severely impaired decision making and was dependent on staff for bed mobility and transfer. Care plans, initiated [DATE], revealed that the resident required total assist from staff and the use of a mechanical lift for transfer out of the bed. Further review of the [DATE] quarterly MDS assessment revealed: Section B Hearing, Speech Vision: Speech Clarity: Coded 2 No speech- absence of spoken words Makes Self Understood: Coded 3 Rarely/never understood Ability to Understand Others: Coded 3 Rarely/never understands Vision: Ability to see in adequate light: Coded 4 Severely Impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Review of a progress note, for [DATE], for Resident # 13 entitled "Daily Skilled Charting" revealed that the resident was alert and was oriented to person, in need of extensive assist of one person for bed mobility and was totally dependent on one person for transfers. Based on this information, Resident #13 would not have been physically capable of moving herself away from Resident #12, the male wandering resident. Review of the clinical record for Resident # 13, on [DATE], revealed no documentation in the record regarding an allegation of inappropriate touching for [DATE]. Review of the clinical record for Resident # 13, on [DATE], revealed the following entry in the progress notes: [DATE] "Follow up: (Resident # 13's Physician's) office was called to inform them of a need for a psych consult due to alleged abuse incident. (Other physician) covering calls and declined psych consult for (Resident # 13) due to him not knowing the customer and not feeling comfortable ordering a psych consult for the victim of the alleged abuse. He told this writer that (Resident # 13's physician) will be back in his office on Tuesday and that we can call him then to get the order." [DATE] 11:24: "Exception note: on [DATE] during an AHCA survey it was reported by customer that she had observed a male customer come into the room and go towards roommate ' s bed and she stated that she saw male customer touch her roommate ' s blanket. She reported that she yelled out and a nurse came to room and assisted customer out of the room. Type of event: abuse allegation Person discovering incident: Was reported to AHCA surveyor by customer's roommate. Skin assessment was completed which revealed bilateral buttock reddened MD notified and no new orders were received. Treatment in place and will continue, treatment continues. Pain assessment completed. DCF operator notified, call not accepted. Date and time physician notified [DATE] approx. 7 pm - no new orders noted. Date and time legal representative notified - [DATE] approx. 7:15 pm." Review of the Abuse Reporting log and the Grievance log revealed no documentation of an allegation of abuse/inappropriate touching or inappropriate behavior relating to the incident involving Resident #13. The Administrator provided a copy of a redacted "24 hour Summary" report for, [DATE], which included the nursing progress notes placed in Resident # 11 and Resident # 12's record by Nurse J. There was no further information regarding the incident and no documentation for the roommate, Resident # 13 in this report. On [DATE], the Director of Nursing stated that the 24 hour summary reports are reviewed in the daily "change of status" meetings and again in a department head meeting. She described the change of status meeting and department head meetings as where "we go over customers from the 24 hour reports with the Unit Managers and then discuss with all the department heads." An interview with the Administrator, on [DATE] at 1:40 p.m., revealed that Resident #11 did tell him about the male resident being in her room that day and "she said it startled her." He stated she identified him by the wrong name, but he found out who the resident was and confirmed that it was Resident #12. He stated when he went to investigate the incident; he discovered that Resident #12 expired on [DATE]. The Administrator stated he informed Resident #11 that the male wandering resident had expired. He stated that she had not told him about the male resident touching her roommate, Resident # 13. He stated "I wasn't aware until she came and told me that this resident wandered, that is when I discovered he had wandered before. I didn't realize he was wandering in rooms." The Administrator stated that he "did not take it any further" because Resident # 12 expired. On [DATE] at 3:40 p.m., the Administrator stated that he and the Director of Nursing had followed up with Resident #11 on this date regarding her statement to the surveyor that Resident #12 touched her roommate Resident #13. He stated, "she told us the same information that she told you. She told us what nurse she told about the touching. She told us that the curtain was open between the beds, and she saw Resident #12 holding the bed covers but couldn't see anything else." The Administrator stated they would be interviewing the nurse and calling the abuse hotline. The Administrator stated that it would be his expectation that if the nurse received a report from a resident regarding inappropriate touching he would have expected her to report the incident to him, the abuse coordinator. On [DATE] at approximately 5:30 p.m., the Director of Nursing reported that the abuse hotline was contacted. She provided the operator's name and identification number. Review of the clinical record for Resident #12 and staff interviews revealed that the facility had awareness, prior to the incident of [DATE], which Resident # 12 wandered into other residents' rooms and put no interventions in place, other than a Wander guard, to prevent wandering out of the facility, and a psychiatric consult: Nursing Progress Note: [DATE] 13:28 "Customer is noted to be wandering throughout facility. For his safety Dr. notified and orders for a psych eval and wanderguard ordered. Family notified." Nursing Progress Note [DATE]: "Spoke to son at 2:30 p.m. He says that his father is not sleeping at night time that is why he wanders around. Son wants his father on different sleeping meds. I told the son that we were having him evaluated and the Dr will decide whatever medication the customer requires to keep him safe." Physician Orders: [DATE]: "May have wander guard for safety." [DATE]: "Psych evaluation." A review of the Initial Diagnostic Interview by a Psychologist, dated [DATE], revealed that, under behaviors, there was a checkmark by "wandering. " Review of the Psychologist's summary revealed, "[AGE] year old Spanish speaking male being referred for psych consult due to concerns of confusion. ... According to nurse, he has been wandering into peers rooms, seems lost and confused. " An interview was conducted with Employee D, an LPN, at 6: 55 p.m. on [DATE]. She stated she regularly works 7:00 p.m. to 7:00 a.m. on weekends and was familiar with and had provided care to Resident #12. She stated that he did wander on the unit and appeared to be "lost and confused." She stated that she would try to keep him with her at the nurse ' s station or with a CNA so that they knew his whereabouts. An interview was conducted with Employee H, a CNA, on [DATE] at 1:50 p.m. She stated she regularly worked 7:00 a.m. to 7:00 p.m. on the weekends and was familiar with Resident #12. She stated that he "liked to wander in and out of other residents' rooms." She stated, "That's what he liked to do." She stated he was somewhat alert and oriented with slight confusion. She stated that she would redirect him when she saw him in other resident rooms. An interview was conducted with Employee F a CNA, on [DATE] at 1:55 p.m. She stated she worked 7:00 a.m. to 7:00 p.m. on weekends and provided care to Resident #12. She stated he wandered in and out of resident rooms; he was looking for his wife, and he would wander around the rooms and open closets. She stated she would "catch him" in other resident rooms and redirect him. Review of the resident's care plans, dated [DATE] and [DATE] with revision dates of [DATE] and [DATE], revealed no care plan or updates with interventions addressing wandering in and out of resident rooms. 2. Review of the facility policy and procedure entitled, "Abuse Neglect, Exploitation ( ANE) Prohibition," effective date [DATE], revision date [DATE], revealed the following relevant information: "Policy: The Center prohibits abuse/sexual misconduct, neglect, involuntary seclusion, and misappropriation of property. " Purpose: For the Center to take all actions that are within its control to prevent occurrences of abuse, neglect, involuntary seclusion and misappropriation of property for all customers. " Abuse, the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting pain and/or mental anguish, any physical or mental mistreatment whether or not an actual injury has occurred, including, but not limited to, the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caregiver of services necessary to maintain physical and mental health. Sexual Abuse, including but not limited to sexual harassment, sexual coercion, sexual assault or sexual misconduct. Process: 4. Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property should include: 4.1 Providing Customers, families and team member ' s information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed. 4.2 Identifying, correcting and intervening in situations in which abuse, neglect, sexual misconduct and or misappropriation of customer property is more likely to occur. 4.3 Develop care plan identifying appropriate intervention to prevent occurrences, when appropriate. 4.5 Sufficient team members to meet the needs of the customer, as required by law. 7. Reports of suspected A/N/E should be reported to the Customer's family/legal representative, physician and DCF. Examples of such reports may include, but are not limited to: 7.3 A Customer-to-Customer action involving a Customer who willfully inflicts injury upon another Customer should be reviewed as abuse. Even though a Customer may have cognitive impairment, he/she could still commit a willful act. 7.3.1 However, there are incidents when a Customer's willful intent cannot be determined. In those cases, a Customer to Customer altercation should be reviewed as lack of supervision and in extreme situations; this would be reportable under neglect. 7.3.2 If "willfulness" is unclear contact VPO and CRM." 7.4 Verbal threats, intimidation. 7.5 Sexual harassment, sexual coercion, or sexual assault. 7.6 Hitting, slapping , punching, kicking, other controlling behavior. 7.7 Confinement to room, separation of Customers from other Customers. 7.8 Exploitation of money, belongings. 7.9 Medication errors or mistreatments depending on the severity. 7.10 If a medication error or missed treatment is suspected to rise to the level of neglect. Center should obtain statement/and or order from physician as appropriate. 8. If the suspected abuse to a Customer is from another Customer, the Customer who has in any way threatened or attacked another should be removed immediately from the setting or situation until safety is achieved. 8.1 The threatening attacking Customer should be placed in a less stimulating environment and monitored by team members to assure their safety. 8.2 The family/Legal Representative and physician should be notified. Any recommendations should be completed (i.e., a psychiatric evaluation, or 1 to 1 supervision) and care plan updated. 8.3 Options for room changes should be provided based on the situation. 8.4 Center should seek alternative placement for the Customer exhibiting the abusive behavior, if warranted. 8.5 The victim of the suspicion of abuse should be evaluated for need of interventions to prevent reoccurrence and plan of care updated, if warranted. 3. The facility implemented the following measures: 1. Review of camera footage from the security cameras. 2. Staff interviewed "in relation to any concerns related to other team members acting or verbalizing being inappropriate with/toward customers." 3. Background screens of current team members reviewed for compliance. 4. Security guard contracted [DATE] to screen visitors, staff vendors prior to visitation (,[DATE] times 7 days). 5. All staff re- in serviced on abuse/neglect policy by [DATE]. 6. Review of visitor sign in book. 7. Review of staffing and supervision levels for the one week period up to and including [DATE]. 8. The abuse hotline was notified of the allegations of abuse for Resident # 11 and Resident # 5 on [DATE]. 9. The physician was notified for Resident # 11 and # 5 on [DATE]. A skin assessment was completed for Resident # 13 on [DATE]. 10. The Responsible party for Resident # 5 was notified of the allegation of abuse on [DATE]. 11. As of [DATE], All staff were re in-serviced on "Abuse, Neglect, Exploitation (ANE) Prohibition" with an objective of "for the Center to take all actions that are within its control to prevent occurrences of abuse, neglect, exploitation, involuntary seclusion and misappropriation of property for all customers." 12. Additionally, survey staff reviewed and found the following facility responses and actions: a. Documentation was reviewed which showed the facility staff interviewed residents and family members. b. Security guards were observed in the building throughout the survey days. c. The facility background screens were reviewed. d. The facility provided documentation of in-service training for 100 % of employees. e. Interviews were conducted with thirteen employees and all reported that they had received current in-service training on abuse. f. The visitor sign in book was observed in the lobby of the facility. g. Documentation of adequate staffing was reviewed and was for the week of [DATE] through [DATE]. h. The Administrator and Director of Nursing were able to verbalize the results of the camera footage reviews and the review of the visitor sign in book. i. The Director of Nursing provided verbal documentation of the reports to the abuse hotline for Resident # 13 and Resident # 5 with operator Id numbers. This documentation was also verified in the clinical records for Resident # 5 and Resident # 13. j. Documentation was reviewed in the clinical records of Resident # 13 and Resident # 5 of notification of the abuse allegations to the physician and responsible parties for the residents. The Facility action plan was accepted and the Immediate Jeopardy was removed [DATE].

Based on resident record review, resident and staff interview and review of facility policies and procedures, it was determined that the facility failed to ensure that all alleged abuse violations were thoroughly investigated, failed to prevent further potential abuse from occurring, and failed to ensure that all residents were protected from further abuse while an investigation was in progress for 4 of 21 residents reviewed for abuse (# 3, # 11, # 13 and # 5). The facility failed to thoroughly investigate an allegation of sexual abuse made on behalf of Resident # 3. The facility failed to demonstrate that it followed its own corrective action plan, initiated after the allegation of sexual abuse, to ensure the safety of all residents and the prevention of further potential abuse, as evidenced by allegations of abuse for Resident # 11, # 13 and #5 reported to the survey team. The facility demonstrated a lack of commitment and action to thoroughly investigate an allegation of sexual abuse and to protect residents from abuse, therefore jeopardizing the safety of vulnerable residents in the facility, resulting in findings of Immediate Jeopardy on [DATE]. The Facility was informed of the Immediate Jeopardy on [DATE] at 3:26 p.m. Review of the facility ' s corrective action revealed that the Immediate Jeopardy was removed on [DATE] and the scope and severity was reduced to a " D " . Findings include; 1. Review of the facility "Contact/Abuse Reporting Log," , on [DATE], revealed an entry dated [DATE] for an allegation of "neglect" related to Resident # 3. The final outcome was listed as "ongoing." On [DATE] at 11: 00 a.m. and [DATE] at 8:49 a.m., interviews were held with the Administrator and the Director of Nursing regarding this allegation. The Administrator stated that on [DATE], Resident # 3 had been sent to the hospital related to altered mental status. He stated that on [DATE], two law enforcement personnel came to the facility and informed him that seminal fluid had been found in the urinalysis sample of Resident # 3 at the hospital. He stated law enforcement told him not to conduct an investigation and not to interview staff so as to not hinder their investigation. The Administrator stated that on [DATE], a representative of a protective service agency came to the facility and informed him that Resident # 3 made an allegation that a staff person may have sexually assaulted her. He stated that Resident # 3 did not return to the facility after her transfer to the hospital on [DATE]. On [DATE] at 12:31 p.m., the Administrator stated that he was aware of the resident ' s location after she had been discharged from the hospital. Review of the clinical record for Resident # 3 revealed that she was admitted to the facility, on [DATE], for skilled nursing services. Review of a nursing progress note on the date of admission, [DATE], revealed that mental status upon admission was documented as alert and oriented. Review of a progress note entitled " Social Service History " , and dated [DATE], revealed that the resident was " able to read and write, understands and responds to questions and has good verbal ability. " The progress note also stated, " Alert to person, place and time. Long Term memory is good and short term memory is good. " Review of a nursing progress note, dated [DATE] at 11:16 a.m., revealed: " Housekeeper came to nurse and said customer grabbed mop when she was cleaning room and was screaming at her. Nurse went into room and customer was combative stating ' they took my lung machine ' . Customer refused to allow nurse to take any vital signs. Customer eventually let vitals be taken which was ,[DATE], pulse 97, temp 97.5. Customer was asked if she had any pain and she put her hand on her chest. Customer was asked if she had chest pain and she said yes. 911 was called and emergency crew arrived. Blood sugar was taken by paramedic and was 424. Customer stated he was trying to kill her. Customer was taken to (hospital). Son was notified and husband was notified. " 2. During an interview on [DATE] at 11:00 a.m., the Administrator reported that the facility took immediate actions as a result of the allegation. He indicated that the facility only had the information reported to them by law enforcement and the protective services agency and did not know if anyone at the facility had sexually assaulted the resident. The Administrator stated " If there is a possibility that it happened here we want to determine who the perpetrator was, when it could have happened, how far back it could have happened. " He provided a form entitled " Credible allegation of compliance " which included: 1. " Immediate report completed [DATE] List of current center team member ' s to be given to police within 1 week from [DATE] Police requested no investigation be completed at center level due to possibly impeding investigation [DATE]. Camera footage from center security cameras to be reviewed/given to police. Date to be determined. Allegation of compliance [DATE] 2. Customers/legal representatives interviewed in relation to any concerns with team members specifically related to inappropriate behavior. Appropriate follow up generated where indicated. Team members interviewed in relation to any concerns related to other team members acting or verbalizing being inappropriate with/toward customers. Background screens of current team members reviewed for compliance. Security guard contracted [DATE] to screen visitors, staff vendors prior to visitation (,[DATE] times 7 days) then to be re- evaluated. Allegation of compliance [DATE] 3. Center team member ' s re- in serviced (151 of 166 team members) on abuse/neglect policy. The remaining team members will be in- serviced prior to starting their assigned duties on their next scheduled shift. Allegation of compliance [DATE] 4. Nursing Home Administrator/Director of Nursing to QI monitor customer concerns for potential concerns related to team members/visitors vendors and inappropriate behavior weekly x 4 weeks then monthly x 2 months until substantial compliance achieved. Findings reported to QA/RM committee for follow up. Allegation of compliance [DATE] " On [DATE] at 8:49 a.m., the Administrator reported that although they were not allowed to talk to staff, residents and families about the specific allegation, the facility interviewed all residents ' with capacity and all families/ legal representatives for those residents without capacity for four weeks in a row. He stated " we asked whether they had witnessed or heard anything, asked them if anyone had touched them that they felt was inappropriate." The Administrator stated, "We interviewed every team member," asked them if they witnessed or heard anything. He stated that there were four employees who they did not interview as the law enforcement detective "told us not to speak with them. " The Administrator stated in service training "on every aspect of abuse" was conducted with all employees beginning on [DATE] with 100 % of staff retrained as of [DATE]. The Administrator provided documentation of the retraining of staff. The Administrator also reported that they reviewed video footage for the week prior to Resident # 3 discharging to the hospital and reviewed the visitor sign in book to determine who had visited Resident # 3 in the week prior to her discharge. He stated that the video footage was of the grounds and the lobby and that nothing unusual was noted. He stated that the only visitors for Resident # 3 were her family. The Administrator stated that the facility also put security in place and has a security guard twenty four hours a day seven days a week who does rounds inside and outside on the property. He stated the facility reviewed staffing and supervision and reviewed who worked with Resident # 3 and determined that there were no identified issues. The Administrator stated "Weekly interviews were conducted with customers and responsible parties- nothing came out of it." The Administrator stated the facility looked at all male team members even though Resident # 3 "had no direct care male caregivers" and looked back a week to determine if any males had provided care for her. He reported that there was no employee at the facility who met the description provided by the protective service agency as the person who may have sexually assaulted Resident # 3. He stated that a male CNA (Certified Nursing Assistant) with the same first name as the person named was suspended pending investigation even though he did not meet the physical description of the employee she described and had never worked on Resident # 3 ' s hall or with Resident # 3. He stated that this employees name was provided to law enforcement. The Administrator did report that Resident # 3 had a male physical therapist that provided therapy services to her and that he had had a conversation with the resident regarding a concern she had about the therapist and her physical therapy. The Administrator stated that she felt the therapist was pushing her to do the therapy and he told her that she could choose to refuse therapy. The Administrator stated that the male physical therapist was a contracted employee. He stated that he gave the therapist ' s name to the police and the "police officer was aware that he was here then and provided therapy for her," but he, the Administrator, did not question or investigate him "because we could not disclose." He stated that he did not report the information to the contracted agency because "we could not disclose." He stated he "was background screened." Review of the clinical record for Resident # 3 revealed physical therapy services were documented and signed by the male physical therapist (Employee K) on [DATE], [DATE] and [DATE]. 3. The Administrator stated, on [DATE] at 11:00 a.m., that on [DATE] the law enforcement detective "gave us the okay for us to continue the investigation." On [DATE] at 8:49 a.m., the Administrator stated again that "[DATE] was the date the detective said we could proceed. " The Administrator stated that he was the Abuse Coordinator and the Risk manager for the facility and that he and the Director of Nursing had been conducting the investigation. He stated that, since [DATE], neither he nor anyone at the facility has attempted to contact Resident # 3 or her family to continue the investigation regarding the allegation of sexual assault that was made on her behalf and reported to him on [DATE]. He stated "We have not received any directive to contact them so we have not contacted them. Senior Leadership hasn ' t said either way to contact or not to contact." The Administrator stated that, since [DATE], neither he nor anyone at the facility had interviewed the four staff that he was originally told not to interview. He stated that the law enforcement detective "hasn't said if we could speak to them now and we haven't asked." Review of the staffing schedules and the CNA (Certified Nursing Assistant) Activities of Daily Living documentation for the week of [DATE] through [DATE] revealed that these four staff worked on Resident # 3's unit and provided care for Resident # 3 during this period. The Administrator stated that, since [DATE], neither he nor anyone at the facility had interviewed the contracted physical therapist (Employee K) who provided services to Resident # 3 in [DATE]. He stated that neither he nor anyone at the facility had contacted the agency that Employee K was contracted through to inform them of an investigation involving an allegation made by a resident that the therapist provided service to or notify them that the therapist's name had been provided to the police in reference to an allegation of sexual assault. 4. On [DATE], at 12:31 p.m., the Administrator and the Director of Nursing participated in an interview to clarify and provide additional information regarding the investigation into the allegation of "neglect" documented in their abuse log, for Resident # 3, and the current status of the investigation and efforts made to ensure protection of all residents. The Administrator stated again that the facility was given clearance by law enforcement to complete their investigation on [DATE]. The Administrator was asked if anyone from the facility had spoken to Resident # 3 or her family since [DATE] and he, again, stated no that he was not given any specific directive to speak with the resident or her family. A telephone interview was held with Resident # 3 by a surveyor, on [DATE] at 10:51 a.m. regarding the allegation of sexual abuse, she stated that she could not remember due to having been sick and on medication at the time and requested that her family member be interviewed. An interview was held with a family member of Resident # 3, on [DATE] at 11:01 a.m., he stated that no one from the facility has contacted him to follow-up on the investigation. The Administrator stated again on [DATE] at 12:31 p.m. that he did not ask law enforcement if the facility could interview the four staff persons who they were previously told they could not interview. The Administrator reported that all residents with capacity and families/ legal representatives of those residents without capacity were interviewed weekly from [DATE] through [DATE]. He stated that the 1st monthly resident and family/legal representative interviews were conducted from [DATE] to [DATE] with all interviewed except for two families that they were unable to reach. The Administrator stated that the first week, interviews were conducted by him, the Director of Nursing, the Clinical Risk Manager and the Executive Administrator. He stated the next three weeks, the interviews were conducted by him, the Director of Nursing and the Clinical Risk Manager and they also conducted the most current interviews from ,[DATE]- [DATE]. He stated that the interviews were "done per verbal plan" which was decided upon by the four interviewers prior to conducting the interviews and that the plan included what questions were to be asked and in what way. The Administrator reported that the residents and families /legal representatives were asked "how they were doing, how the care has been, if they knew how to report abuse and if they needed to report anything, if anyone had treated them badly, touched them inappropriately " and if they had "heard of anything like that taking place." He stated that they did the interviews by room number so they could "ensure that every single resident in every room was done." He reviewed the documentation with the surveyors regarding the interviews by reviewing with the surveyors a book with forms. The forms each stated under Criteria: "Customers monitored for potential concerns as it relates to Team Members/Visitors/Vendors behaving inappropriately to them." Review of the forms revealed a resident room number and bed indicator and a check mark indicating that interviews had been completed. The Administrator indicated there was no documentation of who was interviewed. "It was not differentiated on the documentation," just that a particular room and bed was interviewed. The Administrator did not provide copies of this documentation as he stated it was part of the facility's quality assurance program. During multiple interviews, the Administrator used the terms family, legal representative and responsible party when indicating who was interviewed regarding abuse when the resident lacked capacity. It was not able to be determined who the facility specifically interviewed for residents who were determined to lack capacity as "family," "responsible party," and "legal representative" could be different people. The Administrator used these terms interchangeably and there was no documentation provided as to who was interviewed. The Administrator stated that abuse was not discussed at the Resident Council meetings with members of the Resident Council. Review of the Resident Council Minutes for [DATE] and [DATE] revealed no documentation related to abuse or resident rights. An interview was conducted with the Resident Council President, Resident # 21, on [DATE] at 2:30 p.m. She stated that no one at the facility has had a discussion with her related to abuse or who to report abuse to. The Administrator stated that the facility had a Family Council but that there had not been a family council meeting since the [DATE] allegation. He provided documentation that the last Family Council meeting was held [DATE]. On [DATE] at 12:31 p.m., the Administrator reported that the facility conducted a monthly Quality Assurance Meeting on [DATE] but did not discuss the allegation of sexual abuse at the meeting due to the law enforcement directive not to discuss with anyone. He stated a special Quality Assurance Meeting was held on [DATE] where there was a discussion of the Corrective action plan and the results of the resident/ family/legal representative interviews. The Administrator stated that the facility had a Quality Assurance meeting on [DATE] and the resumption of monthly resident/family /legal representative interviews was discussed and planned. An interview was conducted with the Medical Director, by phone, on [DATE] at 2:43 p.m. The Medical Director was also documented as Resident # 3's physician in Resident # 3's clinical record. The Medical Director stated she was familiar with the circumstances involving Resident # 3 and that there was a law enforcement investigation. She stated that based on hearsay, the hospital found (seminal fluid) in the resident ' s urine but she had not been able to obtain any documentation from the hospital. She stated that the police had not spoken to her. She reported that she did attend the Quality Assurance meetings in [DATE] and [DATE] and stated that she recalled there was a discussion of concerns related to Resident # 3 and that the facility had added 24 hour security. She reported that she had no further knowledge of any other actions that the facility had taken and that to her knowledge, the facility had finished the investigation and it was now closed. On [DATE] at 8:49 a.m., the Administrator stated that the facility had not concluded the investigation into the allegation of abuse for Resident # 3. He stated that law enforcement had not concluded their investigation and "we can't conclude because we don't know the results of the DNA, the possible contamination of the urine, we can't conclude that everything is A OK and is done." 5. Interviews were conducted with ten residents and four families. Nine of the ten residents and all four families interviewed reported that they had not been interviewed by the facility regarding abuse, inappropriate touching, and inappropriate behaviors or if they were aware how to report abuse. Two of the nine residents reported allegations of abuse, one on behalf of herself and her roommate (Resident # 11 and # 13) and one on behalf of himself (Resident # 5) that the facility Administrator reported he had no prior knowledge of: A. On [DATE], at 11:43 a.m., an interview was conducted with Resident #11. Resident #11 was observed to be seated in her room in a motorized wheelchair. Her left hand was noted to be in a splint with her arm positioned on a half tray. Resident #11 stated that she was in fear of retaliation from the staff for talking to the surveyor but agreed to talk with the surveyor. The resident was asked if any facility staff had asked her if she had been inappropriately touched or abused, or seen any other residents inappropriately touched or abused. She stated that no one from the facility had ever asked her that, but she did report abuse recently. She described an incident that she stated occurred on [DATE] and that she had reported it to Employee J at the time of the incident and also had reported this to the Administrator the same day. She stated that on [DATE] at 3:00 a.m., she was in bed and she awoke to a man standing over her. She stated that she put her call light on and no one from the facility responded. She stated she was scared. She stated she observed the man walk over to her roommate's bed, Resident #13, and she observed him touch her roommate. She stated she couldn ' t see what else he was doing and she did not hear him say anything. She stated she yelled out for the nurse and the nurse (Employee J) came in the room and removed the man from her room. She stated that she told the nurse that the man was touching her roommate. She identified the man as a male resident who lived in a room across the hall from her room and who died on [DATE]. Resident #11 also indicated that she had told the Administrator about the man standing over her bed and that he told her she did not have to worry about him anymore because he had expired. A subsequent interview was held with Resident #11, on [DATE] at 12:30 p.m. to clarify information. The resident again stated that she felt like she would have "some trouble" for talking to the surveyors. When asked what that meant, she stated that she had to continue to live in the facility after the surveyors go home and staff might treat her badly for speaking up. The resident did, however, want to continue the conversation. The resident was asked if any staff had talked to her to inquire if she had been inappropriately touched, abused, or seen any other residents inappropriately touched or abused. She stated that no staff had come to her and asked but that she had reported abuse herself. The resident stated, again, that one night she awoke to a male resident in her room standing over her bed. The resident stated she was afraid and put her call light on. The male resident then went to her roommate's bed and touched her roommate, but she couldn't tell where exactly. She stated she was very frightened for herself and the roommate and because no one had responded to the call light she began screaming out for help. She stated when the nurse (Employee J) finally responded, she told her that she had awakened to the male resident standing over her bed; she also informed the nurse that he went to the roommate ' s bed and was touching the roommate. She stated Nurse J told her everything was okay, but she was still afraid. The resident said the administrator talked to her the next day and told her not to worry anymore because the male resident was deceased . The resident stated she could not be completely sure she told the administrator the male resident had been touching her roommate during that conversation. However, she was positive that she did tell the nurse (Employee J) the night it had happened because she was afraid he would return and do it again. The resident stated that no staff member had inquired about inappropriate touching or abuse before she reported the events of [DATE], or since she discussed it with the Administrator. Review of the record for Resident #11 revealed a Minimum Data Set (MDS) Significant Change Assessment, dated [DATE]. Review of this assessment revealed: Section B: Hearing, Speech, and Vision: B0200 Hearing - Coded as 0 - Adequate- no difficulty in normal conversation, social interaction, listening to TV. B0700 Makes Self Understood - Ability to express ideas and wants. Coded as 0 - Understood. B0800 Ability to Understand Others - Understanding verbal content. Coded as 0 - Understands - clear comprehension. B1000 Vision - Ability to see in adequate light. Coded as 0 - Adequate Section C Cognitive Patterns: Brief Interview for Mental Status (BIMS) Summary score: 15. According to the CMS RAI MDS 3.0 Manual: "The BIMS total score is highly correlated with Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: ,[DATE]: cognitively intact ,[DATE]: moderately impaired ,[DATE]: severe impairment" Review of the record for Resident #11 revealed the following two entries related to the event involving Resident #12 standing over and frightening Resident #11: A progress note, dated [DATE] at 06:59, and written by Employee J, a Licensed Practical Nurse (LPN): "Customer requested her APAP then [MEDICATION NAME] for pain and given to her as ordered. Then she voiced that another customer was noted in her room and was frightened, and now she is anxious. Customer was reassurance (sic) but somehow unsatisfied with the answer. Her prn [MEDICATION NAME] was offered and refused. Call bell within reach." A progress note was reviewed, written by a mental health contractor, who had been seeing the resident for "depressed mood," with a date of [DATE]. The progress note indicated that the resident was oriented to person, place and time and had thought content with "no evidence of any perceptual disturbances, paranoia or delusional thinking." The summary stated "Reports she has been struggling lately - Tells me that she was disturbed one night recently by a peer who came to her room and looked at her. Acknowledges that she is safe but still feels afraid." No further information was found relating to the event in Resident #11's clinical record. Review of a nursing progress note written by Nurse J, for Resident #12, the male resident who Resident # 11 reported was standing over her bed at 3:00 a.m. and touching her roommate (Resident # 13) revealed: "Customer is awakened approx. 03:00. He is alert with usual mentation. He does not voice any complaints. Staff noted customer unto another customer's room once, he was removed, redirect and close supervision for the rest of the shift." Review of the facility's abuse reporting log and grievance log revealed no documentation of this incident from Resident #11 in [DATE]. In addition, there was no documentation of an allegation related to inappropriate touching for Resident # 13. A phone interview was conducted with Nurse/Employee J, on [DATE] at 9:24 a.m. The Progress note was read to Employee J and she stated she remembered the situation. She stated that she was at the nurse's station when a CNA (Certified Nursing Assistant) told her that another resident was in the room belonging to Resident #11 and #13. She identified the other resident as Resident #12. She stated that the CNA also told her that Resident #11 wanted a pain pill. Nurse J stated she went in to talk to Resident #11 and Resident #11 told her there had been a man in her room and that he had been in her room many times before that night. She stated she asked the resident why she had not put her call light on the other times if he had been in her room before. She stated that Resident #11 asked her why she was being questioned and why she (the Nurse) was not questioning the man that had been in her room. Nurse J stated she asked the resident if she wanted her [MEDICATION NAME] instead of her pain pill because she was anxious. She stated that Resident #11 declined the [MEDICATION NAME] and requested the pain pill. She described Resident #11 as being "frightened and anxious but not scared." She stated that Resident #11 asked her what she should do if the man kept coming in her room, and Nurse J stated she told the resident to put the call light on and the staff would get him out. She stated that Resident #11 never said anything to her about Resident #12 touching her roommate (Resident # 13) or being over by Resident # 13's roommate's bed. Nurse J stated that she was not aware that Resident #12 was a wanderer. She stated she told the next shift nurses for both Resident #11 and Resident #12 that Resident #12 had been in Resident #11's room. She made no mention of reporting any concerns regarding Resident #13. She stated she did not report this incident to anyone else. Review of the clinical record for Resident # 11 revealed that she would not have been able to physically move away from the threat posed by Resident # 12 standing over her bed at 3:00 a.m. in the morning and the fright that this event caused. Resident # 11 required extensive assist of two person for bed mobility and transfer based on a significant change MDS, dated [DATE] and an [DATE] care plan indicating that she was non- ambulatory and required the assist of two persons and a mechanical lift to get out of bed. Observation and record review was conducted for Resident # 13. An observation of Resident #13, on [DATE] at 11:45 a.m., revealed the resident was lying in bed on her back with eyes closed. She did not respond when addressed. Review of the clinical record for Resident #13, the roommate of Resident #11, revealed no mention of the [DATE] allegation, in spite of Resident #11 stating to two surveyors and the Administrator, on [DATE], that she had informed Employee J of inappropriate touching on [DATE]. Review of the clinical record for Resident #13 revealed a "[DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated [DATE], revealed that the resident had short and long term memory problems with severely impaired decision making and was dependent on staff for bed mobility and transfer. Care plans, initiated [DATE], revealed that the resident required total assist from staff and the use of a mechanical lift for transfer out of the bed. Further review of the [DATE] quarterly MDS assessment revealed Section B Hearing, Speech Vision: Speech Clarity: Coded 2 No speech- absence of spoken words Makes Self Understood: Coded 3 Rarely/never understood Ability to Understand Others: Coded 3 Rarely/never understands Vision: Ability to see in adequate light: Coded 4 Severely Impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Review of a progress note, for [DATE], for Resident # 13 entitled "Daily Skilled Charting" revealed that the resident was alert and was oriented to person, in need of extensive assist of one person for bed mobility and was totally dependent on one person for transfers. Based on this information, Resident #13 would not have been physically capable of moving herself away from Resident #12, the male wandering resident. Review of the clinical record for Resident # 13, on [DATE], revealed no documentation in the record regarding an allegation of inappropriate touching for [DATE]. Review of the clinical record for Resident # 13, on [DATE], revealed the following entry in the progress notes: [DATE] "Follow up: (Resident # 13's Physician's) office was called to inform them of a need for a psych consult due to alleged abuse incident. (Other physician) covering calls and declined psych consult for (Resident # 13) due to him not knowing the customer and not feeling comfortable ordering a psych consult for the victim of the alleged abuse. He told this writer that (Resident # 13's physician) will be back in his office on Tuesday and that we can call him then to get the order." [DATE] 11:24: "Exception noted: on [DATE] during an AHCA survey it was reported by customer that she had observed a male customer come into the room and go towards roommate's bed and she stated that she saw male customer touch her roommate's blanket. She reported that she yelled out and a nurse came to room and assisted customer out of the room. Type of event: abuse allegation Person discovering incident: Was reported to AHCA surveyor by customer's roommate. Skin assessment was completed which revealed bilateral buttock reddened MD notified and no new orders were received. Treatment in place and will continue, treatment continues. Pain assessment completed. DCF operator notified, call not accepted. Date and time physician notified [DATE] approx. 7 pm - no new orders noted. Date and time legal representative notified - [DATE] approx. 7: 15 pm." Review of the Abuse Reporting log and the Grievance log revealed no documentation of an allegation of abuse/inappropriate tou

Based on resident record review, resident and staff interview and review of the facility's abuse prohibition policy and corrective action plan, the facility failed to implement and operationalize their written policies and procedures for the identification and investigation of allegations of abuse and the protection of residents for four of twenty one residents reviewed (# 3, #11, # 13 and # 5). The facility failed to thoroughly investigate an allegation of sexual abuse made on behalf of Resident # 3. After receiving an allegation of sexual abuse related to Resident # 3, the facility reportedly had no knowledge of a potential perpetrator and no knowledge as to whether other residents may have also been subjected to abuse. The facility failed to ensure that they completed a thorough investigation into the allegation. The facility failed to interview the alleged victim, Resident # 3 and failed to interview all staff who provided care for Resident # 3. The facility failed to ensure that they reported the allegation of abuse for Resident # 3 to an outside contracted agency whose employee had provided care to Resident # 3. The facility failed to thoroughly investigate an allegation of resident to resident abuse made by Resident # 11 related to alleged abuse perpetrated on her and her roommate, Resident # 13, by Resident # 12 which included fear reported by Resident # 11, and alleged touching of Resident # 13. The facility failed to ensure that it identified, corrected and intervened in a situation where abuse was more likely to occur. The facility had foreknowledge that Resident # 12 was a known wanderer and had a history of [REDACTED]. The facility failed to ensure that all residents were free from abuse by failing to demonstrate, per their own plan, that all allegations of abuse had been identified, investigated and reported, related to Resident # 11 who stated that she had reported abuse and no action was taken and Resident # 5 and Resident # 5's family who stated he had been abused but delayed reporting to anyone. The facility's abuse policies and procedures did not define or describe how allegations of abuse will be investigated other than to state that a thorough investigation will be completed. The facility's abuse policies and procedures did not delineate how all residents would be protected from harm during an investigation. The facility's demonstrated lack of commitment and action to operationalize and implement abuse policies and procedures after an allegation of sexual abuse for Resident # 3, allegations of abuse reported by Resident # 11 for herself and Resident # 13 and abuse reported by Resident # 5, resulted in findings of Immediate Jeopardy on 1/08/15. The Facility was informed of the Immediate Jeopardy on 1/28/15 at 3:26 p.m. Review of the facility's corrective action revealed that the Immediate Jeopardy was removed on 1/26/15 and the scope and severity was reduced to a "D." Findings include: 1. The Administrator, on 1/22/15, provided the facility's policies and procedures related to abuse entitled "Abuse, Neglect, and Exploitation (ANE) Prohibition" and indicated that this was the facility's current abuse policy. The policy had an effective date of May 1, 2003 and a revision date of December 18, 2012. Review of the policy: "Policy: The Center Prohibits abuse/sexual misconduct, neglect, involuntary seclusion, and misappropriation of property. Purpose: For the Center to take all actions that are within its control to prevent occurrences of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of property for all Customers. Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting pain and/or mental anguish, any physical or mental mistreatment whether or not an actual injury has occurred, including, but not limited to, the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caregiver of services necessary to maintain physical and mental health; Verbal abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to Customers or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a customer; such as telling a Customer that they should never be able to see their family again; Sexual Abuse: including, but not limited to sexual harassment, sexual coercion, sexual assault or sexual misconduct. Physical abuse: any activity that includes, but is not limited to hitting, slapping, pinching or kicking. It also includes controlling behavior through corporal punishment. Mental abuse: including, but is not limited to humiliation, harassment, threats of punishment or deprivation. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Exploitation: the act or process of taking advantage of any Customer by another person or caregiver for monetary, personal or other benefit, gain or profit. Involuntary seclusion: separation of a Customer from other Customers or from her/his room or confinement to her/his room (with or without roommates) against the Customer's will, or the will of the Customer's legal representative; Misappropriation of Customer Property: the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a Customer's belongings or money without the Customer's consent. PROCESS: 1. The Center will have policies and procedures in place that prohibit abuse, neglect, exploitation, involuntary seclusion, and misappropriation of property. 2. The Center should screen potential team members for a history of abuse, neglect or mistreating Customers, including checking with the appropriate licensing boards and registries. 2.1 The Center should not employ individuals who: 2.1.1 Have been found guilty by a court of law of abusing, neglecting, or mistreating others. 2.1.2 Had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. 2.1.3 Possesses a disqualifying offense as per F.S. 453.03 and F.S. 435.04 3. Training should be provided to all team members, through orientation and ongoing sessions, about abuse prohibition: 3.1 Appropriate interventions to deal with aggressive and/or catastrophic reactions of Customers. 3.2 How to report knowledge related to allegations without fear of reprisal. 3.3 How to recognize signs of burnout, frustration and stress that may lead to abuse. 3.4 What constitutes abuse, neglect, and misappropriation of Customer property. 3.5 Interacting with customers to maintain and enhance his/her self -esteem/self -worth. 4. Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property should include: 4.1 Providing Customers, families and team members information on how to and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed. 4.2 Identifying, correcting and intervening in situations in which abuse, neglect, sexual misconduct and or/misappropriation of Customer property is more likely to occur. 4.3 Develop care plan identifying appropriate intervention to prevent occurrences, when appropriate. 4.4 Supervision of team members to identify inappropriate behavior. 4.5 Sufficient team members to meet the needs of the Customer, as required by law. 5. Team members should identify/investigate events, such as suspicious bruising of Customers, occurrences, patterns, and trends that may constitute abuse and investigate according to the individual's allegations, facts and circumstances. This also includes Customer -to Customer abuse. 6. Anyone who witnesses an incident of suspected mistreatment, neglect or abuse, sexual misconduct, including injuries of unknown origin and misappropriation of Customer property is to tell the abuser to stop immediately, and is to report it to the administrator and supervisor immediately. Allegations should be thoroughly investigated. 6.1 The team members alleged to have committed the act of abuse, neglect, or sexual misconduct should be immediately suspended, pending investigation to protect the customer. 7. Reports of A/N/E should be reported to the Customer's family/Legal Representative, physician and DCF. Examples of such reports may include but are not limited to: 7.1 A verbalization or threat or allegation of such. 7.2 An injury of unknown origin that was not observed by any person or the source of the injury could not be explained by the Customer and the injury is suspicious because of the extent of the injury or the location of the injury (e.g. its location in an area not generally vulnerable to trauma) or the number of injuries observed at one time, or the number of incidences of injuries over time. 7.3 A Customer-to-Customer action involving a Customer who willfully inflicts injury upon another Customer should be reviewed as abuse. Even though a Customer may have cognitive impairment, he/she could still commit a willful act. 7.3.1 However, there are incidents when a Customer's willful intent cannot be determined. In those cases, a Customer to Customer altercation should be reviewed as lack of supervision and in extreme situations; this would be reportable under neglect. 7.3.2 If "willfulness" is unclear contact VPO and CRM." 7.4 Verbal threats, intimidation. 7.5 Sexual harassment, sexual coercion, or sexual assault. 7.6 Hitting, slapping, punching, kicking, other controlling behavior. 7.7 Confinement to room, separation of Customers from other Customers. 7.8 Exploitation of money, belongings. 7.9 Medication errors or mistreatments depending on the severity. 7.10 If a medication error or missed treatment is suspected to rise to the level of neglect. Center should obtain statement/and or order from physician as appropriate. 8. If the suspected abuse to a Customer is from another Customer, the Customer who has in any way threatened or attacked another should be removed immediately from the setting or situation until safety is achieved. 8.1 The threatening attacking Customer should be placed in a less stimulating environment and monitored by team members to assure their safety. 8.2 The family/Legal Representative and physician should be notified. Any recommendations should be completed (i.e., a psychiatric evaluation, or 1 to 1 supervision) and care plan updated. 8.3 Options for room changes should be provided based on the situation. 8.4 Center should seek alternative placement for the Customer exhibiting the abusive behavior, if warranted. 8.5 The victim of the suspicion of abuse should be evaluated for need of interventions to prevent reoccurrence and plan of care updated, if warranted. 9. Upon receiving information or report of A/N/E, sexual misconduct, the Administrator or designee should: 9.1 Contact Department of Children and Families (DCF) Adult Protective Services (APS) by phone or by facsimile. 9.2 Complete (immediate) Federal Report of Alleged Violations Involving A/N/E for mandated reporters and email to CAU. 9.3 Complete 5 day Federal Report of Alleged Violations involving A/N/E for Mandated Reporters and email to AHCA Complaint Administration Unit (CAU) by providing investigation results. 9.4 If information or report of A/N/E or sexual misconduct involves an Alpha Care Provider, the Administrator of designee shall contact the Alpha Director of Operations to inform him/her of the investigation and possibility that an Alpha Provider may be contacted by DCF. 9.5 Proceed with appropriate documentation, including plan of care updates. 9.5.1 The investigation documentation shall be kept confidential and in a file in the Director of Nursing's (DON's) office. 9.5.2 The Abuse Reporting Log should be kept current in the DON's office. 9.5.3 Each Adverse investigation should be kept in an individual Manila folder. Abuse investigations are kept in yellow folders. 9.6 FHCA Timeline for Reporting Adverse Incidents should be utilized as necessary. 9.7 Allegations of sexual assault/rape, physical assault and exploitation should be reported to local law enforcement. 10. The Center should protect Customers from further harm during an investigation. 10.1 Provide the Customer with a safe environment by identifying persons with whom he/she feels safe and conditions which would feel safe. 10.2 Assign a representative from Social Services or designee to monitor the Customer's feelings concerning the incident as well as the Customer's involvement in the investigation. 11. Conduct investigations as needed. 11.1 All investigations are part of the Center's Quality Assurance program and are at the direction of general counsel and are subject to attorney/client privilege. 11.1.1 The investigation documentation should be kept confidential and in a file in the DON'S office. 11.1.2 Each investigation should be kept in an individual Manila Folder. 11.2 Copies of internal investigations are not to be provided. 11.3 The Abuse Reporting Log should be kept current in the DON's office. 11.4 The findings of the investigations should be found on the Exception note. On the Exception note the following information should be included but not limited to: 11.4.1 The type of allegation should be identified. 11.4.2 The details of the incident. 11.4.3 The type of injury should be described as well as what licensed team member did to evaluate injury as applicable. 12. The Administrator/DON should analyze all occurrences to determine what changes are needed, If any, to policies and procedures to prevent further occurrences, and should communicate through QA meeting and Clinical Risk Management. 2. The facility policy indicated that "allegations should be thoroughly investigated" but did not delineate how this will be achieved. The facility received an allegation of alleged sexual abuse on 11/25/14 related to Resident # 3 and failed to ensure that a thorough investigation was completed. The facility policy indicated that "The Center should protect Customers from further harm during an investigation" but only describes actions to be taken for the alleged victim and not for the protection of all residents and the facility did not demonstrate that it had ascertained that all residents were free from abuse: Review of the facility "Contact/Abuse Reporting Log," on 1/22/15, revealed an entry dated 11/25/14 for an allegation of "neglect" related to Resident # 3. The final outcome was listed as "ongoing." On 1/22/15 at 11: 00 a.m. and 1/23/15 at 8:49 a.m., interviews were held with the Administrator and the Director of Nursing regarding this allegation. The Administrator stated that on 11/23/14, Resident # 3 had been sent to the hospital related to altered mental status. He stated that on 11/24/14, two law enforcement personnel came to the facility and informed him that seminal fluid had been found in the urinalysis sample of Resident # 3 at the hospital. He stated law enforcement told him not to conduct an investigation and not to interview staff so as to not hinder their investigation. The Administrator stated that on 11/25/14, a protective service agency came to the facility and informed him that Resident # 3 made an allegation that a staff person may have sexually assaulted her. He stated that Resident # 3 did not return to the facility after her transfer to the hospital on [DATE]. On 1/26/15 at 12:31 p.m., the Administrator stated that he was aware of the resident's location after she had been discharged from the hospital. Review of the clinical record for Resident # 3 revealed that she was admitted to the facility, on 10/31/14, for skilled nursing services. Review of a nursing progress note on the date of admission, 10/31/14, revealed that her mental status upon admission was documented as alert and oriented. Review of a progress note entitled "Social Service History," and dated 11/3/14, revealed that the resident was "able to read and write, understands and responds to questions and has good verbal ability." The progress note also stated "alert to person, place and time. Long Term memory is good and short term memory is good." Review of a nursing progress note, dated 11/23/14 at 11:16 a.m., revealed: "Housekeeper came to nurse and said customer grabbed mop when she was cleaning room and was screaming at her. Nurse went into room and customer was combative stating '"they took my lung machine." Customer refused to allow nurse to take any vital signs. Customer eventually let vitals be taken which was 162/80, pulse 97, temp 97.5. Customer was asked if she had any pain and she put her hand on her chest. Customer was asked if she had chest pain and she said yes. 911 was called and emergency crew arrived. Blood sugar was taken by paramedic and was 424. Customer stated he was trying to kill her. Customer was taken to (hospital). Son was notified and husband was notified." Review of Resident # 3's hospital record from the hospital that she was transferred to on 11/23/14 revealed a discharge summary, dated 12/10/14, for a discharge of 11/28/14. Review of the discharge summary revealed: "Final Diagnoses: [REDACTED]." "Hospital Course: Sent to the emergency roiagnom on account of a change in mentation. Work-up done in the emergency room . A CT scan of the brain was negative. The patient, however, note with some sperm in the urine. Hence, detective is involved in her case. The patient was clinically stable ...." The Administrator reported on 1/22/15 at 11:00 a.m. that, after receiving the allegation of abuse on 11/25/14, the facility took immediate actions as a result of the allegation. He indicated that the facility only had the information reported to them by law enforcement and the protective services agency and did not know if anyone at the facility had sexually assaulted the resident. The Administrator stated, "If there is a possibility that it happened here we want to determine who the perpetrator was, when it could have happened, how far back it could have happened." He provided a form entitled, "Credible allegation of compliance" which included: 1. "Immediate report completed 11/25/14. List of current center team member's to be given to police within 1 week from 11/25/14. Police requested no investigation be completed at center level due to possibly impeding investigation 11/25/14. Camera footage from center security cameras to be reviewed/given to police. Date to be determined. Allegation of compliance 11/28/14. 2. Customers/legal representatives interviewed in relation to any concerns with team members specifically related to inappropriate behavior. Appropriate follow up generated where indicated. Team members interviewed in relation to any concerns related to other team members acting or verbalizing being inappropriate with/toward customers. Background screens of current team members reviewed for compliance. Security guard contracted 11/26/14 to screen visitors, staff vendors prior to visitation (24/7 times 7 days) then to be re- evaluated. Allegation of compliance 11/28/14. 3. Center team member's re- in serviced (151 of 166 team members) on abuse/neglect policy. The remaining team members will be in- serviced prior to starting their assigned duties on their next scheduled shift. Allegation of compliance 11/28/14 4. Nursing Home Administrator/Director of Nursing to QI monitor customer concerns for potential concerns related to team members/visitors vendors and inappropriate behavior weekly x 4 weeks then monthly x 2 months until substantial compliance achieved. Findings reported to QA/RM committee for follow up. Allegation of compliance 11/28/14." 3. On 1/23/15 at 8: 49 a.m., the Administrator reported that although they were not allowed to talk to staff, residents and families about the specific allegation, the facility interviewed all residents with capacity and all families/ legal representatives for those residents without capacity for four weeks in a row. He stated, "we asked whether they had witnessed or heard anything, asked them if anyone had touched them that they felt was inappropriate." The Administrator stated, "We interviewed every team member," asked them if they witnessed or heard anything. He stated that there were four employees who they did not interview as the law enforcement detective "told us not to speak with them." The Administrator stated in service training "on every aspect of abuse" was conducted with all employees beginning on 11/25/14 with 100 % of staff retrained as of 11/28/14. The Administrator provided documentation of the retraining of staff. The Administrator also reported that they reviewed video footage for the week prior to Resident # 3 discharging to the hospital and reviewed the visitor sign in book to determine who had visited Resident # 3 in the week prior to her discharge. He stated that the video footage was of the grounds and the lobby and that nothing unusual was noted. He stated that the only visitors for Resident # 3 were her family. The Administrator stated that the facility also put security in place and has a security guard twenty four hours a day seven days a week who does rounds inside and outside on the property. He stated the facility reviewed staffing and supervision and reviewed who worked with Resident # 3 and determined that there were no identified issues. The Administrator stated "Weekly interviews were conducted with customers and responsible parties- nothing came out of it." The Administrator stated the facility looked at all male team members even though Resident # 3 "had no direct care male caregivers" and looked back a week to determine if any males had provided care for her. He reported that there was no employee at the facility who met the description provided by the protective service agency as the person who may have sexually assaulted Resident # 3. He stated that a male CNA (Certified Nursing Assistant) with the same first name as the person named was suspended pending investigation even though he did not meet the physical description of the employee she described and had never worked on Resident # 3's hall or with Resident # 3. He stated that this employee's name was provided to law enforcement. The Administrator did report that Resident # 3 had a male physical therapist that provided therapy services to her and that he had had a conversation with the resident regarding a concern she had about the therapist and her physical therapy. The Administrator stated that she felt the therapist was pushing her to do the therapy and he told her that she could choose to refuse therapy. The Administrator stated that the male physical therapist was a contracted employee. He stated that he gave the therapists name to the police and the " police officer was aware that he was here then and provided therapy for her," but he, the Administrator, did not question or investigate him "because we could not disclose." He stated that he did not report the information to the contracted agency because "we could not disclose." He stated he "was background screened." Review of the clinical record for Resident # 3 revealed physical therapy services documented and signed by the male physical therapist (Employee K) on 11/13/14, 11/14/14 and 11/17/14. The Administrator stated, on 1/22/15 at 11: 00 a.m., that on 1/10/15 the law enforcement detective "gave us the okay for us to continue the investigation." On 1/23/15 at 8: 49 a.m., the Administrator stated, again, that "1/10/15 was the date the detective said we could proceed." The Administrator stated that he was the Abuse Coordinator and the Risk Manager for the facility and that he and the Director of Nursing have been conducting the investigation. He stated that, since 1/10/15, neither he nor anyone at the facility had attempted to contact Resident # 3 or her family to continue the investigation regarding the allegation of sexual assault that was made on her behalf and reported to him on 11/25/14. He stated "We have not received any directive to contact them so we have not contacted them. Senior Leadership hasn't said either way to contact or not to contact." The Administrator stated that, since 1/10/15, neither he nor anyone at the facility had interviewed four staff that he was originally told by law enforcement not to interview, prior to 1/101/15. He stated, since 1/10/15, that the law enforcement detective "hasn't said if we could speak to them now and we haven't asked." Review of the staffing schedules and the CNA (Certified Nursing Assistant) Activities of Daily Living documentation for the week of November 18 through November 23, 2014 revealed that these four staff worked on Resident # 3's unit and provided care for Resident # 3 during this period. The Administrator stated that, since 1/10/15, neither he nor anyone at the facility has interviewed the contracted physical therapist (Employee K) who provided services to Resident # 3 in November 2014. He stated that neither he nor anyone at the facility has contacted the agency that Employee K was contracted through to inform them of an investigation involving an allegation made by a resident that the therapist provided service to or notify them that the therapist's name had been provided to the police in reference to an allegation of sexual assault. 4. On 1/26/15, at 12:31 p.m., the Administrator and the Director of Nursing participated in an interview to clarify and provide additional information regarding the investigation into the allegation of "neglect" documented in their abuse log, for Resident # 3, and the current status of the investigation and efforts made to ensure protection of all residents. The Administrator stated again that the facility was given clearance by law enforcement to complete their investigation on 1/10/15. The Administrator was asked if anyone from the facility had spoken to Resident # 3 or her family since 1/10/15 and he again stated "no" that he was not given any specific directive to speak with the resident. A telephone interview was held with Resident # 3 by the surveyor, on 1/23/15 at 10:51 a.m. regarding the allegation of sexual abuse, she stated that she could not remember due to having been sick and on medication at the time and requested that her family member be interviewed. An interview was held with a family member of Resident # 3 on 1/23/15 at 11: 01 a.m. He stated after (Resident # 3) was discharged from the hospital he moved her to a different facility "for obvious reasons." He stated he does not know one way or another if she was sexually abused while a resident at the facility and was waiting for the lab result for the final determination. He stated that his concern was that no other resident be abused. He stated that no one from the facility has contacted him to follow up on the investigation. On 1/26/15 at 12: 31 p.m., the Administrator reported that the facility conducted a monthly Quality Assurance Meeting on 12/11/14 but did not discuss the allegation of sexual abuse at the meeting due to the law enforcement directive not to discuss with anyone. He stated a special Quality Assurance Meeting was held on 12/18/14 where there was a discussion of the Corrective action plan and the results of the resident/ family/legal representative interviews. The Administrator further stated that the facility had a Quality Assurance meeting on 1/22/15 and the resumption of monthly resident/family /legal representative interviews was discussed and planned. An interview was conducted with the Medical Director, by phone, on 1/26/15 at 2:43 p.m. The Medical Director was also documented as Resident # 3's physician in Resident # 3's clinical record. The Medical Director stated she was familiar with the circumstances involving Resident # 3 and that there was a law enforcement investigation. She stated that based on hearsay, the hospital found (seminal fluid) in the resident's urine but she had not been able to obtain any documentation from the hospital. She stated that the police had not spoken to her. She reported that she did attend the Quality Assurance meetings in December 2014 and January 2015 and stated that she recalled there was a discussion of concerns related to Resident # 3 and that the facility had added 24 hour security. She reported that she had no further knowledge of any other actions that the facility had taken and that to her knowledge, the facility had finished the investigation and it was now closed. On 1/23/15 at 8:49 a.m., the Administrator stated that the facility had not concluded the investigation into the allegation of abuse for Resident # 3. He stated that law enforcement had not concluded their investigation and "we can't conclude because we don't know the results of the DNA, the possible contamination of the urine, we can't conclude that everything is "A OK" and is done." 5. On 1/26/15 at 12:31 p.m., the Administrator reported that all residents with capacity and families/ legal representatives of those residents without capacity were interviewed weekly from 11/26/14 through 12/19/14. He stated that the 1st monthly resident and family/legal representative interviews were conducted from 1/23/15 to 1/25/15 with all residents and /or families interviewed except for two families that they were unable to reach. The Administrator stated that the first week, interviews were conducted by him, the Director of Nursing, the Clinical Risk Manager and the Executive Administrator. He stated the next three weeks, the interviews were conducted by him, the Director of Nursing and the Clinical Risk Manager and they also conducted the most current interviews from 1/23- 1/25/15. He stated that the interviews were "done per verbal plan" which was decided upon by the four interviewers prior to conducting the interviews and that the plan included what questions were to be asked and in what way. The Administrator reported that the residents and families /legal representatives were asked "how they were doing, how the care has been, if they knew how to report abuse and if they needed to report anything, if anyone had treated them badly, touched them inappropriately" and if they had "heard of anything like that taking place." He stated that they did the interviews by room number so they could "ensure that every single resident in every room was done." He reviewed the documentation with the surveyors regarding the interviews by reviewing with the surveyors a book with forms. The forms each stated under Criteria: "Customers monitored for potential concerns as it relates to Team Members/Visitors/Vendors behaving inappropriately to them." Review of the forms revealed a resident room number and bed indicator and a check mark indicating that interviews had been completed. The Administrator indicated there was no documentation of who was interviewed. "It was not differentiated on the documentation," just that a particular room and bed was interviewed. The Administrator did not provide copies of this documentation as he stated it was part of the facility's quality assurance program. During multiple interviews, the Administrator used the terms family, legal representative and responsible party when indicating who was interviewed regarding abuse when the resident lacked capacity. It was not able to be determined who the facility specifically interviewed for residents who were determined to lack capacity as "family" , "responsible party" and "legal representative" could be different people. The Administrator used these terms interchangeably and there was no doc

Based on a review of the facility's job description for the Administrator, resident record reviews, resident and staff interviews and review of facility policies, the facility administration failed to operationalize facility policies regarding Abuse, Neglect and Exploitation of residents for 4 of 21 residents reviewed for abuse (# 3, # 11, # 13 and # 5) , related to an allegation of sexual abuse for Resident # 3, an allegation of abuse reported by Resident # 11 on behalf of herself and Resident # 13 and an allegation of abuse reported by Resident # 5. The facility administration failed to ensure that the residents received the highest degree of quality of care and service in a caring and [MEDICATION NAME] atmosphere which recognized the individual's needs and rights as required in the Administrator's job description. The facility administration failed to demonstrate that safety of residents was a system wide practice after an allegation of sexual abuse was made for Resident # 3, as required in the Administrator's job description. The facility administration demonstrated a lack of action and commitment to investigate abuse and protect residents from abuse which resulted in findings of Immediate Jeopardy on 1/8/15. The Facility was informed of the Immediate Jeopardy on 1/28/15 at 3: 26 p.m. Review of the facility's corrective action revealed that the Immediate Jeopardy was removed on 1/26/15 and the scope and severity was reduced to a "D." Findings include: 1. Review of the facility Administrator's Job Description revealed: Position Title: Administrator Position Summary: The Administrator is responsible for planning and is accountable for all activities and departments subject to rules and regulations promulgated by government agencies to ensure proper health care services to customers. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to the customers. Responsibilities/Accountabilities: (Essential job functions are identified with an asterisk *.) 1. Implements Center objectives as determined and directed by the governing body.* 2. Interprets personnel practices within policy guidelines and recommends changes as necessary.* 3. Meets with licensing authorities as required and accompanies them throughout any survey of the Center.* 4. Ensures the credentialing process is completed for all Licensed Independent Practitioners providing services in the Center.* 5. Authorizes purchases of supplies and equipment within budgetary guidelines established by the governing body.* 6. Superintends physical operations of the Center. 7. Promotes favorable public relations and represents the Center in community as required. 8. Develops and maintains positive relationships with customers, relatives, and employees. 9. Concerns his/herself with the safety of all Nursing Center customers in order to minimize the potential for fire and accidents. Also, ensures that the Center adheres to the legal, safety, health, fire and sanitation codes by being familiar with his/her role in carrying out the Center's fire, safety and disaster plans and by being familiar with current MSDS.* 10. Oversees and guides Department Managers in the development and use of departmental policies and procedures.* 11. Reviews and evaluates the work performance of assigned personnel as well as counsel/discipline assigned personnel according to established Company personnel policy.* 12. Conducts committee meetings such as Quality Assurance & Risk Management, Safety, Daily Morning Meeting, etc...* 13. Interview and hires, Department Heads and other staff positions within the Center as necessary. 14. Confers with consultants to various departments concerning problem areas and available solutions; follows through on reports from Consultants. 15. Monitors reports and information of the Center and reports to the governing body; implements corrective action and budgetary constraints as required.* 16. Oversees and assists in the preparation of annual budgets for each department.* 17. Puts Customer Service First: Ensures that customers and families receive the highest quality of service in a caring and [MEDICATION NAME] atmosphere which recognizes the individual's needs and rights. 18. Performs all other duties as requested. Performs Related Duties: 1. Interacts with customers, families, visitors and Center personnel. 2. Carries out other tasks as requested in situations where hands-on intervention /participation may be required. Safety Related Duties: 1. Function with a high degree of efficiency, predictability and safety. 2. Solicit input from customers and family members regarding safety issues. 3. Proactively report issues and concerns related to safety. 4. Safety is our number one priority. We routinely integrate/implement safety related system-wide practices into our work. Safety is truly a part of our culture. 2. The Administrator, on 1/22/15, provided the facility's policies and procedures related to abuse entitled "Abuse, Neglect, and Exploitation (ANE) Prohibition" and indicated that this was the facility's current abuse policy. The policy had an effective date of May 1, 2003 and a revision date of December 18, 2012. The Administrator, on 1/23/15 at 8:49 a.m., reported that he was the Abuse Coordinator. Review of the policy: "Policy: The Center Prohibits abuse/sexual misconduct, neglect, involuntary seclusion, and misappropriation of property. Purpose: For the Center to take all actions that are within its control to prevent occurrences of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of property for all Customers. Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting pain and/or mental anguish, any physical or mental mistreatment whether or not an actual injury has occurred, including, but not limited to, the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caregiver of services necessary to maintain physical and mental health; Verbal abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to Customers or their families, or within their hearing distance , regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a customer; such as telling a Customer that they should never be able to see their family again; Sexual Abuse: including, but not limited to sexual harassment, sexual coercion, sexual assault or sexual misconduct. Physical abuse: any activity that includes, but is not limited to hitting, slapping, pinching or kicking. It also includes controlling behavior through corporal punishment. Mental abuse: including, but is not limited to humiliation, harassment, threats of punishment or deprivation. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Exploitation: the act or process of taking advantage of any Customer by another person or caregiver for monetary, personal or other benefit, gain or profit. Involuntary seclusion: separation of a Customer from other Customers or from her/his room or confinement to her/his room (with or without roommates) against the Customer's will, or the will of the Customer's legal representative; Misappropriation of Customer Property: the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a Customer's belongings or money without the Customer's consent. PROCESS: 1. The Center will have policies and procedures in place that prohibit abuse, neglect, exploitation, involuntary seclusion, and misappropriation of property. 2. The Center should screen potential team members for a history of abuse, neglect or mistreating Customers, including checking with the appropriate licensing boards and registries. 2.1 The Center should not employ individuals who: 2.1.1 Have been found guilty by a court of law of abusing, neglecting, or mistreating others. 2.1.2 Had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. 2.1.3 Possesses a disqualifying offense as per F.S. 453.03 and F.S. 435.04. 3. Training should be provided to all team members, through orientation and ongoing sessions, about abuse prohibition: 3.1 Appropriate interventions to deal with aggressive and/or catastrophic reactions of Customers. 3.2 How to report knowledge related to allegations without fear of reprisal. 3.3 How to recognize signs of burnout, frustration and stress that may lead to abuse. 3.4 What constitutes abuse, neglect, and misappropriation of Customer property. 3.5 Interacting with customers to maintain and enhance his/her self -esteem/self -worth. 4. Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property should include: 4.1 Providing Customers, families and team members information on how to and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed. 4.2 Identifying, correcting and intervening in situations in which abuse, neglect, sexual misconduct and or/misappropriation of Customer property is more likely to occur. 4.3 Develop care plan identifying appropriate intervention to prevent occurrences, when appropriate. 4.4 Supervision of team members to identify inappropriate behavior. 4.5 Sufficient team members to meet the needs of the Customer, as required by law. 5. Team members should identify/investigate events, such as suspicious bruising of Customers, occurrences, patterns, and trends that may constitute abuse and investigate according to the individual's allegations, facts and circumstances. This also includes Customer -to Customer abuse. 6. Anyone who witnesses an incident of suspected mistreatment, neglect or abuse, sexual misconduct, including injuries of unknown origin and misappropriation of Customer property is to tell the abuser to stop immediately, and is to report it to the administrator and supervisor immediately. Allegations should be thoroughly investigated. 6.1 The team members alleged to have committed the act of abuse, neglect, or sexual misconduct should be immediately suspended, pending investigation to protect the customer. 7. Reports of A/N/E should be reported to the Customer's family/Legal Representative, physician and DCF. Examples of such reports may include but are not limited to: 7.1 A verbalization or threat or allegation of such. 7.2 An injury of unknown origin that was not observed by any person or the source of the injury could not be explained by the Customer and the injury is suspicious because of the extent of the injury or the location of the injury (e.g. its location in an area not generally vulnerable to trauma) or the number of injuries observed at one time, or the number of incidences of injuries over time. 7.3 A Customer-to-Customer action involving a Customer who willfully inflicts injury upon another Customer should be reviewed as abuse. Even though a Customer may have cognitive impairment, he/she could still commit a willful act. 7.3.1 However, there are incidents when a Customer's willful intent cannot be determined. In those cases, a Customer to Customer altercation should be reviewed as lack of supervision and in extreme situations; this would be reportable under neglect. 7.3.2 If "willfulness" is unclear contact VPO and CRM. " 7.4 Verbal threats, intimidation 7.5 Sexual harassment, sexual coercion, or sexual assault 7.6 Hitting, slapping, punching, kicking, other controlling behavior 7.7 Confinement to room, separation of Customers from other Customers 7.8 Exploitation of money, belongings 7.9 Medication errors or mistreatments depending on the severity 7.10 If a medication error or missed treatment is suspected to rise to the level of neglect. Center should obtain statement/and or order from physician as appropriate. 8. If the suspected abuse to a Customer is from another Customer, the Customer who has in any way threatened or attacked another should be removed immediately from the setting or situation until safety is achieved. 8.1 The threatening attacking Customer should be placed in a less stimulating environment and monitored by team members to assure their safety. 8.2 The family/Legal Representative and physician should be notified. Any recommendations should be completed (i.e., a psychiatric evaluation, or 1 to 1 supervision) and care plan updated. 8.3 Options for room changes should be provided based on the situation. 8.4 Center should seek alternative placement for the Customer exhibiting the abusive behavior, if warranted. 8.5 The victim of the suspicion of abuse should be evaluated for need of interventions to prevent reoccurrence and plan of care updated, if warranted. 9. Upon receiving information or report of A/N/E, sexual misconduct, the Administrator or designee should: 9.1 Contact Department of Children and Families (DCF) Adult Protective Services (APS) by phone or by facsimile. 9.2 Complete (immediate) Federal Report of Alleged Violations Involving A/N/E for mandated reporters and email to CAU. 9.3 Complete 5 day Federal Report of Alleged Violations involving A/N/E for Mandated Reporters and email to AHCA Complaint Administration Unit (CAU) by providing investigation results. 9.4 If information or report of A/N/E or sexual misconduct involves an Alpha Care Provider , the Administrator of designee shall contact the Alpha Director of Operations to inform him/her of the investigation and possibility that an Alpha Provider may be contacted by DCF. 9.5 Proceed with appropriate documentation, including plan of care updates. 9.5.1 The investigation documentation shall be kept confidential and in a file in the DON's office. 9.5.2 The Abuse Reporting Log should be kept current in the DON's office. 9.5.3 Each Adverse investigation should be kept in an individual Manila folder. Abuse investigations are kept in yellow folders. 9.6 FHCA Timeline for Reporting Adverse Incidents should be utilized as necessary. 9.7 Allegations of sexual assault/rape, physical assault and exploitation should be reported to local law enforcement. 10. The Center should protect Customers from further harm during an investigation. 10.1 Provide the Customer with a safe environment by identifying persons with whom he/she feels safe and conditions which would feel safe. 10.2 Assign a representative from Social Services or designee to monitor the Customer's feelings concerning the incident as well as the Customer's involvement in the investigation. 11. Conduct investigations as needed. 11.1 All investigations are part of the Center's Quality Assurance program and are at the direction of general counsel and are subject to attorney/client privilege. 11.1.1 The investigation documentation should be kept confidential and in a file in the DON's office. 11.1.2 Each investigation should be kept in an individual Manila Folder. 11.2 Copies of internal investigations are not to be provided 11.3 The Abuse Reporting Log should be kept current in the DON's office. 11.4 The findings of the investigations should be found on the Exception note. On the Exception note the following information should be included but not limited to: 11.4.1 The type of allegation should be identified. 11.4.2 The details of the incident. 11.4.3 The type of injury should be described as well as what licensed team member did to evaluate injury as applicable. 12. The Administrator/DON should analyze all occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences, and should communicate through QA meeting and Clinical Risk Management. " 3. Review of the facility "Contact/Abuse Reporting Log," on 1/22/15, revealed an entry dated 11/25/14 for an allegation of "neglect" related to Resident # 3. The final outcome was listed as "ongoing" . On 1/22/15 at 11: 00 a.m. and 1/23/15 at 8:49 a.m., interviews were held with the Administrator and the Director of Nursing regarding this allegation. The Administrator stated that on 11/23/14, Resident # 3 had been sent to the hospital related to altered mental status. He stated that on 11/24/14, two law enforcement personnel came to the facility and informed him that seminal fluid had been found in the urinalysis sample of Resident # 3 at the hospital. He stated law enforcement told him not to conduct an investigation and not to interview staff so as to not hinder their investigation. The Administrator stated that on 11/25/14, a protective service agency came to the facility and informed him that Resident # 3 made an allegation that a staff person may have sexually assaulted her. He stated that Resident # 3 did not return to the facility after her transfer to the hospital on [DATE]. On 1/26/15 at 12:31 p.m., the Administrator stated that he was aware of the resident's location after she had been discharged from the hospital. Review of the clinical record for Resident # 3 revealed that she was admitted to the facility, on 10/31/14, for skilled nursing services. Review of a nursing progress note on the date of admission, 10/31/14, revealed that her mental status upon admission was documented as alert and oriented. Review of a progress note entitled, "Social Service History," dated 11/3/14, revealed that the resident was "able to read and write, understands and responds to questions and has good verbal ability." The progress note also stated, "alert to person, place and time. Long Term memory is good and short term memory is good." Review of a nursing progress note, dated 11/23/14 at 11: 16 a.m., revealed: "Housekeeper came to nurse and said customer grabbed mop when she was cleaning room and was screaming at her. Nurse went into room and customer was combative stating ' they took my lung machine '. Customer refused to allow nurse to take any vital signs. Customer eventually let vitals be taken which was 162/80, pulse 97, temp 97.5. Customer was asked if she had any pain and she put her hand on her chest. Customer was asked if she had chest pain and she said yes. 911 was called and emergency crew arrived. Blood sugar was taken by paramedic and was 424. Customer stated he was trying to kill her. Customer was taken to (hospital). Son was notified and husband was notified." Review of Resident # 3's hospital record from the hospital that she was transferred to on 11/23/14 revealed a discharge summary, dated 12/10/14, for a discharge of 11/28/14. The discharge summary revealed: "Final Diagnoses: [REDACTED]." "Hospital Course: Sent to the emergency roiagnom on account of a change in mentation. Work-up done in the emergency room . A CT scan of the brain was negative. The patient, however, note with some sperm in the urine. Hence, detective is involved in her case. The patient was clinically stable ... " The Administrator reported that the facility took immediate action after receiving the allegation of abuse on 11/25/14. He indicated that the facility only had the information reported to them by law enforcement and the protective services agency and did not know if anyone at the facility had sexually assaulted the resident. The Administrator stated, " If there is a possibility that it happened here we want to determine who the perpetrator was, when it could have happened, how far back it could have happened. " He provided a form entitled, "Credible allegation of compliance" which included: 1. " Immediate report completed 11/25/14. List of current center team member's to be given to police within 1 week from 11/25/14 Police requested no investigation be completed at center level due to possibly impeding investigation 11/25/14. Camera footage from center security cameras to be reviewed/given to police. Date to be determined. Allegation of compliance 11/28/14 2. Customers/legal representatives interviewed in relation to any concerns with team members specifically related to inappropriate behavior. Appropriate follow up generated where indicated. Team members interviewed in relation to any concerns related to other team members acting or verbalizing being inappropriate with/toward customers. Background screens of current team members reviewed for compliance. Security guard contracted 11/26/14 to screen visitors, staff vendors prior to visitation (24/7 times 7 days) then to be re- evaluated. Allegation of compliance 11/28/14. 3. Center team member's re- in serviced (151 of 166 team members) on abuse/neglect policy. The remaining team members will be in- serviced prior to starting their assigned duties on their next scheduled shift. Allegation of compliance 11/28/14. 4. Nursing Home Administrator/Director of Nursing to QI monitor customer concerns for potential concerns related to team members/visitors vendors and inappropriate behavior weekly x 4 weeks then monthly x 2 months until substantial compliance achieved. Findings reported to QA/RM committee for follow up. Allegation of compliance 11/28/14. " On 1/23/15 at 8:49 a.m., the Administrator reported that, although they were not allowed to talk to staff, residents and families about the specific allegation, the facility interviewed all residents' with capacity and all families/ legal representatives for those residents without capacity for four weeks in a row. He stated, "we asked whether they had witnessed or heard anything; asked them if anyone had touched them that they felt was inappropriate." The Administrator stated, "We interviewed every team member," asked them if they witnessed or heard anything. He stated that there were four employees who they did not interview as the law enforcement detective "told us not to speak with them." The Administrator stated in service training "on every aspect of abuse" was conducted with all employees beginning on 11/25/14 with 100 % of staff retrained as of 11/28/14. The Administrator provided documentation of the retraining of staff. The Administrator also reported that they reviewed video footage for the week prior to Resident # 3 discharging to the hospital and reviewed the visitor sign in book to determine who had visited Resident # 3 in the week prior to her discharge. He stated that the video footage was of the grounds and the lobby and that nothing unusual was noted. He stated that the only visitors for Resident # 3 were her family. The Administrator stated that the facility also put security in place and has a security guard twenty four hours a day seven days a week who does rounds inside and outside on the property. He stated the facility reviewed staffing and supervision and reviewed who worked with Resident # 3 and determined that there were no identified issues. The Administrator stated, "Weekly interviews were conducted with customers and responsible parties- nothing came out of it." The Administrator stated the facility looked at all male team members even though Resident # 3 "had no direct care male caregivers" and looked back a week to determine if any males had provided care for her. He reported that there was no employee at the facility who met the description provided by the protective service agency as the person who may have sexually assaulted Resident # 3. He stated that a male CNA (Certified Nursing Assistant) with the same first name as the person named was suspended pending investigation even though he did not meet the physical description of the employee she described and had never worked on Resident # 3's hall or with Resident # 3. He stated that this employee's name was provided to law enforcement. The Administrator did report that Resident # 3 had a male physical therapist that provided therapy services to her and that he had had a conversation with the resident regarding a concern she had about the therapist and her physical therapy. The Administrator stated that she felt the therapist was pushing her to do the therapy and he told her that she could choose to refuse therapy. The Administrator stated that the male physical therapist was a contracted employee. He stated that he gave the therapist's name to the police and the "police officer was aware that he was here then and provided therapy for her" , but he, the Administrator, did not question or investigate him "because we could not disclose." He stated that he did not report the information to the contracted agency because "we could not disclose" He stated he "was background screened." Review of the clinical record for Resident # 3 revealed physical therapy services were documented and signed by the male physical therapist (Employee K) on 11/13/14, 11/14/14 and 11/17/14. The Administrator stated, on 1/22/15 at 11: 00 a.m., that on 1/10/15 the law enforcement detective "gave us the okay for us to continue the investigation." On 1/23/15 at 8:49 a.m., the Administrator stated, again, that "1/10/15 was the date the detective said we could proceed. " The Administrator stated that he was the Abuse Coordinator and the Risk Manager for the facility and that he and the Director of Nursing had been conducting the investigation. He stated that, since 1/10/15, neither he nor anyone at the facility had attempted to contact Resident # 3 or her family to continue the investigation regarding the allegation of sexual assault that was made on her behalf and reported to him on 11/25/14. He stated, "We have not received any directive to contact them so we have not contacted them. Senior Leadership hasn't said either way to contact or not to contact." The Administrator stated that, since 1/10/15, neither he nor anyone at the facility had interviewed four staff that he was originally told by law enforcement not to interview, prior to 1/10/15. He stated, since 1/10/15, that the law enforcement detective "hasn't said if we could speak to them now and we haven't asked. " Review of the staffing schedules and the CNA (Certified Nursing Assistant) Activities of Daily Living documentation for the week of November 18 through November 23, 2014 revealed that these four staff worked on Resident # 3's unit and provided care for Resident # 3 during this period. The Administrator stated that, since 1/10/15, neither he nor anyone at the facility had interviewed the contracted physical therapist (Employee K) who provided services to Resident # 3 in November 2014. He stated that, neither he nor anyone at the facility, had contacted the agency that Employee K was contracted through to inform them of an investigation involving an allegation made by a resident that the therapist provided service to or notify them that the therapist's name had been provided to the police in reference to an allegation of sexual assault. On 1/26/15, at 12: 31 p.m., the Administrator and the Director of Nursing participated in an interview to clarify and provide additional information regarding the investigation into the allegation of "neglect" documented in their abuse log, for Resident # 3, and the current status of the investigation and efforts made to ensure protection of all residents. The Administrator stated, again, that the facility was given clearance by law enforcement to complete their investigation on 1/10/15. The Administrator was asked if anyone from the facility had spoken to Resident # 3 or her family since 1/10/15 and he, again, stated "no" that he was not given any specific directive to speak with the resident. A telephone interview was held with Resident # 3 by a surveyor, on 1/23/15 at 10:51 a.m. regarding the allegation of sexual abuse. She stated that she could not remember due to having been sick and on medication at the time and requested that her family member be interviewed. An interview was held with a family member of Resident # 3 on 1/23/15 at 11:01 a.m. He stated after (Resident # 3) was discharged from the hospital he moved her to a different facility "for obvious reasons. " He stated he does not know one way or another if she was sexually abused while a resident at the facility and was waiting for the lab result for the final determination. He stated that his concern was that no other resident be abused. He stated that no one from the facility had contacted him to follow up on the investigation. On 1/26/15 at 12:31 p.m., the Administrator reported that the facility conducted a monthly Quality Assurance Meeting on 12/11/14 but did not discuss the allegation of sexual abuse at the meeting due to the law enforcement directive not to discuss with anyone. He stated a special Quality Assurance Meeting was held on 12/18/14 where there was a discussion of the Corrective action plan and the results of the resident/ family/legal representative interviews. The Administrator further stated that the facility had a Quality Assurance meeting on 1/22/15 and the resumption of monthly resident/family /legal representative interviews was discussed and planned. An interview was conducted with the Medical Director, by phone, on 1/26/15 at 2:43 p.m. The Medical Director was also documented as Resident # 3's physician in Resident # 3's clinical record. The Medical Director stated she was familiar with the circumstances involving Resident # 3 and that there was a law enforcement investigation. She stated that based on hearsay, the hospital found (seminal fluid) in the resident's urine but she had not been able to obtain any documentation from the hospital. She stated that the police had not spoken to her. She reported that she did attend the Quality Assurance meetings in December 2014 and January 2015 and stated that she recalled there was a discussion of concerns related to Resident # 3 and that the facility had added 24 hour security. She reported that she had no further knowledge of any other actions that the facility had taken and that to her knowledge, the facility had finished the investigation and it was now closed. On 1/23/15 at 8:49 a.m., the Administrator stated that the facility had not concluded the investigation into the allegation of abuse for Resident # 3. He stated that law enforcement had not concluded their investigation and "we can't conclude because we don't know the results of the DNA, the possible contamination of the urine, we can't conclude that everything is "A OK" and is done." 4. On 1/26/15 at 12:31 p.m., the Administrator reported that all residents with capacity and families/ legal representatives of those residents without capacity were interviewed weekly from 11/26/14 through 12/19/14. He stated that the 1st monthly resident and family/legal representative interviews were conducted from 1/23/15 to 1/25/15 with all residents and/or families interviewed except for two families that they were unable to reach. The Administrator stated that the first week, interviews were conducted by him, the Director of Nursing, the Clinical Risk Manager and the Executive Administrator. He stated the next three weeks, the interviews were conducted by him, the Director of Nursing and the Clinical Risk Manager and they also conducted the most current interviews from 1/23- 1/25/15. He stated that the interviews were "done per verbal plan" which was decided upon by the four interviewers prior to conducting the interviews and that the plan included what questions were to be asked and in what way. The Administrator reported that the residents and families /legal representatives were asked "how they were doing, how the care has been, if they knew how to report abuse and if they needed to report anything, if anyone had treated them badly, touched them inappropriately" and if they had "heard of anything like that taking place." He stated that they did the interviews by room number so they could "ensure that every single resident in every room was done". He reviewed