Every finding on record at Focused Care at Lamesa

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #44, Resident #1 and Resident #22) of 4 residents reviewed for infection control. CNA C failed to sanitize hands between glove changes during incontinent care on 07/27/26 for Resident #44. LVN A failed to wear proper PPE (a gown) when providing wound care on 07/27/26 for Resident #1 who was on EBP and while assisting LVN B with wound care on 07/27/26 for Resident #22 who was on EBP. LVN B failed to wear proper PPE (a gown) when assisting LVN A with wound care on 07/27/26 for Resident #1 who was on EBP. These failures could place residents at risk for the spread of infection and cross contamination.Resident #44 Record review of Resident #44's admission Record dated 07/30/26, reflected a [AGE] year-old female with an original admission date of 11/05/24. Resident #44 had diagnoses which included: cerebral infarction (stroke), muscle wasting (loss of muscle mass), depression, seizures and hypertension (high blood pressure). Record review of Resident #44's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, indicating the resident was cognitively intact. Section GG - Functional Abilities reflected the resident required substantial/maximal assistance with toileting hygiene. Section H - Bowel and Bladder reflected the resident was occasionally incontinent of bladder and bowel. Record review of Resident #44's Comprehensive Care Plan, revised 04/01/26, reflected Resident #44 was frequently incontinent of bowel and bladder. Interventions included: Monitor for incontinence Q2H/PRN, change promptly and apply protective skin barrier. During an observation on 07/27/26 at 9:52 AM of incontinent care for Resident #44, CNA C removed the soiled brief and provided incontinent care. CNA C changed gloves and placed a clean brief on the resident. CNA C failed to sanitize hands between the glove changes. Resident #1 Record review of Resident #1's admission Record dated 07/30/26, reflected a [AGE] year-old female with an original admission date of 03/20/26. Resident #1 had diagnoses which included: cerebral infarction (stroke), acquired absence of right leg above knee (amputation of right leg above the knee), hypertension (high blood pressure), and generalized muscle weakness. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 07, indicating the resident was severely cognitively impaired. Section M - Skin Conditions reflected the resident had one unstageable pressure ulcer (an injury to tissue caused by pressure where depth of the injury cannot be determined). Record review of Resident #1's Comprehensive Care Plan, revised 05/14/26, reflected the resident was on EBP with an intervention for staff to maintain EBP while performing wound care. Further review of the care plan, revised on 07/24/26, reflected the resident had a pressure injury (damage to the skin and underlying soft tissues caused by pressure) to the sacrum (area at the base of the spine), with an intervention for daily wound care and application of a wound dressing. Record review of Resident #1's current Physician's Orders, dated 07/28/26, reflected the resident had an order for daily wound care and application of a wound dressing to the coccyx (tailbone), with a start date of 07/17/26. Further review reflected Resident #1 had an order for Enhanced Barrier Precautions with a start date of 04/16/26. During an observation of wound care on 07/27/26 at 10:15 AM, LVN A performed wound care to Resident #1's coccyx wound, according to Physician's Orders. LVN A put on gloves but failed to put on a gown prior to performing wound care for Resident #1. LVN B assisted LVN A to turn the resident and remove and replace linens during wound care. LVN B put on gloves but failed to put on a gown prior to assisting LVN A during wound care for Resident #1. Enhanced Barrier Precaution signage was noted at the top of Resident #1's bed and a PPE cart was noted outside Resident #1's room. Resident #22 Record review of Resident #22's admission Record, dated 07/30/26, reflected a [AGE] year-old female with an original admission date of 12/04/23. Resident #22 had diagnoses which included: congestive heart failure (a chronic condition where the heart muscle cannot pump blood efficiently), chronic obstructive pulmonary disease (a long-term lung condition that blocks airflow and makes it hard to breathe), dementia (a decline in mental ability which interferes with daily life), and muscle wasting. Record review of Resident #22's Quarterly MDS assessment, dated 05/29/26, reflected a BIMS score of 00, indicating the resident was severely cognitively impaired. Record review of Resident #22's Comprehensive Care Plan, revised 07/27/26, reflected the resident was on EBP with an intervention for staff to maintain EBP while performing wound care. Further review of the care plan, revised on 07/24/26, reflected the resident had a Kennedy ulcer (a rapidly developing skin wound that often appears during the final weeks of life) with an intervention for daily wound care and application of a wound dressing. Record review of Resident #22's current Physician's Orders, dated 07/28/26, reflected the resident had an order for daily wound care and application of a wound dressing to the sacrum with a start date of 07/20/26. Further review reflected Resident #22 had an order for Enhanced Barrier Precautions with a start date of 07/27/26. During an observation of wound care on 07/27/26 at 10:40 AM, LVN B put on gloves and a gown and performed wound care to Resident #22's sacral wound, according to Physician's Orders. LVN A assisted LVN B to turn the resident and remove and replace pillows and linens during wound care. LVN A put on gloves but failed to put on a gown prior to assisting LVN B during wound care. Enhanced Barrier Precaution signage was noted at the top of Resident #22's bed and a PPE cart was noted outside Resident #22's room. During an interview on 07/27/26 at 10:56 AM, LVN A stated she failed to wear a gown while providing wound care for Resident #1. LVN A stated a gown, and gloves should always be worn while providing wound care and stated she did not think about putting a gown on until she had already started the wound care procedure. She stated she was trained on EBP through computer-based training and in-service training at the facility. LVN A stated the purpose of EBP was to protect staff and residents from cross-contamination of germs. She stated she should have also worn a gown while assisting LVN B with Resident #22's wound care due to assisting with a high-contact activity, such as removing and replacing linens and pillows. LVN A stated a potential negative outcome for failure to wear a gown during wound care for a resident on EBP was cross-contamination. During an interview on 07/27/26 at 11:00 AM, LVN B stated she failed to wear a gown while assisting LVN A during wound care for Resident #1. She stated she should have worn a gown for high-contact activity, such as turning the resident and handling the bed linens, due to the resident being on EBP. She stated she was trained on EBP upon hire and also through computer-based training during the past month. LVN B stated the purpose of EBP was to protect the residents from the spread of germs. She stated a gown should be worn for activities such as changing linens, transferring, dressing, and when the resident had an indwelling device such as a catheter. LVN B stated a potential negative outcome for failure to wear a gown during wound care for a resident on EBP was the spread of germs. During an interview on 07/27/26 at 3:25 PM, CNA C stated she did not sanitize her hands in between glove changes during incontinent care for Resident #44. She stated she was focused on the task she was doing and forgot to use hand sanitizer when she changed her gloves. CNA C stated she usually carried a bottle of hand sanitizer in her pocket, but she was assigned to do showers, so she did not have it with her. She stated she was trained on proper hand sanitizing through in-services and computer-based training. CNA C stated hands should be sanitized before beginning incontinent care, between glove changes, and when care was completed. CNA C stated a potential negative outcome for failure to properly sanitize hands was infection. During an interview on 07/28/26 at 10:18 AM, the ADM stated she was not aware staff were not properly sanitizing hands between glove changes and were not wearing a gown while performing and assisting with wound care for residents on EBP. She stated nursing administration was responsible for ensuring hand sanitizing and EBP protocol were followed. The ADM stated all staff were trained on hand hygiene and EBP and staff were monitored through nursing administration rounds, skills checks, and regular in-services. She stated her expectation of staff was that proper PPE was used for EBP residents and hand hygiene was performed per policy. The ADM stated a potential negative outcome for failure to utilize proper PPE and perform hand hygiene was infection. During an interview on 07/28/26 at 10:37 AM, the DON stated she was not aware staff were not properly sanitizing hands between glove changes and were not wearing a gown while performing and assisting with wound care for residents on EBP. She stated nursing administration was responsible for ensuring protocol was followed for EBP and hand hygiene. She stated the purpose of EBP was to prevent the spread of infection. She stated a gown should be worn during wound care and should also be worn by anyone assisting with wound care. The DON stated hand hygiene should be performed before and after contact with a resident and between each glove change. She stated all staff were trained on EBP and hand hygiene through in-services and were monitored through skills checks conducted by nursing administration. The DON stated a potential negative outcome for failure to perform proper hand hygiene and wear proper PPE during care of a resident on EBP was infection. Record review of the facility's policy titled Hand Hygiene, revised 10/24/2022 reflected: PolicyHand hygiene is used to prevent the spread of pathogens in healthcare settings. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub (ABHR) to destroy harmful pathogens, such as bacteria or viruses, on the hands. 1. You should always perform hand hygiene: -Before applying and after removing personal protective equipment (e.g. gloves, gown, mask, face shield/goggles) . Record review of the facility's policy titled Enhanced Barrier Precautions, dated 10/24/2022 reflected: PolicyEnhanced Barrier Precautions (EBP) are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes. EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO, or who have open wound or indwelling medical device. Procedure .2. Determine if a resident has any wounds . Examples of chronic wounds include, but are not limited to, pressure ulcers.4. High contact resident care activities:.Wound care: any skin opening requiring a dressing. Record review of the facility's undated sign posted above the bed of Resident #1 and Resident #22, titled, Enhanced Barrier Precautions, reflected: PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities.Wound Care; any skin opening requiring a dressing

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 51). The facility failed to ensure Resident #51 wore a smoking apron as indicated in his physician orders during the smoke break on 07/27/26 at 11AM. This failure could place residents at risk for inadequate protection from potential injury.Findings included: Record review of Resident #51's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #51 had the following diagnoses: anxiety (mental health condition), hypertensive retinopathy, bilateral (damage to the blood vessels in the eye caused by high blood pressure), vascular dementia, unspecified severity, with other behavioral disturbance (decline in thinking skills caused by conditions like strokes that block or reduce blood flow and oxygen to the brain), intermittent explosive disorder (mental health condition defined by sudden, repeated bursts of extreme anger), weakness, muscle wasting and atrophy, not elsewhere classified, multiple sites (thinning, shrinking, and loss of muscle mass, and strength), and lack of coordination. Record review of Resident #51's clinical record revealed his comprehensive MDS assessment, completed 1/9/26, listed him with a BIMS score of 7, which indicated severe cognitive impairment. The MDS indicated Resident #51 used tobacco at the time of the assessment. Record review of Resident #51's physician active orders, dated 7/27/26, revealed an order dated 6/18/26 that a smoking apron was to be used on all smoke breaks. Record review of Resident #51's Care Plan Report, dated 10/14/19, revealed Resident #51 smoked and tobacco abuse. The goal was Resident #51 would remain free from smoking related injuries through the next evaluation. Interventions initiated on 5/1/26 were that Resident #51 would keep all lighters/matches with facility staff for safety, Resident #51 would participate in supervised smoke breaks, Resident #51 would wear a smoking apron while smoking for protection, and a smoking evaluation would be completed upon admission by a licensed nurse. Record review of Resident #51's Safe Smoking Assessment, dated 7/12/26, revealed Resident #51 could independently light smoking materials safety, Resident #51 could dispose of ashes or other tobacco-related residue appropriately, Resident #51 required direct supervision while smoking, all smoking materials would be kept at the nurse's station, and the care plan was up to date or updated. During an observation on 7/27/26 at 11:00 a.m., Resident #51 was observed outside smoking with other residents. HK D and HK E passed out smoking materials, lit cigarettes, and supervised residents during the smoke break. Resident #51 was observed smoking a lit cigarette independently. Resident #51 was not wearing a smoking apron. There were no cigarette ash or burns observed on his clothing. During an interview on 7/28/26 at 9:37 a.m., HK D stated she passed smoking materials and supervised residents during the 11:00 AM smoke break on 7/27/26. HK D stated she was aware that Resident #51 and another resident wore smoking aprons. HK D stated Resident #51 sometimes refused to wear the smoking apron. HK D stated Resident #51 was supposed to wear the apron. HK D stated she would still allow Resident #51 to smoke when he refused to wear the smoking apron. HK D stated she did not know why she allowed this. HK D stated she did not know why Resident #51 was supposed to wear the smoking apron. HK D stated she did not remember if Resident #51 wore a smoking apron yesterday during the 11:00 AM smoke break. HK D stated she was trained in the smoking policy and smoking supervision requirements. HK D stated a potential negative outcome was that Resident #51 could get burned. During an interview on 7/28/26 at 10:00 a.m., HK E stated she passed smoking materials, smoking apron, and supervised residents during the 11:00 AM smoke break on 7/27/26. HK E stated she was not aware Resident #51 was required to wear a smoking apron while smoking. HK E stated she was not supposed to allow residents who were required to wear smoking aprons to smoke if they refused to wear them. HK E stated she would notify the charge nurse if a resident refused to wear a smoking apron and then allow them to address the situation. HK E stated she was only given one smoking apron by another staff member as they prepared to go outside to smoke so she gave it to another resident whom she knew wore the smoking apron. HK E stated she had never seen Resident #51 wear a smoking apron during smoke breaks. HK E stated Resident #51 smoked a cigarette without a smoking apron on 7/27/26 during the 11:00 AM smoke break. HK E stated they were notified of residents who were required to wear smoking aprons during morning meetings and by other staff as she did not have access to the resident's electronic health records. HK E stated the smoking aprons were to prevent residents from burning themselves or their clothing. HK E stated she was trained in the smoking policy and how to supervise residents during smoke breaks at the town hall meetings held on the second Tuesday of every month. HK E stated a potential negative outcome was that residents could catch on fire or get burned. During an interview and observation on 7/28/26 at 11:30 AM, Resident #51 stated he smoked cigarettes. Resident #51 stated he did not wear a smoking apron while smoking. Resident #51 stated he was willing to wear a smoking apron and stated he had not refused to wear a smoking apron. Observation reflected there were no burns or burn marks observed on Resident #51's clothing. A full interview was unable to be obtained due to the resident's level of cognitive functioning. During an interview on 7/28/26 at 11:50 AM, the ADM stated the smoking policy was that all residents who smoked were required to be supervised by staff, smoking assessments were completed upon admission and then quarterly thereafter. The ADM stated smoking aprons were provided to residents that were at risk of burning themselves. The ADM stated there were seven scheduled smoke breaks each day. The ADM stated she was not aware Resident #51 had physician orders that required him to wear a smoking apron and was not wearing it. The ADM stated all staff that supervised smoke breaks had received training on the requirements, how to properly monitor residents, and how to know who was supposed to wear a smoking apron. The ADM stated there was also a list of residents who were required to wear smoking aprons located inside the box that stored the smoking materials. The ADM stated the person supervising the residents, herself, and the DON were responsible for ensuring residents wore smoking aprons. The ADM stated she expected staff to follow physician orders or the staff member could hold the cigarette for the residents if they chose to allow the resident to smoke without the apron. She stated a potential negative outcome was that residents could get burned. During observation and interview on 7/28/26 at 12:04 PM the DON stated during the smoke breaks, staff passed the smoking materials to residents, lit the cigarettes, and gave smoking aprons to residents required to wear them. The DON stated she was not aware there was a resident that was not wearing a smoking apron that was required to. The DON stated she just learned today that Resident #51 was supposed to wear a smoking apron when she was outside this morning and observed him wearing an apron. The DON stated she asked the staff member who supervised the smoke break after she observed Resident #51 wearing a smoking apron and who told her there was a recent change a couple of weeks ago and that he was required to wear the apron because he was observed with ashes on his clothing after smoking. The DON stated she was on leave during that time and was not made aware of the orders when she returned to work. The DON stated she was not aware if Resident #51's name was added to the list of residents who were required to wear smoking aprons that were located inside the box that stored the smoking materials. The DON stated the list in the smoking materials box was how staff were notified of residents that were required to wear smoking aprons. The DON stated staff had been trained on smoking supervision responsibilities, but she was not sure when they were last trained. The DON stated she and the ADON were responsible to ensure residents were wearing aprons as required. The DON stated she needed to identify which staff member added the orders into the resident's electronic medical record since they did not update her on the changes. The DON stated she expected staff to ensure residents wore smoking aprons that were on the list and to notify her if someone was not smoking safely and of any changes regarding the resident's ability to smoke. The DON stated she expected staff to follow physician orders. The DON stated a potential negative outcome was that residents could get burned. Resident #51's name was observed on the list of residents required to wear smoking aprons that were inside the smoking materials container. In an email on 8/03/26 at 11:57 AM, the ADM stated they did not have specific policies on following physician orders. Record review of facility provided policy titled, Smoking revised October 12, 2022, revealed in part: It is the policy of this community to accommodate residents who desire to smoke, including electronic cigarettes by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. PROCEDURE 6. A Licensed Nurse will complete a Resident Smoking Assessment to assess residents who express a desire to smoke, including electronic cigarettes, upon admission, quarterly, annually and upon significant change of condition identification, and present it to the Interdisciplinary Team (IDT) for review. 8. IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke. This is documented on the Resident Smoking Assessment, the resident's Plan of Care, and discussed with the resident and Responsible Party at resident care conference meetings. 9. Resident will be informed of smoking violations and after three (3) infractions may be discharged from the facility as an unsafe smoker.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for food storage. On 07/26/2026 facility failed to properly label food stored in the refrigerator. This failure could place residents at risk for foodborne illness.Findings included: The following observation was made on 07/26/2026 at 09:55 a.m. during the initial tour of the kitchen:Bowl of white pudding with no label.Bowl of red sauce with no label. During an interview on 07/26/2026 at 02:35 p.m., the DS stated the bowl of white pudding was yogurt, and the red sauce was cranberry sauce. He stated the bowls were not labelled when placed in the refrigerator. He stated all items should be labelled when placed in the refrigerator. During an interview on 07/27/2026 at 03:30 p.m., the DS stated all food in the refrigerator should be labelled and dated. He stated all dietary staff were trained in proper food storage. He stated he was not aware the bowl was not labelled. He stated he checked refrigerators 3 times a week on Monday, Wednesday and Friday. He stated his Assistant Manager checked them on Tuesday and Thursday. He stated the purpose for labelling and dating food was food safety. He stated the potential negative outcome could be food borne illness. During an interview on 07/27/2026 at 03:55 p.m., the ADM stated all food in the refrigerator should be labelled and dated. She stated the purpose of labeling the food was to know when it was opened and when it would expire. She stated all staff were trained in proper food storage. She stated she was not aware food was being stored without a label. She stated the DS and ADM were responsible for making sure food was properly stored. She stated the DS checked the refrigerators weekly and the dietitian checked them monthly. She stated the potential negative outcome could be food borne illness. Record review of the facility's policy titled Food Labeling and Dating, revised 1/2018 reflected: Food should be stored in a safe and sanitary method to prevent contamination and food-borne illness. All food should be stored according to local, state and federal regulations.2. Refrigerators.c. Refrigerated food should be dated, labeled and sealed.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 5 medication carts (Overstock Medication Cart and Treatment Cart) observed for storage. The facility failed to ensure the Overstock Medication Cart and Treatment Cart were secured when unattended on 7/26/26. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation and interview on 7/26/26 at 10:06 AM, the Overstock Medication Cart and Treatment Cart were observed next to each other by the nurse's station with the locks popped out and without staff present. Residents, staff, and visitors were observed in and around the area since the nurse's station was in the center of the building in a high traffic area. LVN B was observed sitting at the nurse's station working on a computer and she was not faced towards the Overstock Medication Cart and Treatment Carts. Additionally, the nurse's station counter was higher than LVN B's eyes and obstructed her view from the Overstock Medication Cart and Treatment Carts. LVN F came from around the corner from hall 4 and approached the Overstock Medication Cart and Treatment Carts. All the drawers of the Overstock Medication Cart were opened and various blister packs of pills and bottles of medications and medical supplies were observed in the drawers of the Overstock Medication Cart that opened. The drawer that contained the narcotic medications opened however the lock box was secure. All the drawers of the Treatment Cart were opened and various creams, ointments, and gels that were used to treat skin issues were observed in the drawers of the Treatment Cart that opened. Additionally, there were bottles of iodine, gloves, bandages, and gauze. The drawer that contained the internal lock box was locked. LVN F stated she was responsible for the Overstock Medication Cart but not the Treatment Cart. LVN F stated she did not have the key to the Treatment cart and did not know who left it unlocked but only the nurses had keys to that cart. LVN F stated she was covering and she passed out medications and was in the process of transferring medications from the Overstock Medication Cart to the Medication Aide cart that had run out. LVN F stated the medications kept in the Overstock Medication Cart were medications currently prescribed to residents that did not fit in the Medication Aide Cart. LVN F stated all carts that contained medications in them must be always locked while unattended. LVN F stated she was unaware that she left the Overstock Medication Cart unlocked. LVN F stated the system to ensure medication carts were locked at all times was to ensure they locked them when they were left unattended. LVN F stated she was trained on Medication Carts, Medication Pass, and Medication Storage but she was not sure when she was last trained. LVN F stated she was responsible for ensuring the Overstock Medication Cart was locked before she walked away from it. LVN F stated a potential negative outcome was that residents and visitors could open it and take medications. During an interview on 7/26/26 at 10:28 AM, LVN B stated she was one of the charge nurse's during the shift. LVN B stated neither of the carts were assigned to anyone in particular but only the nurse's had a key to the Treatment cart, and the Overstock Medication Cart was for storage of resident's medications. LVN B stated LVN F accessed the Overstock Medication Cart and left it unlocked and it was LVN F's responsibility to ensure she locked it before she left it unattended. LVN B stated she did not know who left the Treatment Cart unlocked. LVN B stated both the Treatment cart and the Overstock Medication Cart must be locked while unattended. LVN B stated she was not aware both carts were unlocked and unattended. LVN B stated they monitored medication carts and checked them routinely to ensure they were locked. LVN B stated she was trained on medication carts, medication storage, and medication pass but could not remember the last time she was trained. She stated she expected staff to ensure all medication carts were locked, medications were dated, labeled, and that the keys were not left where someone could grab them. LVN stated a potential negative outcome was that residents and staff could access the medications in the cart and grab the wrong pills or get ahold of narcotics. During an interview on 7/28/26 at 11:50 AM, the ADM stated the policy was that medication carts and treatment carts should be locked anytime they were unattended and anytime a staff was not actively in the cart. The DON stated she was not aware staff left treatment and medication carts unlocked and unattended. She stated the nurses were responsible for ensuring the treatment cart was locked when unattended. The ADM stated the DON, and the ADM were responsible for ensuring medication carts were locked when unattended. The ADM stated they currently did not have a designated treatment nurse but both nurses working on the shift had access to the treatment cart. The ADM stated staff were trained on medication pass, medication storage, and medication carts upon being hired, quarterly, and by being in-serviced periodically. The ADM stated the DON, the ADON, and herself also checked medication carts daily during rounds. The ADM stated she expected staff to lock the carts before they walked away from them. The ADM stated a potential negative outcome was that medications could have been stolen or ingested by residents, visitors, and staff members. During an interview on 7/28/26 at 12:04 PM, the DON stated that the policy was that medication carts should be locked at all times when staff were not standing with them. The DON stated she was made aware afterwards that staff left the medication and treatment carts unlocked and unattended. The DON stated the ADM, ADON, and herself did rounds throughout the day and checked the carts and would address any concerns with staff at that time. The DON stated the treatment cart was also supposed to be locked because there were items stored in there that were supposed to be kept away from children. The DON stated staff were trained and in-serviced on medication carts, storage, and medication pass. She stated she expected staff to lock the carts when they walked away from them. The DON stated a potential negative outcome was that residents or staff could have stolen and/or ingested the medications. Record review of the facility provided policy, Security of Medication Cart, revised April 2007, revealed in part: Policy Heading: The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.4. Medication carts must be securely locked at all times when out of the nurse's view.5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 (Resident #58) of 6 residents reviewed for respiratory care. The facility failed to ensure that Resident #58's oxygen tubing was stored properly while not in use when it was observed on the floor during an initial tour observation on 07/26/26 and on an observation on 07/27/26. This failure could place residents at risk for respiratory compromise and infection.Record review of Resident #58's admission Record dated 07/28/26 reflected a [AGE] year-old female with an original admission date of 07/22/17. Resident #58 had diagnoses which included: cerebral infarction (stroke), chronic respiratory failure (a condition where the respiratory system fails to properly exchange oxygen), and cognitive communication deficit (trouble with communication caused by problems with thinking skills). Record review of Resident #58's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 00, indicating the resident was severely cognitively impaired. Section O - Special Treatments, Procedures and Programs revealed Resident #58 used oxygen therapy while a resident. Record review of Resident #58's Comprehensive Care Plan, revised 03/18/26, reflected Resident #58 had dyspnea (shortness of breath and chest tightness) and chest pain related to cardiac insufficiency (heart failure). Interventions included: Apply O2 for c/o chest pain as ordered. Record review of Resident #58's current Physician Orders dated 07/28/26, reflected the following order with a start date of 07/12/26: May use O2 @ 2L-4L to maintain O2 sat 90 and above. Record review of Nursing Progress Notes, dated 07/13/26 at 1:42 PM, reflected the following: Resident resting quietly in bed. Respirations nonlabored and even. Incontinent b/b with care provided every 2 hours. Resident had a low O2 sat of 87% @ RA at beginning of shift with hospice notified. [Name] RN states they will have an oxygen concentrator delivered tomorrow. Oxygen tank used with O2 at 2lpm via nasal cannula. O2 sat up to 92% with oxygen in place later rechecked resident with O2 sat at 97% @ RA. Resident not wanting to use oxygen. No complaints of SOB. Call light at reach. During an observation and attempted interview on 07/26/26 at 11:26 AM, Resident #58's oxygen tubing and nasal cannula (tube that inserts into nostrils to deliver oxygen) were observed on the floor near the resident's bed. Resident #58 was observed in bed and did not respond to surveyor questions. During an observation and attempted interview on 07/27/26 at 9:33 AM, Resident #58's oxygen tubing and nasal cannula were observed on the floor near the resident's bed. Resident #58 was observed in bed and did not respond to surveyor questions. During an interview on 07/28/26 at 10:18 AM, the ADM stated she was not aware that oxygen tubing was not being properly stored while not in use by the resident. She stated oxygen tubing should be stored in a labeled bag and should not be on the floor. She stated all nursing staff as well nursing administration, and the ADM were responsible for ensuring oxygen tubing was properly stored. The ADM stated all staff had been trained on proper oxygen tubing storage through in-services and computer-based training modules. She stated her expectation of staff was that all oxygen tubing was stored properly in a plastic bag and kept off the floor. The ADM stated a potential negative outcome for failure to properly store oxygen tubing was increased risk of infection to residents. During an interview on 07/28/26 at 10:37 AM, the DON stated she was not aware that oxygen tubing was not being properly stored while not in use by the resident. She stated oxygen tubing should not be on the floor and should be stored in a bag when not in use. The DON stated all nursing staff had been trained on proper oxygen storage through respiratory training conducted twice per year through computer-based training modules. She stated nursing administration was responsible for ensuring the proper storage of residents' oxygen tubing. The DON stated a potential negative outcome for failure to properly store oxygen tubing was infection. Record review of the facility's policy titled Oxygen Therapy, dated 04/2021 revealed: PolicyIt is the policy of this community to ensure all oxygen administration is conducted in a safe manner. Procedure .10. Keep Oxygen cannula and tubing used PRN in a plastic bag when not in use.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #1) of 5 residents reviewed for care plans. The facility failed to develop a care plan for use of a Wander Guard electronic signaling device, utilized for wander-management, for Resident #1. This failure could place residents at risk of not receiving the care required to meet their individualized needs.Record review of the admission record for Resident #1, dated 04/14/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: dementia without psychosis, history of falling, unsteadiness on feet, and weakness. Record review of the quarterly MDS assessment for Resident #1, dated 01/23/26, revealed Resident #1 had a BIMS score of 05 indicating he had severe cognitive impairment. Record review of the comprehensive care plan for Resident #1, last reviewed on 03/25/26, revealed no care plan for the use of the Wander Guard electronic signaling device. During an initial interview on 04/14/26 at 11:05 AM, the ADM stated Resident #1 had a Wander Guard signaling device placed on his person fairly soon after admission due to the resident being new to the facility, being independently ambulatory, and not looking like a resident. She stated the wandering device was placed for his protection and so that a visitor would not mistakenly allow him to leave the facility. During an initial interview on 04/14/26 at 12:16 PM, the DON stated Resident #1 became more agitated with his placement after being in the facility for a couple of weeks and realizing his placement was not short-term. She stated the FNP was made aware of the resident's agitation, and she gave a verbal order to the DON for medication to help with agitation and also gave an order to place the Wander Guard signaling device for the resident's protection, until he adjusted to placement in the facility and could be re-evaluated. The DON did not recall the exact date of the verbal order, but stated it was within a week or two of admission. During a telephone interview on 04/14/26 at 1:28 PM, the FNP for Resident #1 stated she provided psychiatric services for the resident. She stated she gave a verbal order to the DON for the Resident #1 to have a Wander Guard signaling device placed due to the resident being in an adjustment phase of his long-term care placement, having a diagnosis of dementia, and being independently ambulatory. She stated she did not usually notate wander-management device placement in her notes, and she did not recall the exact date the verbal order for the signaling device was given. The FNP stated she believed the verbal order was given around the first week of December. During a telephone interview on 04/14/26 at 1:43 PM, Family Member for Resident #1 stated they were asked by facility administration if they felt a wander-management device was needed for Resident #1 on the day he was admitted to the facility. Family Member stated they did not feel it was necessary at the time of admission, but the resident did not adjust to placement right away and they felt it was a good idea to place the device after a few weeks in the facility. Family Member stated they did not observe the device on Resident #1 but was aware it was in place. During an interview on 04/14/26 at 4:26 PM, LVN A stated Resident #1 wore a Wander Guard device on his ankle. She stated she believed it was placed a week or so after the resident's admission to the facility. LVN A stated wander-management devices were usually a part of the resident care plan so staff would know the device should be placed on the resident. She stated she did not recall if Resident #1's care plan included the use of a signaling device for wandering. LVN A stated the care plan was used by all staff as an information guide for the residents' specific needs and plan of care. During a follow-up interview on 04/14/26 at 4:53 PM, the DON stated she was not aware Resident #1's care plan did not include the use of the Wander Guard device. She stated she was responsible for assuring the care plan for Resident #1 was updated because she had taken the verbal order for the device and failed to add it to the care plan. She stated the MDS coordinator usually updated the care plan but would not have known to update the care plan due to the verbal order being given to the DON and the DON not passing the information on to the MDS coordinator. The DON stated she just missed adding the information to the care plan and passing on the information to the MDS coordinator. She stated, I should have done it as soon as I took the order. She stated the care plan was used by all direct care staff for a resident's specific care needs. The DON stated a potential negative outcome for failure to update the care plan to include Wander Guard placement, was a direct care staff may not know a resident was supposed to have it on. During a follow-up interview on 04/14/26 at 5:06 PM, the ADM stated she was not aware Resident #1's care plan had not been updated to include the use of the Wander Guard signaling device. She stated the MDS coordinator usually updated the care plan, according to orders and information shared during morning stand-up meetings. She stated the DON was responsible for assuring the care plan was updated and for giving information to the MDS coordinator for a verbal order that would require an updated plan of care. The ADM stated the care plan was used by all staff to know how to care for a resident. She stated a potential negative outcome for failure to update the care plan to include Wander Guard placement, was staff may not be aware to check for placement of the device. Record review of the facility-provided policy titled Signaling Device, dated 04/2020, revealed: Policy.The community must ensure the resident's safety while utilizing the least restrictive means available.A plan of care will be developed and implemented with specific approaches and goals for the wanderer. Record review of the facility-provided policy titled Comprehensive Care Plan, revised 4/25/2021, revealed: PolicyEvery resident will have an individualized interdisciplinary plan of care in place. ProcedureThe Interdisciplinary Team will review the healthcare practitioner's notes and orders.and implement a Comprehensive Care Plan to meet the residents' immediate care needs including but not limited to. b. Physician orders.l. Psychosocial Mood State/Adjustment to Placement/PASRR needs as indicated .

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for 1 of 1 meal (lunch meal) on 01/07/2026 reviewed for meal accuracy, in that: DM B failed to serve the correct portion size of spaghetti noodles, marinara sauce and tossed salad according to the prepared menu for lunch for 50 residents.Dietary Aide C failed to follow the recipe for meat marinara sauce, causing them to run out of meat marinara sauce before they finished serving the lunch meal on 01/07/2026, and 9 residents did not receive meat marinara sauce. These failures could affect residents who received food from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss.The findings include:During an observation on 01/07/2026 between 12:13 PM- 1:01 PM, DM B served the lunch meal and served spaghetti noodles with a plastic pasta utensil, tossed salad with plastic tongs and plain marinara sauce after running out of meat marinara sauce with a rubber spoon. These utensils did not have a serving size on them.During an observation on 01/07/2026 at 1:02 PM one can of marinara sauce was observed in the kitchen's pantry, and the label revealed the can contained 105 ounces of marinara sauce.During an interview on 01/07/2026 at 1:03 PM with DM B she stated she did not know the serving size portion of the spoon she used to serve the plain marinara sauce because the spoon did not have a size portion on it. She stated she did not know the serving size portion for the pasta utensil she used to serve the paste because it did not have a size on it, but that was what they always used when they served pasta. She stated she did not know the serving size portion of the tossed salad she served but it was barley a full serving or probably less than a serving. She stated that she assumed she gave the correct portions sizes even though the utensils did not have a size on them. She stated she did not prepare the food for the lunch meal that Dietary Aide C prepared the food. She stated she thought he prepared enough food for 51 residents. She stated she was not sure why they ran out of meat marinara sauce but sometimes they use two cans of marinara sauce and today they used one can. She stated there were 9 meal trays that did not receive meat marinara sauce only plain marinara sauce since they ran out. She stated she would look in the recipe book for the recipe for meat marinara sauce and then stated it was not in the book, but she could print one out. She stated she had been trained over following recipes and proper scoop size for serving portions.During an interview on 01/07/2026 at 2:00 PM, The ADM stated she was aware the kitchen ran out of meat marinara sauce during the lunch meal. She stated she had contacted DM A, and he was on his way back to the facility. She stated it was already decided that any resident that did not receive the meat marinara sauce would be provided with a protein snack. She stated DM A would in-service staff on following recipes and using the appropriate serving size portions.During an interview on 01/07/2026 at 2:18 PM, Dietary Aide C stated he cooked the meat marinara sauce for the lunch meal on 01/07/2026. He stated he cooked a whole roll of meat (10 pounds) and used one can of marinara sauce. He stated, sometimes they used the recipes and sometimes we go by how we would make it at home. He stated he did not follow a recipe on 01/07/2026 he made it how he would make it at home; he cooked the meat until it was brown and then added the sauce. He stated he knows they have recipes but did not use the recipe.During an interview on 01/07/2026 at 3:55 PM, DM A stated DM B was new and had worked at the facility for about 3-4 months. He stated she had completed her food handler and managers training. He stated staff should have followed the recipes when they prepared meals. He stated education was the way to teach staff to follow the recipes and use the appropriate serving scoop or ladle. He stated he started education and in-service staff, so they know they must follow the recipes and serve proper portions.Record review of the facility diet spreadsheet portion size revealed residents should receive a number 8 scoop of spaghetti noodles which provided half a cup of noodles, 6-ounce ladle of meat marinara sauce which provided three fourths of a cup of meat marinara sauce and two number 8 scoops of tossed salad which provided one cup of tossed salad.Record review of the facility's recipe for Marinara Meat Sauce revealed suggested portion: 6 oz L. 50 servings, ingredients 9lbs of ground beef and one gallon plus two and three eights' qt. of marinara sauce Record review Texas Food Handler Certificate dated 10/22/2025 revealed DM B completed the course on 10/22/2025.Record review of Learn2Serve Texas Food Manager Certificate Program dated 11/11/2025 revealed DM B successfully completed Texas Food Safety Manager Certificate Examination on 11/11/2025.Record review of the facility Dietary Policy: Adherence to Standardized Recipes, not dated revealedPolicy StatementThe Dietary Department shall prepare all meals, and nourishments in accordance with approved standardized recipes. This ensures nutritional adequacy, food safety, consistency in meal preparation, and compliance with physician-ordered diets and regulatory requirements.Purpose This policy ensures residents meals meet nutritional and therapeutic needs, promote consistency across shifts, maintains accurate portion sizes and textures, and supports regulatory compliance.ScopeThis policy applies to all dietary staff, including the Dietary Manager, cooks, dietary aides, and any staff involved in food preparation, portioning, or service.Standardized Recipe UseAll food items shall be prepared using facility-approved standardized recipes. Recipes must include ingredients, exact measurements, preparation and cooking instructions, yield, portion size, and texture modification requirements.Recipe ModificationsRecipes shall not be altered without approval from Dietary Manager or Registered Detestation.Staff ResponsibilitiesDietary staff are responsible for accurate ingredient measurement, following preparation instructions, using appropriate equipment for texture modification, and serving correct portion sizes. Record review of the facility policy Preparation of Foods dated 04/2022 revealedPolicyFood is to be prepared by methods that conserve nutritive values, flavor, and appearance.Procedure4. All recipes in use will be standardized and will be maintained in a file book accessible to the cooks. The cook is responsible for food preparation using those recipes which reflect the planned menu.8. Recipes and cooking instructions will be followed.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 16 of 21 confidential residents. The facility failed to ensure 16 of 21 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, access to Grievance forms, information regarding who the facility Grievance officer was with their contact information, and accommodations to file an anonymous Grievance. This failure could place the residents at risk of unresolved Grievances and decreased quality of life. Findings include: During a confidential interview on 05/12/2025 at 10:00 AM with the resident council, 16 confidential residents stated they did not know how to file a formal Grievance. Residents attending Resident Council stated they did not have access to Grievance forms, and they did not know where Grievance forms were kept. Additionally, residents in Resident Council were not aware of who their Grievance Officer was, nor the process to resolve Grievances. They stated they had never seen a posting in the facility pertaining to Grievances. Residents in Resident Council stated they did not know how to file anonymous Grievances, and they were not aware they had the option to file a formal complaint anonymously. 14 of the 16 residents in attendance had been residing at the facility for 6 months or longer. Observation of prominent postings on 05/12/2025 at 11:00 AM; the facility did not have instructions regarding the Grievance procedure with any of their prominent postings. Grievance forms were not readily available to residents in the facility, and there were no accommodations to submit a Grievance anonymously. During an interview on 05/13/2025 at 10:45 AM the ADM stated she was the Grievance Officer for the facility, and she was responsible for ensuring Grievances were resolved. The ADM stated all grievances were recorded by facility staff, and blank grievance forms were kept in the administrator's office or at the nurse's station. The ADM stated the blank grievance forms were not accessible to residents without requesting the form from a facility staff. The ADM stated Grievances were given to each department head to ensure resolution and the ADM followed up to ensure Grievances were resolved as soon as possible. The ADM stated residents were informed of their right to file a Grievance upon admission, during safe surveys, and during resident council meetings. The ADM stated, although there was no procedure in place currently that allowed residents to obtain a Grievance form on their own or to file it anonymously, she would set up a Grievance box and have the forms accessible immediately. The ADM stated if a resident was unable to file a Grievance and/or wanted to file anonymous Grievances and they were unable to, the resident could've been at risk of psychosocial harm, as it could have been upsetting to the resident if their complaints were not addressed. During an interview on 05/13/2025 at 11:15 AM the DON stated the ADM was the facility's Grievance coordinator, but any staff could have filled out a Grievance form for a resident. The DON stated Grievance forms were filled out by facility staff, and there was no location for residents to obtain Grievance forms on their own. The DON stated if a resident wanted to file an anonymous Grievance, she would have filled the form out for them and left the resident's name off of it. The DON stated there was not a way for a resident to obtain a Grievance form without requesting one from a facility staff. The DON stated residents were advised of their right to file Grievances upon admission and during Resident Council meetings. The DON stated there was not a posting with instructions on filing Grievances in the facility, but it was communicated verbally by staff to residents. The DON stated Grievances were resolved by each Department head, and the ADM followed up to ensure they were able to address complaints timely. The DON stated, if a resident was unable to file a Grievance or of the resident wanted to file an anonymous Grievance, and they were unable to, this could have placed the resident at risk of psychosocial harm. The DON stated the resident could have feared retaliation or might not express their concerns if they were unable to file anonymous Grievances. The DON stated if a resident could not file a Grievance, the resident's concerns may have gone unheard and unresolved. Record review of the facility policy, Grievance (Section: Administration, Department: Administration), Effective 04/01/2017, revealed the following documentation: POLICY: Our facility will assist residents, their representatives, other interested family members or resident advocates in filing grievances or complaints when such requests are made. The facility will make prompt efforts to resolve all grievances. PROCEDURE 1. Any resident, his or her representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedures is posted on the resident bulletin board.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Residents #39) reviewed for infection control. 1. CNA A failed to change her gloves and utilize hand hygiene during incontinence care with Resident #39. These failures could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #39's undated face sheet revealed a [AGE] year-old female originally admitted to the facility 11/5/2024. Resident #39 had a medical history of hypertension (high blood pressure), depression, and cerebral infarction (a condition where brain tissue dies due to a lack of blood flow, causing necrosis in the brain). Record review of Resident #39 of annual MDS dated [DATE] Section H- Bladder and bowel revealed Resident #39 was frequently incontinent of bowel and bladder. During an observation on 5/12/2025 at 10:01 AM, CNA A donned clean gloves, removed Resident #39's brief and cleaned the peri area. CNA A assisted resident to turn onto her right side and cleaned Resident #39's buttocks. CNA A removed the dirty brief and grabbed a clean brief. CNA A placed the clean brief onto Resident #39 and removed dirty gloves. CNA A failed to change her gloves and utilize hand hygiene during incontinence care. During an interview with the DON on 5/13/2025 at 10:56AM, she stated staff are trained on infection control annually. She stated hand hygiene training and PPE is done quarterly. She stated the ADON and the DON are responsible for training staff. She stated her expectation of staff is to change their gloves during incontinence care and use hand sanitizer in between glove changes or if they are visibly soiled, she expects them to wash their hands with soap and water. She stated the potential negative outcome could be a UTI or contamination. She stated CNA A would be getting re-trained on incontinence care. She stated surveillance is monitored by routine check offs and monitoring for infection trends. During an interview with the ADM on 5/13/2025 at 11:15AM she stated the ADON and ADM are the infection control preventionist. She stated training on infection control and hand hygiene is done upon hire, annually and as needed. She stated her expectation of staff is for them to utilize hand hygiene between glove changes and to change their gloves during incontinence care. She stated the potential negative outcome could be spreading infection to the residents or to the staff. She stated she was not aware CNA A had not been changing her gloves and using hand hygiene during incontinence care but there would be more training. During an interview with CNA A on 5/13/2025 at 11:35AM, she stated when she was hired about a month ago, she was not trained on infection control. She stated she did not know who the infection preventionist was. She stated she had been trained on infection control and hand hygiene during her career. She stated she was not aware of having to change her gloves during incontinence care. She stated she does change her gloves when providing incontinence care for a bowel movement. She stated the potential negative outcome of not changing your gloves and using hand sanitizer could be spreading infection and being unsanitary. She stated she is now aware of having to change her gloves during incontinence care. Record review of facility policy titled Hand Hygiene last revised 10/24/2022 revealed: Hand hygiene is used to prevent the spread of pathogens in healthcare settings. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub to destroy harmful pathogens such as bacteria or viruses on the hands. .1. You should always perform hand hygiene: Before applying and after removing personal protective equipment (e.g. gloves, gown, mask, face shield .) Record review of blank facility document titled Nursing Services- Competency Evaluation, dated 6/13 revealed; .remove soiled clothing or brief. Place soiled brief/clothing in plastic bag .remove gloves, clean hands (may use gel) apply new gloves .clean starting at waist band place soiled items in plastic bag .remove gloves, place soiled items in plastic bag. Clean hands (may use gel) and apply clean gloves .position clean brief under resident .

Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #36) reviewed for supervision, 1. The facility failed to provide effective monitoring and interventions to reduce Resident #36's wandering which was intrusive to other residents' privacy and unsafe for Resident #36 and other residents 2. The facility failed to keep the administrative offices closed and not accessible to the residents when no staff were present. These failures could place residents at risk for injury and not receiving adequate supervision in order to reduce the risk of accidents and meet plan goals. The findings include: Record review of Resident #36's admission record, dated 05/12/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (memory loss and decline in other mental abilities), cognitive communication deficit (struggles to communicate), and wandering. Record review of Resident #36's comprehensive MDS assessment, dated 04/11/25, the staff assessment for mental status revealed Resident #36 had short-term memory problems and long-term memory problems and Resident #36's cognitive skills for daily decision making was severely impaired - never/rarely made decisions. The MDS further revealed Resident #36 exhibited wandering 4 to 6 days, but less than daily. Record review of Resident #36's comprehensive care plan, undated, revealed a Focus area, Resident is an elopement risk/wanderer and is at risk for possible injury r/t impaired safety awareness and diagnosis of dementia. Wears wanderguard Goal: Resident's safety will be maintained throughout the review date and Interventions: .4. Provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. With an initiation date of 04/02/25. On 05/11/25 at 1:55 PM, a confidential interview was conducted with a resident and the resident stated another female resident walks the halls and got into her room and tried to unplug the TV. The resident stated the female resident just walks and was not aggressive. Observation on 05/12/25 at 8:53 AM, Resident #36 was observed to be sitting at the foot of the bed for Resident #24. Resident #24 was observed with his eyes closed and was facing towards the wall. Resident #36 was touching and moving the blanket at the foot of the bed. Observation on 05/12/25 at 9:56 AM, Resident #36 was observed wandering into the Resident Council meeting in the dining room. Observation on 05/12/25 at 10:04 AM, Resident #36 was observed walking up to another resident in the dining room and standing right in front of her in her personal space. Surveyor was required to ask for staff assistance during the Resident Council Meeting. Observation on 05/12/25 at 10:08 AM, the AD walked Resident #36 out of the Resident Council meeting and took her to her room. Observation on 05/12/25 at 11:30 AM, Resident #36 was observed wandering towards the front windows in the lobby and the wanderguard alarm began alarming. Observed a CNA assist Resident #36 away from the front lobby door. Observation on 05/12/25 at 1:57 PM, Resident #36 was observed wandering down the 200-hallway where administrative offices are located. Resident #36 was observed walking into the administrator's office and no staff was observed in the administrator's office. Observation on 05/12/25 at 2:02 PM, Resident #36 was observed wandering into Resident #24's room and walked to his personal fridge. Observation on 05/12/25 at 2:03 PM, LVN A was observed redirecting Resident #36 out of Resident #24's room. Observation on 05/12/25 at 2:43 PM, Resident #36 was observed wandering down the 100-hallway yelling out randomly. Interview on 05/12/25 at 2:52 PM, LVN B stated she was aware of the wandering behavior for Resident #36. LVN B stated the residents did complain when Resident #36 was first admitted to the facility about her going into other resident's rooms. LVN B stated she will shut some resident's doors or will place stop signs outside their door to help Resident #36 not go into the other resident's rooms. LVN B stated the staff will try to keep Resident #36 with them to keep her busy, but she is on her own when staff get busy with other things. LVN B stated she has seen Resident #36 fall asleep on an empty bed in another resident's room before. LVN B stated she has been trained on how to redirect the resident by offering snacks or changing their direction. LVN B stated most of the residents are used to Resident #36 by now. LVN B stated a potential negative outcome to the residents with Resident #36 wandering into their room was it could get physical and someone could get hurt. Interview on 05/12/25 at 3:07 PM, the DON stated she was aware of Resident #36's wandering. The DON stated they have been working with psychiatric services for the behavior and stated her medications have been adjusted over a couple of weeks. The DON stated some of the residents are aggravated with Resident #36's wandering into their rooms, but she believed Resident #36 wandered into other rooms less often at this time. The DON stated most residents will redirect Resident #36 themselves and some residents use the stop signs at their doors. The DON stated the stop signs help prevent Resident #36 from going into those rooms, but she has seen Resident #36 go into some resident rooms and she will put her hands on their items. The DON stated the colorful items and stuffed animals are the items Resident #36 will pick up. The DON stated Resident #36 had even gone in her office at one time when it was left open and had drunk most of her diet coke one time. The DON stated Resident #36 required a lot of redirections from staff. The DON stated a potential negative outcome for the residents was Resident #36 could hurt another resident or another resident could hurt Resident #36 if she wandered into their room. Interview on 05/13/25 at 10:10 AM, the ADM stated she expected staff to maintain a safe environment for her and other residents at all times. The ADM stated she tries to shut her office when she leaves but forgets at times. The ADM stated staff kept items in their offices that could harm a resident if left unsupervised. The ADM stated she was not aware of any other resident's complaining of Resident #36 wandering into their room and stated the facility can order stop signs to help prevent the wandering into other resident's rooms. The ADM stated Resident #36 was easily redirected and staff had been trained on how to redirect residents. The ADM stated a potential negative outcome to Resident #36 was she could agitate other residents or she could get into something she shouldn't with the administrative offices not being shut when not in use. Interview on 05/13/25 at 11:35 AM, the DON stated the facility did not have a specific policy for wandering behaviors.

Based on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 16 residents (Resident #40) reviewed for advance directives. The facility failed to ensure Resident #40's Out of Hospital Do Not Resuscitate (OOHR) form was signed and dated by the resident's physician and included the physician's license number. The facility failed to ensure Resident #40's OOH DNR contained accurate dates from Resident #40's Legal Guardian and the two witnesses. This failure could place residents at risk for not having their end of life wishes honored and having incomplete records. Findings included: Record review of the face sheet, dated 05/13/2025, revealed Resident #40 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Paraplegia (type of paralysis that results in partial or complete loss of movement and sensation in the legs and lower part of the body), Schizoaffective disorder, bipolar type (chronic mental health condition characterized by abnormal thought processes and dysregulated emotions), and Obesity (complex disease involving having too much body fat). The advance directive was listed as DNR. Record review of Resident #40's MDS assessment, dated 04/11/2025, revealed Resident #40 had a BIMS score of 04, which indicated severely impaired cognition. Record review of the current physician order summary for Resident #40, dated 05/13/2025 indicated the resident had an active order of DNR with an order date of 04/10/2025, with no end date. Record review of Resident #40's Out of Hospital Do Not Resuscitate (OOHR) form, undated, revealed it was completed by a qualified relative, two witnesses, Legal Guardian, and a physician. The OOHR did not contain the following: a complete signature date for witness #1, a signature date for witness #2, an accurate signature date (year 2035 listed) for the Legal Guardian, a physician's signature, a signature date for the physician, or a license number for the physician. During an interview on 05/13/2025 at 10:45 AM the ADM stated advance directives were completed upon admission for residents who requested one. The ADM stated some residents had advance directives when they arrived at the facility. The ADM stated advance directives were completed by nursing staff and social services. The ADM stated it was her expectation that all advance directives were completed accurately. The ADM stated she was not aware Resident #40's advance directive was not completed properly. The ADM stated the DON was responsible for ensuring all advance directives were filled out correctly. The ADM stated the advance directive was also reviewed during the resident's care plan meetings. The ADM stated Resident #40's advance directive must have been overlooked, and it would be corrected as soon as possible. The ADM stated if a resident's advance directive was not filled out accurately, the resident's wishes may not be honored. During an interview on 05/13/2025 at 11:15 AM the DON stated she was responsible for reviewing residents' advance directives to ensure they were completed properly. The DON stated she was not aware Resident #40's advance directive was not completed accurately. The DON verified Resident #40's advance directive was not completed correctly and stated it was overlooked. The DON stated she completed the advance directive for Resident #40, and she did not realize it was not accurate. The DON stated she would ensure the advance directive was updated as soon as possible. The DON stated it was her expectation that all advance directives were completed correctly to ensure the resident's wishes were followed. The DON stated if a resident's advance directive was not completed properly or fully, the resident was at risk of not having their wishes followed. Record review of the facility policy, Advance Directive, Effective 4/2020, revealed the following documentation: PROCEUDRE: 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 31 of 31 residents reviewed for infection control (Residents #1- #31). 1. The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination from residents (Resident #3, #4, #6, and #28) positive with COVID-19. 2. The facility failed to place readily visible signage on the door of Resident #1-#30 who was actively on contact precautions. 3. The DM and CNA A entered the room of a resident (Resident #6 and #28) who was on transmission-based precautions without proper PPE. 4. Housekeeper D entered the room of a resident (Resident #14 and #19) who was on transmission-based precautions without proper PPE. 5. The HA entered the room of a resident (Resident #30) who was on transmission-based precautions without proper PPE. 6. The HA provided a resident (Resident #4) who was on transmission-based precautions snacks without proper PPE. 7. The facility failed to implement and maintain contact precautions and prevent cross contamination for resident (Resident #31) by cohorting him with a positive resident (Resident #13) with COVID-19. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), pneumonia (lung infection) and muscle weakness. Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Record review of Resident #1's care plan, dated 10/22/24, did not the residents positive status for COVID-19. Record review of Resident #1's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/21/2024. Record Review of Resident #1's nursing progress notes entered by LVN D dated 10/21/24 at 5:10 PM indicated Resident #1 tested positive for COVID-19 on 10/21/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #1 tested positive on 10/21/24 with the following symptoms: lethargy and weakness. Resident #2 Record Review of Resident #2's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: diabetes (blood sugar condition), reduced mobility, morbid obesity and major depressive disorder. Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Record review of Resident #2's care plan, dated 10/14/24, reflected the following: A focused area, initiated on 11/09/20, Resident #2 was at risk for exposure to respiratory virus (COVID-19) due to worldwide pandemic and local state and community cases identified. The goal initiated on 11/09/20, was that Resident #2 was to minimize risk of potential exposure over through next review date. Record review of Resident #2's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/16/2024. Record Review of Resident #2's nursing progress notes entered by LVN E dated 10/18/24 at 4:09 AM indicated Resident #2 tested positive for COVID-19 on 10/18/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #2 tested positive on 10/16/24 with the following symptoms: congestion, chills and runny nose. Resident #3 Record Review of Resident #3's face sheet revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: cognitive communication deficit (difficulty communicating), pneumonia (lung infection), anxiety disorder (increased worry) and muscle wasting atrophy (loss of muscle tissue). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Record review of Resident #3's care plan, dated 10/14/24, reflected the following: A focused area, initiated on 11/09/20, Resident #3 was at risk for exposure to respiratory virus (COVID-19) due to worldwide pandemic and local state and community cases identified. The goal initiated on 11/09/20, was that Resident #3 was to minimize risk of potential exposure over through next review date. Record review of Resident #3's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/16/2024. Record Review of Resident #3's nursing progress notes entered by the DON dated 10/16/24 at 7:58 PM indicated Resident #3 tested positive for COVID-19 on 10/16/24. Record review of the email sent by the DON on 10/29/24 at 10:00 AM revealed Resident #3 tested positive on 10/16/24 with the following symptoms: asymptomatic. Resident #4 Record Review of Resident #4's face sheet revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: schizophrenia (chronic mental illness), dementia (memory loss) and cognitive communication deficit (difficulty communicating). Record Review of Resident #4's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 10, indicating the resident was moderately cognitively impaired. Record review of Resident #4's care plan, dated 10/14/24, reflected the following: A focused area, initiated on 10/14/24, Resident #4 was COVID positive and had clinical concerns. The goal initiated on 10/15/24, was that Resident #4 would be monitored for secondary infections/virus. Record review of Resident #4's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/16/2024. Record Review of Resident #4's nursing progress notes entered by LVN E dated 10/18/24 at 4:12 AM indicated Resident #4 tested positive for COVID-19 on 10/18/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #4 tested positive on 10/14/24 with the following symptoms: lethargy and dizziness. Resident #5 Record Review of Resident #5's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: traumatic brain injury, anxiety (increased worry) and bipolar disorder (mental illness that causes mood swings). Record Review of Resident #5's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 09, indicating the resident was moderately cognitively impaired. Record review of Resident #5's care plan, dated 8/14/24, reflected the following: A focused area, initiated on 1/2/23, Resident #5 was COVID positive and had clinical concerns. The goal initiated on 10/15/24, was that Resident #5 would be monitored for secondary infections/virus. Record review of Resident #5's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/14/2024. Record Review of Resident #5's nursing progress notes entered by the DON dated 10/14/24 at 6:33 PM indicated Resident #1 tested positive for COVID-19 on 10/14/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #5 tested positive on 10/14/24 with the following symptoms: congestion cough and SOB. Resident #6 Record Review of Resident #6's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted [DATE], with the following diagnoses: need for assistance with personal care, muscle wasting atrophy (loss of muscle tissue), and lack of coordination. Record Review of Resident #6's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Record review of Resident #6's care plan, dated 08/24/24, reflected the following: A focused area, initiated on 10/21/24, Resident #6 was COVID positive and had clinical concerns. The goal initiated on 10/15/24, was that Resident #6 would be monitored for secondary infections/virus. Record review of Resident #6's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/14/2024. Record Review of Resident #6's nursing progress notes entered by the DON dated 10/14/24 at 5:36 PM indicated Resident #6 tested positive for COVID-19 on 10/14/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #6 tested positive on 10/14/24 with the following symptoms: congestion, sneezing and runny nose. Resident #7 Record Review of Resident #7's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), major depressive disorder, and schizophrenia (chronic mental illness). Record Review of Resident #7's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Record review of Resident #7's care plan, dated 9/05/24, reflected the following: A focused area, initiated on 12/14/21, Resident #7 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 11/09/20, was that Resident #7 was to increase knowledge deficit related to infection control practices and/ or minimizing risks related to virus through next review date. Record review of Resident #7's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/16/2024. Record Review of Resident #7's nursing progress notes entered by the DON dated 10/16/24 at 10:16 AM indicated Resident #7 tested positive for COVID-19 on 10/16/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #7 tested positive on 10/16/24 with the following symptoms: fatigue. Resident #8 Record Review of Resident #8's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with the following diagnoses: malignant neoplasm of the brain (cancer growth in the brain), diabetes (blood sugar condition) and dementia (memory loss). Record Review of Resident #8's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Record review of Resident #8's care plan, dated 10/2/24, did not address the residents positive status of COVID-19. Record review of Resident #8's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/20/2024. Record Review of Resident #8's nursing progress notes entered by the DON dated 10/20/24 at 12:24 PM indicated Resident #8 tested positive for COVID-19 on 10/20/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #8 tested positive on 10/20/24 with the following symptoms: asymptomatic. Resident #9 Record Review of Resident #9's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), muscle weakness. And cognitive communication deficit (difficulty communicating). Record Review of Resident #9's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 13, indicating the resident was not cognitively impaired. Record review of Resident #9's care plan, dated 9/18/24, reflected the following: A focused area, initiated on 11/09/20, Resident #9 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 11/09/20, was that Resident #9 was to minimize risk of potential exposure over through next review date. Record review of Resident #9's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/16/2024. Record Review of Resident #9's nursing progress notes entered by the DON dated 10/16/24 at 11:21 AM indicated Resident #1 tested positive for COVID-19 on 10/16/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #9 tested positive on 10/16/24 with the following symptoms: congestion and runny nose. Resident #10 Record Review of Resident #10's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with the following diagnoses: heart failure, muscle weakness, anxiety (increased worry) and lack of coordination. Record Review of Resident #10's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Record review of Resident #10's care plan, dated 9/11/24, reflected the following: A focused area, initiated on 5/24/22, Resident #10 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 5/24/22, was that Resident #10 would remain free from virus through next review date. Record review of Resident #10's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/21/2024. Record Review of Resident #10's nursing progress notes entered by LVN D dated 10/21/24 at 3:09 PM indicated Resident #10 tested positive for COVID-19 on 10/21/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #10 tested positive on 10/21/24 with the following symptoms: congestion and runny nose. Resident #11 Record Review of Resident #11's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: epilepsy (seizure disorder), morbid obesity and lack of coordination. Record Review of Resident #11's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was slightly, cognitively impaired. Record review of Resident #11's care plan, dated 0/7/24 reflected the following: A focused area, initiated on 5/03/23, Resident #11 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 5/03/23, was that Resident #11 would increase knowledge deficit related to infection control practices and/or minimize risk to virus through next review date. Record review of Resident #11's Order Summary Report, dated 10/29/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/18/2024. Record Review of Resident #11's nursing progress notes entered by the DON dated 10/18/24 at 4:16 PM indicated Resident #11 tested positive for COVID-19 on 10/18/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #11 tested positive on 10/18/24 with the following symptoms: weakness. Resident #12 Record Review of Resident #12's face sheet, dated 10/23/24 revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: muscle weakness, COVID-19 and schizophrenia (chronic mental disorder). Record Review of Resident #12's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Record review of Resident #12's care plan, dated 9/5/24, reflected the following: A focused area, initiated on 10/29/20, Resident #12 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 10/29/20, was that Resident #12 was to minimize risk of potential exposure over through next review date. Record review of Resident #12's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/18/2024. Record Review of Resident #12's nursing progress notes entered by the DON dated 10/18/24 at 5:10 PM indicated Resident #12 tested positive for COVID-19 on 10/18/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #12 tested positive on 10/18/24 with the following symptoms: asymptomatic. Resident #13 Record Review of Resident #13's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: anxiety (increased worry), pneumonia (lung infection), and schizophrenia (chronic mental illness). Record Review of Resident #13's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 13, indicating the resident was not cognitively impaired. Record review of Resident #13's care plan, dated 10/2/24, reflected the following: A focused area, initiated on 10/12/22, Resident #13 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 10/12/22, was that Resident #13 would remain free from virus through next review date. Record review of Resident #13's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/21/2024. Record Review of Resident #13's nursing progress notes entered by LVN D dated 10/21/24 at 3:08 PM indicated Resident #13 tested positive for COVID-19 on 10/21/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #13 tested positive on 10/21/24 with the following symptoms: runny nose and weakness. Resident #14 Record Review of Resident #1's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with the following diagnoses: dementia (memory loss), muscle weakness and muscle wasting atrophy (loss of muscle tissue). Record Review of Resident #14's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 11, indicating the resident was moderately cognitively impaired. Record review of Resident #14's care plan, dated 10/23/24, reflected the following: A focused area, initiated on 10/16/24, Resident #14 was COVID positive and had clinical concerns. The goal initiated on 10/16/24, was that Resident #4 would be monitored for secondary infections/virus. Record review of Resident #14's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/16/2024. Record Review of Resident #14's nursing progress notes entered by the DON dated 10/16/24 at 5:10 PM indicated Resident #14 tested positive for COVID-19 on 10/16/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #14 tested positive on 10/16/24 with the following symptoms: congestion, chills and runny nose. Resident #15 Record Review of Resident #15's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with the following diagnoses: dementia (memory loss), anxiety (increased worry), and cognitive communication deficit (difficulty communicating). Record Review of Resident #15's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Record review of Resident #15's care plan, dated 8/7/24, reflected the following: A focused area, initiated on 6/7/23, Resident #15 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 6/07/23, was that Resident #15 would increase knowledge deficit related to infection control practices and/or minimize risk related to virus through next review date. Record review of Resident #15's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/14/2024. Record Review of Resident #15's nursing progress notes entered by the DON dated 10/14/24 at 6:35 PM indicated Resident #15 tested positive for COVID-19 on 10/14/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #15 tested positive on 10/14/24 with the following symptoms: congestion and Runny nose. Resident #16 Record Review of Resident #16's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted [DATE], with the following diagnoses: muscle weakness, COVID-19 and dementia (memory loss). Record Review of Resident #16's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 09, indicating the resident was moderately cognitively impaired. Record review of Resident #16's care plan, dated 10/22/24, reflected the following: A focused area, initiated on 2/15/23, Resident #16 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 2/15/23, was that Resident #16 was to minimize risk of potential exposure over through next review date. Record review of Resident #16's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/18/2024. Record Review of Resident #16's nursing progress notes entered by LVN E dated 10/18/24 at 4:21 AM indicated Resident #16 tested positive for COVID-19 on 10/18/24. Record review of the email sent by the DON on 10/29/24 at 10:00 AM revealed Resident #16 tested positive on 10/17/24 with the following symptoms: asymptomatic. Resident #17 Record Review of Resident #17's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with the following diagnoses: dementia (memory loss), anxiety (increased worry), diabetes (blood sugar deficit) and lack of coordination. Record Review of Resident #17's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 3, indicating the resident was severely cognitively impaired. Record review of Resident #17's care plan, dated 08/21/24, reflected the following: A focused area, initiated on 10/15/23, Resident #17 was at risk for exposure to respiratory virus (COVID-19). The goal initiated on 10/15/23, was that Resident #17 would remain free from virus through next review date. Record review of Resident #17's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/18/2024. Record Review of Resident #17's nursing progress notes entered by the DON dated 10/18/24 at 4:20 PM indicated Resident #1 tested positive for COVID-19 on 10/18/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #17 tested positive on 10/18/24 with the following symptoms: asymptomatic. Resident #18 Record Review of Resident #18's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with the following diagnoses: lack of coordination, schizophrenia (chronic mental disorder), and dementia (memory loss). Record Review of Resident #18's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 07, indicating the resident was severely cognitively impaired. Record review of Resident #18's care plan, dated 9/25/24, reflected the following: A focused area, initiated on 06/07/23, Resident #18 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 06/07/23, was that Resident #18 would remain free from virus through next review date. Record review of Resident #18's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/14/2024. Record Review of Resident #18's nursing progress notes entered by LVN D dated 10/15/24 at 5:57 PM indicated Resident #18 tested positive for COVID-19 on 10/15/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #18 tested positive on 10/14/24 with the following symptoms: congestion and runny nose. Resident #19 Record Review of Resident #19's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with the following diagnoses: dementia (memory loss), muscle wasting and atrophy (loss of muscle tissue), and muscle weakness. Record Review of Resident #19's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Record review of Resident #19's care plan, dated 08/07/24, did not address the residents positive COVID-19 status. Record review of Resident #19's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/21/2024. Record Review of Resident #19's nursing progress notes entered by LVN D dated 10/21/24 at 5:10 PM indicated Resident #19 tested positive for COVID-19 on 10/21/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #19 tested positive on 10/21/24 with the following symptoms: runny nose, congestion and weakness. Resident #20 Record Review of Resident #20's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted [DATE], with the following diagnoses: cerebral infarction (dying brain tissue that occurs due to blocked or reduced blood flow), muscle wasting atrophy (loss of muscle tissue), , abnormal weight loss and lack of coordination. Record Review of Resident #20's Comprehensive MDS assessment dated [DATE], revealed under Section C, no data was entered. Record review of Resident #20's care plan, dated 09/11/24, reflected the following: A focused area, initiated on 11/09/20, Resident #20 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 11/09/20, was that Resident #20 was to minimize risk of potential exposure over through next review date Record review of Resident #20's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/21/2024. Record Review of Resident 20's nursing progress notes entered by LVN D dated 10/21/24 at 3:17 PM indicated Resident #20 tested positive for COVID-19 on 10/21/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #20 tested positive on 10/21/24 with the following symptoms: asymptomatic. Resident #21 Record Review of Resident #21's face sheet, dated 10/23/24, revealed a [AGE] year-old male that was initially admitted to the facility on [DATE] and readmitted [DATE], with the following diagnoses: diabetes (blood sugar deficit), dementia (memory loss) and lack of coordination. Record Review of Resident #21's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 11, indicating the resident was moderately cognitively impaired. Record review of Resident #21's care plan, dated 09/5/24, reflected the following: A focused area, initiated on 11/09/20, Resident #21 was at risk for exposure to respiratory virus (COVID-19) die to worldwide pandemic and local state and community cases identified. The goal initiated on 11/09/20, was that Resident #21 would increase knowledge deficit related to infection control practices and/or minimize risks related to virus through next review date. Record review of Resident #21's Order Summary Report, dated 10/23/24, reflected the resident was to be assessed for s/s of COVID-19, isolate immediately and proceed with further precautions.; Ordered 10/14/2024. Record Review of Resident #21's nursing progress notes entered by LVN D dated 10/14/24 at 5:46 PM indicated Resident #21 tested positive for COVID-19 on 10/14/24. Record review of the facility list (untitled/undated) of COVID-19 residents/staff revealed Resident #21 tested positive on 10/14/24 with the following symptoms: congestion and runny nose. Resident #22 Record Review of Resident #22's face sheet, dated 10/23/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted [DATE], with the following diagnoses: muscle weakness, muscle wasting atrophy (loss of muscle tissue) and cognitive communication deficit (difficulty communica

Based on observation , interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: The facility failed to ensure the kitchen steamtable was maintained in safe operating condition. The facility failed to ensure that the kitchen oven was maintained in safe operating condition. The facility failed to ensure that the kitchen coffee machine was maintained in safe operating condition. These failures could place residents at risk for receiving cold meals/coffee and at risk for fire emergencies. The findings included: Observation on 03/26/24, at 09:25 AM, revealed the door to the coffee machine ajar and unable to close. Observation on 03/26/24, at 12:35 PM, revealed two pieces of folded cardboard in the left and the right doors of the oven. Observation on 03/26/24, at 12:36 PM, revealed the Food Service Manager retrieving the pureed food items from the oven and placing them on the right side of the steam table, not utilizing the middle of the steam table. During an interview on 03/28/24 at 09:08 AM, the Food Service Aide stated that the coffee machine had been out for two months. She said sometimes it worked and sometimes it doesn't. She said the oven doors had been broken for years. She said she could guess for at least three years. She said she had observed people trying to come and fix it, but it did not work. She said they have to place the pieces of cardboard on the doors, or the doors will open and fall on staff. She said if food was cooking, then the doors could open during the cooking process. She said they placed the cardboard so the ovens would heat up. She said the potential negative outcome was the doors falling on staff, or the cardboard could potentially burn, putting residents at risk if there were a fire. She said the cardboard had never fallen in the oven without the staff's knowledge. She said she did not know who was responsible for fixing broken equipment. During an interview on 03/28/24 at 09:27 AM, the Food Service Manager stated they had the cardboard in both oven doors to keep them from opening while using the oven and when they were not using the oven. She said they could potentially open and injure staff if they do not use the cardboard in the doors. She said the burn on her right forearm was from the oven. She said that if the doors were not correctly sealed, the food might not be cooking properly, but that they check the food by taking the temperature to ensure it was cooked. She said she had been employed with the facility for a year and a half, and the oven doors had always been that way. She said she had not noticed if they had to cook longer because of the broken oven doors. She said the entire facility was responsible for ensuring all broken equipment was fixed. She said everyone was aware that the oven doors were not working correctly. She said the ADM asked about the oven doors a couple of weeks ago. She said the overall potential negative outcome of the broken oven doors was employee injury and food safety. She said it was a gas stove but does not remember if there had ever been issues with gas leaks or other problems. She said the coffee machine had only been broken for about a week. She said the reason she said it had only been a week, and others would say a different time frame, was because the right side was leaking, and the left side was what broke a week ago. She said the potential negative outcome of the coffee machine not working properly was they may not mix the concentrate correctly, and the temperatures of the coffee might be off. She said that the DM had attempted to fix the coffee machine, but she was unsure what was wrong. She said she had been trained on what to do when there was broken equipment, and that was to let the DM know. She said the steam table had been broken since she started working at the facility. She said the Maintenance Supervisor looked at it once a couple of months ago. She said the potential negative outcome of the steam table not working correctly was the food temperatures could be off, but they do not place food on the portion that does not work. She said because the middle portion of the steam table did not work, they could not put all of their food on the steam table. She said she expected all kitchen equipment to work correctly. During an interview on 03/28/24 at 09:58 AM, the DM stated that the oven doors had been broken for at least [AGE] years. He said they had been using cardboard for the past 6 years to keep the door closed. He said that was implemented by a former employee who found that the cardboard worked. He said he had been trying to fix the oven for years and had last attempted in January 2024. He said the oven was so old that the parts for the oven doors were no longer being made. He said he had previously requested a new stove but was told that the budget needed more funding. He said the potential negative outcome of using the cardboard to keep the oven doors closed was employee safety and fire. He said although it was a gas stove, he had not smelled gas before. He said the oven door was not braced without cardboard and would not stay closed. He stated the door would fall. He stated that the temperatures between both ovens was different. He said the left side gets hot, but the right side was so so. When asked to describe so so,. He said the right side worked at about 85%. He said they know their food was fully cooked because they take temperatures. He said they have never had to delay meal serving times because of having to cook the food longer in the ovens. He said the system for monitoring was that if the equipment was broken, they replaced it, but certain items, if they cost more, were out of his ability to approve for replacement. He said he had been trained regarding broken equipment and maintenance repairs. He said they do not do preventative maintenance on their kitchen equipment. He said they monitor and address the issue if and when it breaks. He said the coffee machine had been out for the past 6 months. He said he was unsure of the date, but the last time a technician was at the facility for the coffee machine, he was told it was the compressor. He said the door of the machine had also broken. He said the potential negative outcome was that the concentrate might not be measured correctly. He said he drank the coffee, and it tasted good to him. He said he was aware that the coffee machine was broken. He said he expected all broken equipment to be fixed. He said the middle portion of the steam table had been broken for about 5 years. He said the potential negative outcome was they could not place all items on the steam table, which could affect food temperatures. He said they do check all food temperatures before serving. He said he was aware that the middle portion of the steam table was not working and believed it was a heating element out. He said he was responsible for ensuring all equipment was fixed and functioning at its total capacity. He stated he never reported the steam table or the coffee machine to anyone, including the ADM. During an interview on 03/28/24 at 10:41 AM, the ADM stated that she was aware that the doors on the oven were not working correctly. She said the DM and the Plant of Operations said the oven was so old that the parts needed for the oven were no longer being made. She said she was unsure who suggested the cardboard as a solution. She said they discussed a new oven at one point, but there was never a definitive date. She said using the cardboard in the oven doors could be a fire hazard. She said she was unaware of anyone ever getting hurt. She said she was unaware that the coffee machine and the middle portion of the steam table were not working. She said they used the concentrate to make coffee but thought that was the process. She said she had no potential negative outcome from the faulty coffee machine. She said she didn't know if there was an actual measurement for concentrate for the coffee. She said that the potential negative outcome for the steam table would be that the food might not be at the proper temperature. She said the system for monitoring broken equipment was that if the Maintenance Supervisor could not fix it, they would contract out and then replace it if it could not be fixed. She said she had been trained to ensure that all equipment was working correctly and was ultimately responsible for ensuring that all equipment was not broken and working correctly. She said she does monthly kitchen walk-throughs and had not observed any broken equipment. She said she did not have any documentation to reflect her monthly observations of the kitchen. During an interview on 03/28/24 at 11:02 AM, the Maintenance Supervisor stated he knew that the oven doors, coffee machine, and steam table were not working at their total capacity. He stated the DM ordered parts for the oven, but they did not work. He stated he believed the facility needed a new oven, but it was not up to him. He stated that on the steam table, there was a section that was not working. He stated he was told about 5 months ago by the Food Service Manager that the steam table needed to be fixed. He stated that the oven doors had been broken for a while, at least over a year. He said that no one had told him about the coffee machine and that he believed the repairs for the coffee machine were contracted out. He said he did not know why the coffee machine had not been fixed. He said he did not do any preventative maintenance on any kitchen equipment. He said regarding training, he googled things and asked for help. He said he was not licensed and was considered more of a handyman. He said the potential negative outcome for broken equipment was that the oven could burn the staff, but he does not think there had been an issue. He said he did not know a potential negative outcome for the broken coffee machine. He said he could not get the coffee machine to work. He said he had no specific training for being the maintenance supervisor and the identified broken equipment. He said he learned independently and paid attention to others who tried to help him. He said he had not received formal training. He said he did not have a policy on fixing equipment. Record review of the U.S. Food and Drug Administration Food Code revealed: 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. Record review of an email provided by the DM, dated 01/17/23 at 2:05 PM revealed that the DM sent an email to the Head of Plant Operations stating that they needed parts for the oven. (The specific part was not indicated.) Record review of an email provided by the DM, dated 03/9/23, revealed that the coffee vendor had scheduled the facility to be seen 03/14/23-03/17/23. (No specifics to fix the machine was indicated.) Record review of facility policy, Equipment Safety (dated April 2022) revealed: Policy All equipment is handled and operated in a safe manner to prevent accident or injury. Procedure All food service equipment is regularly inspected and kept in good repair. 43344

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food was accurately dated and labeled. The facility failed to protect foods from potential contamination. Foods were not handled in a manner to prevent contamination. Food contact equipment and other equipment was not maintained in a clean manner. Foods were not stored according to manufacturer's recommendation. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation on [DATE] at 09:34 AM, revealed concord grape jelly, dated [DATE], was on the dry pantry shelf. More than 75% of the jelly was gone. The label on the back of the jar reflected, Refrigerate after opening. Observation on [DATE] at 9:41 AM, revealed unlabeled and undated pancakes and toast in the microwave. Observation on [DATE] at 09:25 AM, revealed opened box coffee concentrate in the broken coffee machine without a lid. Observation on [DATE] at 09:25 AM, revealed a uncovered jar of oil and butter on the stove. Further observation revealed the butter was not actively used until 12:07 PM when the Food Service Manager put butter on the rolls. The butter and oil remained uncovered for the duration of the day. Observation on [DATE] at 09:25 AM, revealed unknown food particles and an unidentifiable crust on the stove's cooking range. Observation on [DATE], at 09:26 AM, revealed unknown food particles were along the underside of both oven doors. Observation on [DATE], at 09:30 AM, revealed unknown food particles, grease, paper, and plastic were alongside the left side of the griddle. Observation on [DATE] at 11:21 AM, revealed 2 uncovered chocolate pudding desserts were under another tray of pudding desserts, exposing the two uncovered pudding desserts to the bottom of the tray. Observation on [DATE], at 11:26 AM, revealed the DM placed uncovered pureed zucchini in the oven under a pan of fried chicken, exposing the pureed zucchini to the bottom of the tray that held the fried chicken. Observation on [DATE], at 11:20 AM, revealed 37 uncovered drinks. At 11:35 AM, the Food Service Aide placed ice in the drinks but did not cover the drinks afterwards At 11:48 AM, the Food Service Aide only covered ,d+[DATE] drinks with lids, leaving the other 35 drinks uncovered. At 11:52 AM, the Food Service Aide reached over the uncovered cups to grab an item. At 12:04 AM, the Food Service Aide covered 33 of the 35 remaining uncovered drinks, leaving two drinks still uncovered. The two drinks remained uncovered until placed in the fridge at 12:15 PM. Observation on [DATE], at 12:07 PM, revealed a large bowl of salad that contained fresh tomatoes and cumbers and was placed on the steam table in between hot foods, not on ice The uniced salad remained on the steam table between hot foods until 12:49 PM when the Food Service Manager served the last tray. Observation on [DATE], at 06:54 AM, revealed concord jelly, dated [DATE], was on the dry pantry shelf. More than 25% of the jelly was gone. The jar label reflected, Refrigerate after opening. Observation on [DATE], at 06:55 AM, revealed an uncovered jar of oil and butter on the stove. Observation on [DATE], at 06:59 AM, unknown food particles and an unidentifiable crust were observed on the stove's cooking range. Observation on [DATE], at 07:00 AM, revealed unknown food particles were along the underside of both oven doors. Observation on [DATE], at 07:01 AM, revealed unknown food particles, grease, paper, and plastic were alongside the left side of the grill. Observation on [DATE], at 7:08 AM, revealed 25 unlabeled, undated peanut butter and jelly sandwiches on the bottom shelf of a metal rack. Observation on [DATE], at 7:10 AM, revealed a sprinkler head in the ceiling to the right of the stove with dust and unknown debris. During an interview on [DATE] at 09:08 AM, the Food Service Aide stated that the food was in the microwave undated and unlabeled because it was meant for the DM, and he had yet to get it. She said the potential negative outcome for uncovered food was things could fall in it, and then the residents at the facility could get it. She said she was not aware that the items identified were uncovered. She said she was busy trying to get her work done. She said food should be covered immediately if not being actively served. She said she was aware that the two desserts were not covered but only noticed when they removed the tray on top of it. She then immediately placed the lids on the desserts. She said she was aware that the juices were not covered. She said the manager was responsible for covering the food when it was not being served. She said that regarding the dirty equipment (stove/oven), including the dirty sprinkler head, residents could get sick if they were using dirty equipment. She said she was unaware if the dirty equipment included the sprinkler head. She said the DM was strict about keeping things clean and did not know why the stove or the sprinkler head was not clean. She said items that were to be refrigerated could potentially spoil and make residents sick. She said she knew the jelly was on the shelf in the dry pantry but did not know she needed to refrigerate it. She said they labeled the food but did not read the label stating the food item required to be refrigerated after it had been opened. She said they were all responsible for putting food items that needed refrigeration in the refrigerator. She said placing cold foods on ice could prevent food from spoiling, or the food that was supposed to be served cold would be served hot, and residents would not like it. She said residents would not like hot salad. She said she knew the salad was not on ice, and she believed that was how they usually served it. She said she had been trained to place cold items with fresh vegetables and anything with egg or milk on ice. She said she would have been responsible for putting the food items on ice, but they all could do it. She said the potential negative outcome for unlabeled or undated food was that people might not know when it was prepared and that old food could be given to the residents. She said she did not work overnight but believed that was where the sandwiches came from. She said that she was aware that the sandwiches were there. She said she had been trained to date and label all food. She said they placed the date received, opened, and knew to dispose of it three days after it had been opened. She said all of them were responsible for dating and labeling food. During an interview on [DATE] at 09:27 AM, the Food Service Manager stated that the potential negative outcome of uncovered food was debris that could get in the food. She said she knew there were some uncovered items but did not know they were supposed to be covered. She said that they did not have a system for covering food. She said she had been trained to cover food if placed in the refrigerator but not if they placed food in the oven. She agreed that the uncovered items in the oven could have things fall in it if they were placed directly under a pan. She said she was unaware that the sprinkler head in the kitchen needed to be cleaned. She said she rarely looked at the sprinkler head. She said she was aware of the stove being dirty on the side, but it was difficult to clean that portion of the stove. She said that using dirty equipment could contaminate the resident's food. She said their system was to clean after each meal. She said they should immediately clean up spills and the oven range and underneath weekly. She said she cleaned the eyes of the stove on [DATE] but did not have a reason why it was not clean as of [DATE]. She said everyone was responsible for cleaning kitchen equipment. She said the potential negative outcome of not refrigerating appropriate food items was it could cause disease to grow in the food, be served to the residents, and then make them sick. She said she was aware that the jelly label said to refrigerate after opening it but that she would put the jelly in the refrigerator and then put it on the shelf. She said the system for monitoring was they should place it in the fridge each time they saw it. She said everyone was responsible. She said the potential for not putting the salad on ice was that bacteria could grow, and residents could have received warm salad. She said she knew the salad was not on ice and that she was serving from the steam table. She said it was placed on the steam table for convenience while serving. She said they were all responsible for putting the appropriate foods on ice. She said the potential negative outcome of not labeling or dating food was that a resident could be allergic to it if you did not know what it was. She said bacteria could grow because they don't know when it was prepared, and it could be served to the residents and make them sick. She said she was aware of the peanut butter and jelly sandwiches but was unaware that they were on the shelf and not labeled. She said she had been trained to label all food items. During an interview on [DATE] at 09:58 AM, the DM said the potential negative outcome for food being uncovered was that things could get into the food and potentially be served to the residents. She said she knew that food was uncovered, specifically the pureed food, which he placed in the oven himself. He said he was unaware of the other uncovered items. He said he did not have a system to ensure that food was covered until actively being served. Unless actively being served, he said he had been trained to cover things and ensure there was a barrier over the food to ensure nothing fell in the food. He said he expected all food to be covered unless it was actively being served. He said he had been trained to ensure a barrier was protecting the food, especially if an item was over it. He said the potential negative outcome of dirty equipment was that it could infect the residents' food. He said it could cause cross-contamination. He said the potential negative outcome of a dirty sprinkler head was that debris could not fall off the sprinkler head and into the food and that the sprinkler might not function properly. He said he was unaware of the sprinkler head. He said they were not allowed to touch the sprinkler heads, and the fire department was responsible for those. He said the fire department did not like to come out. He said he should have called them. He said he was aware of the dirty stove and the debris on the right side of the stove that they could not reach to clean. He said he had been trained to clean all equipment in the kitchen. He said that he did have a cleaning schedule that they followed. He said if food was supposed to be refrigerated or not, then bacteria could grow inside. He said bacteria could make staff and residents sick. He said he was unaware that the jelly was on the shelf in the dry pantry. He said the system to monitor was everyone should be watching and placing the appropriate items in the fridge. He said that not placing appropriate food on ice, such as fresh vegetables, could cause the food items not to be cold and served warm and might not be palatable. He said he was unaware that the salad was not served on ice as he was not paying attention. He said the system was their policy and procedures. He said the cook was responsible for ensuring the appropriate foods, such as eggs, milk, and fresh vegetables, were placed on ice. He expected that all proper foods should be placed on ice while serving. He said the potential negative outcome of not labeling food was that staff might not know when the food was made and could go bad or be served to the residents. He said he saw them the morning of [DATE] and was aware that the snacks (sandwiches) were there because staff had told them they had failed to place the snacks out the night before. He said he did not know why he did not remove them as it slipped his mind. He said the system for monitoring was that once they receive food or make food, they label it immediately. He said he expected all foods should be labeled. He said he and his staff had all been trained in all the identified deficient practices. During an interview on [DATE] at 10:41 AM, the ADM stated that she was unaware that food was uncovered in the kitchen. She said they were unaware if there was a system for uncovered food in the kitchen. She said all dietary staff was responsible. She said she expected food to stay covered unless actively being served. She said the potential negative outcome of food not being covered was that food could become contaminated and served to the residents. She said the potential negative outcome of dirty equipment was it could make the residents sick because dirt or debris could get in the food. She said she had been in the kitchen the previous month and did not see any issues, but the dietary staff had also been doing deep cleaning and after-meal service. She said the dietary staff were responsible for cleaning all equipment. She said there was no reason for any dirty equipment but that she could observe the gunk alongside the stove and griddle. She said the DM told her that the dietary could not reach that part of the stove. She said that all the dietary staff was responsible for ensuring that the kitchen equipment was clean, and she expected all kitchen equipment to be cleaned. She said she was unaware of the jelly being opened and still on the dry shelf. She said the potential negative outcome was that there could be food poisoning. She said the dietary staff ensured that the appropriate foods were refrigerated. She said if the food that was supposed to be on ice was not on ice, then there was a potential for foodborne illness, and it might not taste as good. She said she was unaware that the dietary staff was serving salad without it being on ice. She said she expected all food that was to be served cold to be served cold. She said the dietary staff were responsible for ensuring that the appropriate foods were served on ice. She said the potential negative outcome for unlabeled and undated food was that residents could be served expired food, which could potentially make the residents sick. She said she expected all food to be labeled and dated. She said she was unaware of the sandwiches that were unlabeled and undated. She said the dietary staff was responsible for dating and labeling food. Record review of the facility's cleaning schedule, dated [DATE], revealed the following: The cook was responsible for cleaning the oven to include the range and had been cleaned by the Food Service Manager daily until the [DATE]. (No details to indicate the fire sprinkler) Record review of the U.S. Food and Drug Administration Food Code revealed: ,d+[DATE].14 Food Preparation During preparation, unpackaged food shall be protected from environmental sources of contamination. ,d+[DATE] Preventing Contamination from Other Sources FOOD shall be protected from contamination ,d+[DATE].11 Labeling Label information shall include: The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: At any time during the operation when contamination may have occurred Record review of the facility policy, Food Storage (dated [DATE]) revealed: Policy All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws, and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness. Procedure Food removed from its original packaging will be labeled with the receive date, open date, and contents of the package. Cold foods to be served on the serving line will be put on a bed of ice to keep cold. 43344

Based on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 2 of 17 residents (Residents #23, and #47) reviewed for transfers, in that: The facility did not provide Resident #23 and Resident #47 with a written bed-hold policy when the residents were transferred out to the hospital or were on therapeutic leave. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred and at risk for of being improperly discharged and placed in unsafe conditions. The findings were: Record review of Resident #23's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include spinal stenosis (narrowing of the spinal canal), and constipation. Record review of Resident #23's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record Review of Resident #23's census from the EMR revealed that on 06/09/23, 07/07/23 and 07/24/23 he was on therapeutic leave. On 07/27/23 billing was stopped. The DON indicated in writing on the document that he had went home to visit his family . Record review of Resident #23 admission record indicated that his representative received the bed-hold and readmission policy on 10/29/23 indicating that the facility procedure was upon transfer or discharge, review the bed hold policy with the resident/representative, either in person or via telephone communication. Record review of Resident #47's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Schizoaffective disorder (a combination of mood disorder and schizophrenia), anxiety disorder (increased worry), and intermittent explosive disorder (mental disorder that include outbursts). Record review of Resident #47's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record Review of Resident #47's census from the EMR revealed that on 02/09/24 and 03/16/24 billing was stopped. The DON indicated in writing on the document that both dates he had discharged to a behavioral hospital. Record review of Resident #47's admission record indicated that he received the bed hold and readmission policy on 01/09/24 indicating that the facility procedure was upon transfer or discharge, review the bed hold policy with the resident/representative, either in person or via telephone communication. During an interview on 03/27/24 at 09:16 AM, the DON said they did not do bed holds, and their company had never had them do bed holds for transfers. She said they did not give anything to the residents when they were transferred out. During an interview on 03/27/24 at 11:50 AM, the DON stated that she was unaware of the facility's bed hold policy. She said she did not feel that there was a potentially negative outcome because they always had beds available. She said they did not have a system for issuing written notice of bed holds. She said she had not been trained on the facility bed hold policy. She said her expectation of the bed hold policy was that she be trained but that the facility policy be followed. She said the Director of Resident Accounts would be responsible for the bed holds. She stated that other than the Director of Resident Accounts, she believed other charge nurses would be responsible. She said she was unaware of the two residents (resident #23 and Resident #47) who did not receive notice of the facility bed hold during their leave. During an interview on 03/27/24 at 12:00 PM, the ADM stated the potential negative outcome of not following the bed hold policy was if the facility were at capacity, the risk would be for residents who go out on leave or the hospital would not have a bed (if they returned). She said she did not feel that was an issue because they were far from being at full capacity, so essentially, there was no potential negative outcome. She said the purpose of the bed hold policy was to let residents know their rights about holding their bed if needed. She said she was unaware that the two residents had not received written notification of the bed hold policy. She said she expected training to be implemented regarding the bed hold policy and that all facility policies would be followed. She said the Director of Resident Accounts and herself would be responsible, as would nursing staff if it was a weekend or holiday. During an interview on 03/27/24 at 12:15 PM, the Director of Resident Accounts stated she was unaware that the two ( Resident #23 and Resident #47) residents identified had not received written notice and that they all had received a copy of the bed hold policy upon admission. She said at admission, they let the resident know that if they were at full capacity and go out on pass, they could potentially lose their room. She said the resident's signature on the bed hold policy at admission held their room. She said there was no specific number of days that the room was held for, but that their system to monitor was that they signed the bed holds policy at admission and that they held their bed. She said she was responsible for the bed hold agreement but had never been trained to give it to the residents outside of admission. She said she only expected the bed hold agreement to be provided during admission. During an interview on 03/28/24 at 11:58 AM, Resident #23 stated that he had never received anything about the bed hold policy when he left and went with his family if he had been to the hospital. He said he did not understand what it was and did not want to pay anything extra if he did not have to. He said he did not know anything about the facility policy. He said he did not know if he received anything during admission because his family helped with all the paperwork. Record review of the facility policy, Bed Hold Reservation Agreement (undated) revealed, 483.15 (d) (I) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- The duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence at the nursing facility; The reserve bed payment policy in the state plan under 447.40 of this chapter, if any; The nursing facility policies regarding bed hold periods, which must be consistent with paragraph Euro (I) of this section, permitting a resident to return; and The information specified in paragraph Euro(I) of this section. 483.15 (d)(2) Bed- hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed hold policy described in paragraph (d) (I) of this section. Policy It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. Additionally, this facility permits residents to return to the facility after hospitalization or therapeutic leave if their needs can be met by the facility, they require the services provided by the facility and they are eligible for Medicaid or Medicare covered services or services covered by another payor. Residents and their representative will be provided with a bed hold and return information at admission and before a hospital transfer or therapeutic leave. Nursing and social work staff are educated about the resident's bed hold and return rights to ensure that required information is provided at the time the resident leave the facility. 43344

Based on record review, observations and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 7 of 17 residents (Residents #12, #14, #23, #28, #40, #44 and #47) reviewed for care plans as follows: Resident #12 did not have a care plan for urinary incontinence. Resident #14 did not have a care plan for urinary incontinence. Resident #23 did not have a care plan for urinary incontinence. Resident #28 did not have a care plan for urinary and dehydration. Resident #40 did not have a care plan for cognitive loss, vision, communication, urinary incontinence, and dental care. Resident #44 did not have a care plan for falls. Resident #47 did not have a care plan for cognitive loss. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include : Record review of Resident #12's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include hypothyroidism (underactive thyroid), and diabetes (high blood sugar). Record review of Resident #12's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence Section H Bowel and Bladder revealed Resident #12 was occasionally incontinent of urine. Record review of the Resident #12's care plan dated 03/5/24 did not reveal a care plan for urinary incontinence. Record review of Resident #14's face sheet, dated 03/26/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include difficulty walking, reduced mobility and overactive bladder. Record review of Resident #14's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence Section H Bowel and Bladder revealed Resident #14 was occasionally incontinent of urine. Record review of the Resident #14's care plan dated 11/14/23 did not reveal a care plan for urinary incontinence. Record review of Resident #23's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include spinal stenosis (narrowing of the spinal canal), and constipation. Record review of Resident #23's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence Section H Bladder and Bowel revealed that Resident #23 was always incontinent of urine. Record review of Resident #23's care plan, dated 03/05/24, revealed no care plan for urinary incontinence. Record review of Resident #28's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dehydration, cognitive communication deficit, diabetes (low blood sugar), dementia (memory loss), difficulty walking and muscle weakness). Record review of Resident #28's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence 14. Dehydration Section H revealed that Resident #28 was occasionally incontinent of the urine. Record review of Resident #28's care plan, dated 02/19/24, revealed no care plan for urinary incontinence and dehydration. Record review of Resident #40's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include reduced mobility, need for assistance with personal care, constipation, muscle weakness, cognitive communication deficit, absence of right and left leg below the knee. Record review of Resident #40's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 02. cognitive loss 03. Vision 4. Communication 06. Urinary Incontinence 15. Dental Care Section B Hearing, Speech and vision revealed that Resident #40 had minimal difficulty in hearing, and he was usually easily understood and understood others. His vision was impaired, and he required corrective lenses. Section H Bladder and Bowel revealed that Resident #40 was occasionally incontinent of urine. Section L revealed that Resident #40 had broken or loosely fitting full or partial dentures. Record review of Resident #40's care plan, dated 03/05/24, revealed no care plan for cognitive loss, vision, communication, urinary incontinence and dental care. Record review of Resident #44's face sheet, dated 03/26/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), muscle weakness, unsteadiness on feet, and lack of coordination. Record review of Resident #44's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 11. Falls Section J Health conditions revealed no history of falls. Record review of Resident #44's care plan, dated 03/26/24 revealed no care plan for falls. Record review of an email dated 04/01/24 at 1:44 PM from the ADM and Regional MDS Coordinator revealed Resident #44 triggered for falls because wandering occurred and she had balance problems during transition. Record review of Resident #47's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Schizoaffective disorder (a combination of mood disorder and schizophrenia), anxiety disorder (increased worry), and intermittent explosive disorder (mental disorder that include outbursts). Record review of Resident #47's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 02. Cognitive Loss Record review of Resident #47's care plan, dated 02/06/24, revealed no care plan for cognitive loss. Record review of an email dated 04/01/24 at 1:44 PM from the ADM and Regional MDS Coordinator revealed Resident #47 triggered for cognitive loss because staff assessment or clinical record suggested presence of inattention, disorganized thinking, altered level of consciousness. During an interview on 03/27/24 at 10:35 AM, the Regional MDS Coordinator stated that if the care plan reflected resolved, the resident had that issue at some point but no longer had the identified problem. During an interview on 03/27/24 at 11:03 AM, Resident #44 stated she had not had any falls and had not participated in care plan meetings. She said she had not fallen before, and staff were not making any special efforts to ensure that she did not fall that she knew of . During an interview on 03/27/24 at 11:05 AM, Resident #23 stated that he wore a brief regularly. He said he could not change himself because he could not use his arms. He said he did not participate in his care plan meeting because he had chose not to. During an interview and observation on 03/27/24 at 11:08 AM, Resident #28 stated that he used his urinal every night because it was easier and more convenient. He said he wore briefs periodically to help with accidents. He said he drank plenty of water all the time. He said he had been talked to about care plan meetings but had not remembered attending one. An empty urinal was observed on Resident #28's bedside table. An opened package of adult briefs was also observed on the floor beneath Resident #28's bed. During an interview and observation on 03/27/24 at 11:12 AM, Resident #40 stated that he wore glasses to be able to see. He said although he spoke and understood English, he preferred speaking Spanish. He said depending on how big the English word was would determine whether he understood it. He said he wore a brief and required the assistance of staff. He said if he was assisted, he could not complete his ADLs. He said he needed to go to the dentist. He was not in pain but had 4 teeth that needed to be pulled . He said he does not remember ever participating in a care plan meeting. A pair of glasses was observed on Resident #40's shirt. During an interview on 03/27/24 at 11:14 AM, Resident #14 stated that she had participated in a care plan meeting in another facility but not in the current facility. She said she did not know when the facility had care plan meetings. She said she wore briefs and required staff assistance to change her. She said she could help staff a little bit but not much. During an interview on 03/27/24 at 11:18 AM, Resident #12 stated that he did wear a brief and requires help from staff. During an interview on 03/27/24 at 11:31 AM, the Regional MDS Coordinator stated that a care plan identified residents' needs and issues that residents might have. She said they used the RAI manual to complete the MDS. She said the items triggered in Section V of the MDS should be care planned. She stated that if the triggered item was not an issue, the items do not have to be care planned . She said sometimes information was inaccurate, and interviews with the person completing the MDS, staff, and residents would help identify those inaccuracies. She said a potential negative outcome of inaccurate care plans could be missed documentation. She said she was unaware of any missing care plans. She said that, of the care plans identified as missing, she did not see a significant issue because the missing items were addressed in interventions for other care plans. She said she agreed that the problem, goals, and interventions should be consistent with one another. She said the system to monitor care plans was that they conduct quarterly care plans and reviews and do weekly care plan meetings. She said they also conduct weekly risk meetings to review care plans. She said she also performed audits periodically. She said the facility person assigned to complete care plans was the MDS Coordinator. She said she (the MDS Coordinator) was out with her ill family member and was not at the facility. She said she had been trained on how to complete care plans, and so had the MDS Coordinator. During an interview on 03/27/24 at 11:41 AM, the DON stated that the care plan was a plan that provides all nursing staff with a plan of care for each resident. She said the potential negative outcome of missing or inaccurate care plans was the resident could receive subpar treatment, and confusion could be caused among staff. She said it could potentially cause poor care for the resident. She said she was unaware that any residents were missing care plans. She said she had not received any reports about issues with care plans. She said the care plan should start with the CAAs from Section V. She and her nursing staff care planned for acute problems, and the MDS Coordinator would care plan for the CAAs. She said she expected all care plans to be accurate. She said they do not have to include all triggered areas CAAs, but the MDS would reflect whether they were care planned. She used Resident #28 as an example. She said in his case, at one time, Resident #28 had diarrhea, and due to the diarrhea, he became dehydrated. She said it would be an accurate coding but unnecessary for the care plan. When asked if she knew he was using the urinal every night, she said she was. When asked if she knew he wore adult briefs, she said she was unaware of that information. She said she had been trained to complete accurate care plans. She said she was responsible for ensuring that care plans were complete and accurate. She said she oversaw the MDS Coordinator. She said that as it relates to resolved care plans, those care plans have been fixed and were no longer needed. She said nurses can see resolved care plans, but CNAs cannot. During an interview on 03/27/24 at 11:47 AM, the ADM stated that the potential negative outcome of inaccurate or incomplete care plans was that residents could receive inappropriate care. She said the purpose of the care plan was to ensure all needs of the residents were being met. She said all staff used the care plan. She said she was unaware that any residents were missing any care plans. She said the system to monitor care plans was the MDS Coordinator. She said she knows that there were audits conducted, but she was unsure of the schedule and outcome of the audits. She said she had not been trained regarding the completion of the care plan. She said she expected care plans to be completed accurately and meet the needs of the resident. She said the MDS coordinator was responsible for completing care plans. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, October 2023, revealed the following: an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Record review of the facility policy, Care Plan Expectation (undated), revealed the following: Accountability for care planning is as follows: The DON is responsible for ensuring care plans are completed timely and are reflective of each resident. The MDS Coordinator and IDT will be responsible for any care plans triggered by the MDS/CAAs Licensed nurses will be responsible for the acute care plans such as falls, infections . 43344

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 4 of 6 (Residents #1, #31, #38 and #45) and 2 of 2 (CNA C and CNA D) and 1 of 1 (LVN A) staff reviewed for infection control. 1. CNA C failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #45. 2. CNA D failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #1. 3. LVN A failed to clean surface before placing wound supplies on surface while providing wound care to Resident #31 and Resident #38. These failures could place residents at risk for spread of infection and cross contamination. Findings include: 1. Resident #1 Record review Resident #1's face sheet dated 03/27/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included stroke, quadriplegia (paralysis of all 4 limbs) major depressive disorder (mental illness, feeling of sadness), hypertension (high blood pressure) and anxiety (feeling of fear). Record review of Resident #1's comprehensive MDS assessment, dated 10/16/23 reflected no BIMS score, staff assessment reflected severely impaired cognitive skills for daily decision making. Resident #1 was dependent on staff for toileting hygiene, and personal hygiene. Record review of Resident #1's care plan dated 03/05/24 reflected a focus area which indicated Resident #1 had an ADL self-care performance deficit r/t disease processes with interventions that Resident #1 was totally dependent on staff for personal hygiene and toilet use. Resident #31 Record review of Resident #31's face sheet dated 03/27/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included stoke, major depressive disorder (mental illness, feeling of sadness), hemiplegia (paralysis) left side, pressure ulcer, diabetes (high blood sugar), and hypertension (high blood pressure). Record review of Resident #31's comprehensive MDS assessment, dated 01/10/24 reflected a BIMS of 00 which indicated severely impaired cognition. Resident #31 had pressure ulcer injury and care and was at risk for pressure ulcers. Record review of Resident #31's care plan dated 02/19/24 reflected a focus area which indicated Resident #31 had an unstageable pressure injury to the left heel with interventions to administer treatments as ordered. Record review of Resident #31's physician's orders dated 03/27/24 reflected an order dated 03/13/24 for wound care to the left heel every day and PRN as follows: Cleanse with wound cleanser or NS pat dry with gauze, apply collagen powder and mix with anasept, then add calcium with alginate, cover with border gauze, and may secure with tape as needed. Resident #38 Record review of Resident #38's face sheet dated 03/27/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), diabetes (high blood sugar), bipolar disorder (mental illness that causes extreme mood swings), schizoaffective disorder (mental illness that affects how a person thinks, feels, and behaves) and altered mental status. Record review of Resident #38's comprehensive MDS assessment, dated 02/16/24 reflected a BIMS of 09 which indicated moderate impaired cognition. Resident #38 had pressure ulcer injury and care and was at risk for pressure ulcers. Record review of Resident #38's care plan dated 02/14/24 reflected a focus area which indicated Resident #31 had an unstageable pressure injury with interventions to administer treatments as ordered and to monitor for effectiveness. Record review of Resident #38's physician's orders dated 03/27/24 reflected an order dated 03/27/24 for wound care daily and PRN to left heel as follows: Cleanse with wound cleanser or NS, apply santyl and cover with border gauze, may secure with tape. An order dated 03/27/24 reflected wound care every day and PRN to the right MTP (big toe) as follows: cleanse with wound cleanser and pat dry, then apply Thera-honey, cover with border gauze. Resident #45 Record review Resident #45's face sheet dated 03/27/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included stroke, hemiplegia (paralysis) right side, altered mental status, and muscle weakness. Record review of Resident #45's comprehensive MDS assessment, dated 08/25/23 reflected BIMS 00 which indicated severely impaired cognition. Resident #45 was dependent of staff for toileting hygiene, and personal hygiene. Record review of Resident #45's care plan dated 01/29/24 reflected a focus area which indicated Resident #45 had an ADL self-care performance deficit r/t disease processes with interventions Resident #45 was totally dependent on staff for personal hygiene and toilet use. 2. During an observation on 03/26/24 at 02:46 PM, revealed incontinent care was provided to Resident #45 by CNA C. Observed CNA C make multiple wipes using the same disposable washcloth on the resident's upper abdomen. CNA C changed her gloves and put on new gloves and no handwashing or hand sanitizer use was observed. CNA C rolled the dirty brief under the resident. CNA C removed her gloves and put on new gloves and no handwashing or hand sanitizer use was observed. The aide cleaned the buttocks area with multiple back and forth swipes using the same disposable wipe. CNA C changed her gloves and used hand sanitizer and put on new gloves. CNA C placed a new brief under the old rolled up brief and assisted the resident to their back, removed the old brief and place the cleaned brief on the resident and repositioned the resident. During an interview on 03/26/24 at 04:00 PM with CNA C, she stated she did make several back-and-forth wipes with one disposable cleaning cloth when wiping the resident's lower abdomen. She stated she should have folded the wipe after each wipe or got a new wipe. She stated she did forget to use hand sanitizer between glove changes. She stated there was no reason not to wash her hands or use hand sanitizer except she forgot because she was nervous. She stated she had been trained on incontinent care. She stated the potential negative outcome could be cross contamination. 3. During an observation on 03/26/24 at 03:00 PM, revealed incontinent care was provided to Resident #1 by CNA D. While cleaning the coccyx area observed CNA D make multiple wipes using the same disposable wipe. CNA D folded the disposable wipe and made multiple wipes on both sides of the coccyx. CNA D removed her gloves and put on new gloves and no hand washing, or hand sanitizer use observed. CNA D rolled the old brief under the resident and placed the new brief under the dirty brief. CNA D removed her gloves and put new gloves on and no hand washing, or hand sanitizer use observed. CNA D placed clean the brief on the resident and covered the resident with a blanket. During an interview on 03/26/24 at 03:54 PM with CNA D, she stated when cleaning a resident, they should wipe once and fold the wipe and wipe again. She stated she made multiple wipes on the buttocks with the same wipe. She stated she thought she had folded the wipe each time. She stated her hands should be washed or use hand sanitizer between glove changes. She stated she did forget to use hand sanitizer between glove changes. She stated there was no reason she should have not used hand sanitizer between glove changes. She stated placing the clean brief under the rolled brief could cause cross contamination. She stated I just got caught up in the moment of doing incontinent care and forgot. You made me nervous. She stated she had received training on incontinent care. She stated the potential negative outcome could be cross contamination, infection or catching something. 4. During an observation on 03/27/24 at 09:30 AM, revealed wound care was provided to Resident #31, observed LVN A gather wound care supplies and place them in a clean tray. LVN A carried the tray into Resident #31's room and placed it on the bed side table. LVN A took gauze and tape out of tray on bed side table and placed on the resident's mattress. LVN A picked up the gauze and placed it over the wound. LVN A picked up the tape and secured the gauze to Resident #31's foot. During an observation on 03/27/24 at 10:00 AM, revealed wound care was provided to Resident #38. Observed LVN A gather wound care supplies and placed them in a clean tray. LVN A carried the tray into Resident #38's room and placed it on the bed side table. LVN A took cup of dry gauze, cup with santyl, and gauze and placed on bed side table. LVN A took cup of gauze and removed the gauze and dried Resident #38's wound bed. LVN A placed the cup back on the bed side table. LVN A picked up a cup of Santyl and using a wooden medicine spoon placed santyl in the wound bed. LVN A placed the cup of Santyl back on bed side table. LVN A picked up gauze and placed it on wound bed. During an interview on 03/27/24 at 11:10 AM with LVN A, she stated she should have cleaned the mattress and bed side table before placing supplies on it. She stated, I just did not think about cleaning the mattress or bedside table. She stated she had been trained on wound care and the proper steps. She stated the potential negative outcome could be bacteria getting on supplies and cross contamination. During an interview on 03/27/24 at 03:00 PM with the DON, she stated the CNAs should follow policy when doing incontinent care. She stated the CNAs should use a new wipe with each wipe. She stated hands should be washed or ABHR used between glove changes. She stated all staff had been trained on handwashing and CNAs had been trained on incontinent care. She stated the potential negative outcome could be UTI if not wiping appropriately, injury to skin, infection, and skin breakdown. She stated wound care supplies should not be placed on unclean surfaces. She stated nurses had been trained on proper wound care. She stated the potential negative outcome could be spread of infection. During an interview on 03/28/24 at 09:00 AM with the ADM, she stated CNAs should not use one wipe for multiple wipes. She stated the ADON and DON were responsible for monitoring CNAs competency skills. She stated all staff had been trained on incontinent care. She stated the potential negative outcome could be infection. She stated hands should be washed or ABHR used between glove changes. She stated staff had been trained on handwashing. She stated the ADON and DON was responsible for monitoring staff for competency skills. She stated the potential negative outcome could be infection, transmitting infection to the resident from unclean hands as well as to themselves. She stated the nurse should have cleaned the surface before setting supplies on table or bed. She stated staff have been trained on wound care. She stated the ADON and DON was responsible for monitoring for compliance and competences. She stated the potential negative outcome could be risk of infection to the resident. Record review CNA C's competency evaluation for Peri/Incontinent Care dated 01-16-24 reflected CNA C met all competency skills for incontinent care. Record review of the hand hygiene competency check off audit form for CNA C dated 10/12/23 reflected CNA C passed the skills check off. Record review of CNA D's competency evaluation for Peri/Incontinent Care dated 01-16-24 reflected CNA D met all competency skills for incontinent care. Record review hand of the hygiene competency check off audit form for CNA D dated 09/13/23 reflected CNA D passed the skills check off. Record review of LVN A 'swound care competency dated 12-30-23 reflected LVN A passed skills competency. Record review of the facility's policy titled Perineal Care, dated 10/01/21, reflected the following: Policy: to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Steps in the Procedure 8d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same side of the disposable wipe, change the surface position of the disposable wipe and/or obtain a clean wipe to clean the labia . 11. Remove gloves and discard into designated container. Wash and dry your hands thoroughly . Record review of the facility policy titled Hand Hygiene, dated 08/04/21, reflected the following: Policy: Hand Hygiene is used to prevent the spread of pathogens in healthcare settings. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub (ABHR) to destroy harmful pathogens, such as bacteria or viruses, on the hands. 1. You should always perform hand hygiene: . Before applying and after removing personal protective equipment (e.g., gloves, gown, mask, face shield/goggles) 2. You must perform hand hygiene (hand washing or the use of an ABHR) after contact with bodily fluids, such as urine . Record review of the facility's wound care competency, undated, reflected the following: Wound Care Competency . Gathers supplies (disinfectant for table/treatment cart, scissors, dressings, tape, wound cleanse or normal saline, PPE supplies, biohazard bag, and regular trash receptacle). Clean and disinfect work surfaces, allowing drying time to be complete, and establish a clean field .

Based on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 1 treatment cart observed for drug storage. The facility failed to ensure LVN B did not leave wound cleanser on top of the treatment cart unsupervised. This failure could place residents at risk of harm due to misuse or accidental ingestion. ,. The findings were: Record review Resident #12's face sheet dated 03/26/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included stroke, diabetes (high blood sugar), dementia (cognitive loss), hypertension (high blood pressure), and major depressive disorder (mental illness, feeling of sadness). Record review of Resident #12's quarterly MDS assessment, dated 02/20/24 revealed a BIMS score of 13, which indicated cognition was intact. Section M - skin conditions reflected Resident #12 had application of nonsurgical dressings and ointments/medications. Record review of Resident #12's care plan dated 02/09/24 reflected a focus area Resident #12 had wound to his left bka (below knee amputation) stump, with interventions to perform treatments per MD orders. Record review of Resident #12's physician's orders dated 03/26/24 reflected wound care to stump wound every day as follows: Cleanse with wound cleanser or NS, pat dry with 4x4 gauze, apply Thera-honey to wound bed and then xeroform, cover with foam or dry dressing. Order dated 03/05/24. Record review of the wound cleanser spray bottle label undated reflected Warnings: Keep out of reach of children. For external use only. Do not use in the eyes. If swallowed, get medical help or contact a Poison Control Center immediately. During an observation and interview on 03/27/24 at 09:00 AM LVN B prepared wound care supplies outside of Resident #12's room. She placed 4x4 gauze in a cup and sprayed it with wound cleanser. She placed the wound cleanser spray bottle on top of the treatment cart. She gathered the supplies and entered Resident #12's room. She closed the resident's door and pulled the privacy curtain. The treatment cart remained outside of Resident #12 room. After completing wound care LVN B went to the treatment cart and pushed treatment the cart to the nurse's station. The wound cleanser spray bottle remained on top of the treatment cart. LVN A took the treatment cart down to hall 300 to room [ROOM NUMBER]. LVN A prepared wound supplies for a resident and before gathering supplies placed the wound cleanser spray bottle in treatment cart. During an interview on 03/28/24 at 11:00 AM with LVN B, she stated the wound cleanser spray bottle should have been placed back inside the treatment cart before she left the treatment cart unattended. She stated there was no reason she left it on top of the cart. She stated she had been trained to keep all supplies and medications always locked when the cart was unattended. She stated the wound cleanser spray bottle had a warning to keep out of reach of children and if swallowed to get medical help. She stated the potential negative outcome could be a resident getting the bottle and drinking it. She stated the wound cleanser could cause resident harm. During an interview on 03/27/24 at 03:00 PM with the DON, she stated the wound cleanser spray bottle should not be left on top of the treatment cart unattended. She stated all staff had been trained on medication and supply storage. She stated the potential negative outcome could be a resident drinking the solution causing diarrhea or an upset stomach. During an interview on 03/28/24 at 09:00 AM with the ADM, she stated the wound cleanser spray bottle should not be left out on top of the medication cart unsupervised. She stated staff had been trained on proper storage of supplies and medications. She stated the ADON and DON were responsible for monitoring for compliance. She stated the potential negative outcome could be a resident could get it and ingest it. Record review of the facility's policy titled Storage of Medications, dated 09-2018 reflected the following: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. General Guidance . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access .

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 5 (Resident #1) reviewed for abuse and neglect. The DON failed to respond to LVN A's report of the AP verbalizing that she would make Resident #1 clean up his own excrement from the toilet and the floor as a result no investigation was initiated. LVN B failed to report allegations of ANE after the AP verbalized that she would make Resident #1 clean up his own excrement from the toilet and the floor and that he would not be allowed to go smoke if this was not completed and as a result an investigation was not initiated. An IJ was identified on 11/21/23 at 4:50 PM. The IJ template was provided to the facility on [DATE] at 4:40 PM. While the IJ was removed on 11/22/23 at 02:58 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated because all staff had not been trained on 11/22/23. This failure could place residents at risk of allegations not thoroughly being investigated and residents being at risk for emotional and physical abuse and exposure to alleged perpetrators. Findings Included: Record review of Resident #1's face sheet, dated 11/21/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (brain disorder), schizophrenia (mental illness), dementia (impaired memory), cognitive communication deficit (difficulty paying attention), history of falling, difficulty walking, unsteadiness on feet and lack of coordination. Record review of Resident #1's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section G Functional status I. Toilet use: provide supervision with one person to physically assist. J. Personal Hygiene: Limited assistance with one person to physically assist. Mobility Devices B. [NAME] Section H Bladder and Bowel Bowel Continence Frequently incontinent Section I Active Diagnoses Anxiety Disorder, depression, and Schizophrenia Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 was incontinent of: Bladder Record review of Resident #1 care plan dated 09/05/21 revealed the following: Focus Resident #1 was at Risk for Falls as evidenced By: History of Falls, Cognitive Impairment, Unsteady Gait, Medication use. Record review of Resident #1 care plan dated 07/29/21 revealed the following: Focus Resident #1 had impaired Visual Functioning and was at Risk for a decrease in ADLs and Injuries r/t Disease Process Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 had an ADL self-care performance deficit r/t disease processes. Intervention TOILET USE: Resident requires supervision set up assistance with one person assistance at times Record review of Resident #1 care plan dated 12/15/21 revealed the following: Focus Resident #1 had a diagnosis of Depression. Resident #1 was at risk for self-care deficit, ineffective coping, deficient diversional activity, and insomnia. During an interview on 11/21/23 at 9:54 AM, the ADM stated Resident #1 had a bowel movement and was given a laxative. She said Resident #1 had feces on the toilet and the floor. She said Housekeeper C came and told the AP that she would disinfect after she (the AP) had cleaned up the feces. She said the AP refused. She said the AP refused and then said Resident #1 would clean up his mess. She said this verbal interaction occurred in front of the charge nurse (LVN A and LVN B). She said after the charge nurse (LVN B) told her she could not make him, the AP still took Resident #1 down to his room with cleaner, and the resident cleaned up his floor and the bathroom. She said the AP told Resident #1 that he could not smoke until it was cleaned. She said the AP did complete her entire shift on this date. She said she did not learn about the incident until the following day (11/14/23) when LVN A reported it to her at 8:30 AM. She said at that time, she spoke with Resident #1, and he could recall the incident and that it did happen. She said Resident #1 was concerned about the AP being fired and did not want the AP fired because she had children to care for. She said that the AP was terminated because of the incident. The ADM stated that she was notified of the incident the next day 11/14/23 by LVN A. During an interview on 11/21/23 at 9:54 AM, the DON stated LVN A was leaving, and LVN B took over the shift when the incident occurred. She said both charge nurses (LVN A and LVN B) told the AP that she could not do this and that it was not okay. She said this incident occurred around 6 PM on 11/13/23. She said the AP was not referred because they wanted to wait to see what the state would do. During an interview on 11/21/23 at 10:30 AM, Resident #1 stated he did not know the date of the incident, but he remembered what happened. He said that he was supposed to get a shower. He said he was really sorry for using the restroom on the floor and the toilet. He said the staff told him he could not leave his room until he cleaned up his mess. He said he did not know her name. He said she was mad at him, he was nervous, and it made him feel bad. He said he cleaned it up the best he could. He said he did not have any more toilet paper, so he did his best with paper towels. He said no one came in to help him clean. He said that he was told that he could not smoke that day. He said he did not get to smoke that day. He said he was able to smoke the next day. He said no one came to talk to him or check on him. He said no one had done anything like that to him before. During an interview on 11/21/23 at 11:07 AM, LVN B stated that she was unsure of the exact date and time of the incident with the AP and Resident #1. She said Resident #1 had feces on the toilet. She said she told the AP that she would have to clean it. She said the AP told her that she would not clean it up. She said she had Resident #1 clean it up. She said she was aware of this the following day when the investigation was started. She said she was busy and remembered them (Resident #1 and the AP) going down the hall. She said she assumed that the AP would take Resident #1 down the hall to his room and check him to ensure he had no feces on him. She said she did not think anything of it. She said she did not report this to anyone. She said she assumed that she would not have him clean the feces. She said she was mad when she told her that she (the AP) would have to clean it. She said she could tell she was angry because of her facial expression. She said the AP thought cleaning the feces was the housekeeper's job. She said it was her understanding that no one followed up with Resident #1. She said she believed Resident #1 went to his smoke break because she saw him coming down the hallway but did not physically see him smoke. She said smoking was Resident #1 favorite part of his day. She said LVN A was present for the verbal altercation. She said she was coming in for her shift, and LVN A was leaving for the day. She said she was unsure if the AP was having a bad day or moment. She said the AP does what she was typically told. She said she should have reported it as soon as she heard it, but the reason why she did not report it was because she was busy with her other nursing duties, and she did not think that she would do it During an interview on 11/21/23 at 11:28 AM, the Activity Director stated she was unsure when the AP made Resident #1 clean up his fecal matter off the floor and the toilet. Still, she remembered she stayed past her shift to help with the evening shift. She said she heard the AP tell Resident #1 directly that he was going to have to clean up his mess. Resident #1 said he could not clean it up, and the AP kept yelling yes, you can, yes, you can. She said she heard LVN B tell her no that she (the AP) could not do that. She said after LVN B told her no, she left to do medications for the other residents. She said she saw Resident #1 going to his room. She said she did not see the AP at that time. She said 20 minutes later, she went down the hall, and Resident #1 attempted to leave his room. She said she then saw the AP tell Resident #1 no that he could not come out and that she needed to check his room first to ensure it was done right. She said when the AP came out, she told Resident #1, Good job, and then he was allowed to go. She said that after she saw that, she went to LVN B and told her what she saw. She told LVN B, Did you know she made him (Resident #1 clean that up? She said LVN B responded, No, but the DON had been notified, and she had already called. She said she witnessed the AP yelling at one of the laundry ladies, stating that she was not paid to clean that up. She said that she supervised smoking that evening, and Resident #1 was allowed to smoke. She said that after the incident, she was told to report it to the ADM immediately. During an interview on 11/21/23 at 11:38 AM, the DON stated the incident occurred on the 12th. She said she was notified the morning that she came in on 11/13/23. She said she was notified by LVN A the night before. She said she was told that the AP was griping about having to clean up the mess. She said she followed up with LVN B to see if the mess had been cleaned and handled. She said LVN B told her it had been handled and the mess had been cleaned. The DON said, I just left it there. She said she never followed up to see who cleaned up the feces. During an interview on 11/21/23 at 11:45 AM, LVN B stated that she could not remember who reported that Resident #1 had cleaned up the fecal matter. She said she had so much going on the night of the incident. She said she was trying to remember if it was the activity director or who it was because she was busy. She said she was busy with passing medications and was the only nurse in the evening. She said the AP worked her entire shift that evening. She said that the incident happened at shift change around 6:00 PM. She said she received a text from the DON asking if the mess had been cleaned up. She said she did not know how the DON knew about the incident. She said she assumed LVN A told her about it. She said the potential negative outcome was the comment about making Resident #1 clean his poop would make him feel bad. She said Resident #1 needs assistance. She said this is why he is at the facility. She said Resident #1 may have been confused and felt he had done something wrong. She said the AP would have been sent home if this had been reported. She said that the AP not being sent home would have placed Resident #1 and the other residents at risk for abuse. During an interview on 11/21/23 at 2:24 PM, the ADM stated once she was made aware of the incident, she started educating staff on ANE. She said they educated staff on housekeeping and staff responsibilities regarding cleaning up body fluids. She said this incident was not covered in their QAPI meeting. She said this was not covered in their QAPI meeting because they had their meeting on 11/07 or 11/08 of November, and the incident occurred on the 13th. She said the QAPI meetings are on the 2nd Wednesday of the month. She said there was never a time that they deviated outside of the scheduled QAPI meetings. She said regarding the incident, she expected that the AP would have been removed from the facility immediately. She said it was abuse. She said it was a form of shaming and degrading Resident #1. She said when the AP threatened to withhold Resident #1's smoke break, this was a form of punishment. She said she was unaware that any of the nurses had reported the information to the DON. She said she was unaware that the DON was aware of the information until after LVN A wrote her statement. She said the AP worked the incident date from 6:00 AM to 6:00 PM. During an interview on 11/21/23 at 4:50 PM, the DON stated that she did not consider what the AP said verbal abuse because the AP did not tell the statement directly to Resident #1. She called and asked about the mess being cleaned but did not follow up with who cleaned it. During an interview on 11/22/23 at 12:00 PM LVN, A stated that 11/13/23 she worked from 6 AM to 6 PM. She said Resident #1 had come to her and asked where his room was. She said she told Resident #1 where his room was. She said while giving LVN B a report that the AP found excrement on the toilet and the floor. She said she overheard the AP say she would make Resident #1 clean it. She told the AP she could not do that and would not make Resident #1 clean it. She said Resident #1 was seated at the nurse's station. She said she was not sure if he heard what was being said. She said he may not understand what was happening even if he did hear. She said Resident #1 was very forgetful and needed constant reminders. She said the incident occurred around 6:15 or 6:20 PM. After giving the report, she told LVN B she needed to leave because her shift was over. She said the AP had not made Resident #1 clean up the excrement before she left. She said after leaving work, she went to the DON's home and reported that the AP said she would make Resident #1 clean up her mess. She said the DON's initial response was, What? She repeated what she had told her. She said the DON stated, She cannot do that. She said that the DON told her she would call the facility. She said the DON had called to ask if the body fluids had been cleaned. She said she was unsure if LVN B knew who had cleaned it up at the time. The following day (11/14/23), LVN A said the Activity Director told her during a smoke break that Resident #1 had cleaned up the mess. LVN A said that she reported it to the DON again because anything could have happened. She said the DON at that time did not know that the AP had followed through with making Resident #1 clean up his mess. LVN A said she did not follow up the day before because she did not think she would do it. She said Resident #1 could have potentially consumed the chemical, the fumes could have made him sick, and he would not do well with cleaning because of his cognitive state. She said Resident #1 could have spilled the chemical on himself or even fallen. She said this could also be considered emotional abuse because being incontinent is embarrassing, and this entire incident could have embarrassed him and caused him to lose his dignity. She said even if a person is lower level cognitively, they should not be subject to abuse. She said she would not want this done to her loved one because it could hurt your feelings. She said the AP has a strong personality, and LVN B does not. She said this may have been why LVN B did nothing. Record review of the video surveillance revealed the following occurred on 11/13/23 (The video surveillance did not have any sound): Observed Resident #1 walking by himself using a walker towards his room. The AP was walking quickly in front of him. She enters a room on the right, obtains a trash can and something unidentifiable in her left hand, and takes it in his room. She comes out. Resident #1 enters the room. The AP walked in and out of multiple rooms, talking with staff in the hallway. Resident #1 comes out of the room, the AP appears to say something, and Resident #1 returns. After 2 minutes, Resident #1 came back out of the room. The AP exits another room and goes back into Resident #1 room, and Resident #1 goes back into the room. The AP returns to the room and exits with the trash can. Resident #1 left his bedroom and walked down the hall. Record review of the facility policy, Abuse (Revised 01/01/2023), revealed the following: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, involuntary Seclusion/Confinement, and or Misappropriation of property. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, caretakers, friends, or other individuals. This includes physical, verbal Reporting/Investigation: The law requires the abuse coordinator or designee or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statements summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate, and any staff who worked prior to and during the time of the incident. Interviews may include employees of various departments and ships. A thorough physical assessment will be conducted on residents involved in the allegation of abuse neglect. Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential causes. Protection: It is utmost important that the residents suspected of being abused, and all other residents must be protected during the initial identification, an investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Upon notification of the allegation, the abuse coordinator or designee will perform the following: identify the perpetrator that is identified by eyewitness or during the investigation and remove the perpetrator from further contact with the resident pending outcome of the investigation. Record review of the facility job description for Licensed Vocational Nurses (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct Resident Care and Support functions. Essential Functions Identifies problems and guides personnel to their solution Pursue more specific investigation as needed. Consistently follows established standards, policies, and procedures in providing nursing care Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Responds appropriately in urgent and/ or emergency situations. Record review of the facility job description for Director of Nursing (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct resident care and support functions. Essential Functions To assure resident safety Identifies problems and guides personnel to their solutions. Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Supports standards of nursing care through adherence to existence policies and procedures. Record review of the facility policy, Resident Rights (12/2016), revealed the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity Policy Interpretation and Implementation dignified existence Be treated with respect, kindness and dignity Be free from abuse, neglect, misappropriation of property, and exploitation; Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints Perform services for the facility if he chooses or refuses to perform services for the facility The Adm and the DON were notified on 11/21/23 at 4:50 PM and IJ situation was identified due to the above failures and the ID template was provided. The following Plan of Removal submitted by the facility was accepted on 11/22/23 at 01:50 PM: F609 Plan of Removal Any allegation of abuse/neglect will be investigated immediately by EDO/designee, and residents will be protected immediately. EDO/designee will review daily all incidents and accidents and grievances for potential allegations of abuse/neglect in the standup meeting, and will investigate immediately, and residents will be immediately protected. All incontinent residents have the potential to be affected by this alleged deficient practice. No other residents were identified to have been affected by this alleged deficient practice. Abuse/Neglect inservices for all staff in the community completed 11/22/2023 and ongoing. Alleged Perpetrator terminated 11/14/2023 following the incident that occurred 11/13/2023. DON has been suspended pending further investigation effective 11/21/2023. Ad hoc QAPI conducted 11/21/2023 to discuss IJ with Medical Director. LVN B suspended pending further investigation effective 11/21/2023. Resident #1 had a Psychiatric evaluation by the NP on 11/20/2023. No new orders or changes in treatment after this evaluation. A follow-up telehealth psychiatric assessment was completed 11/22/2023. No new orders or changes to plan of care recommended. Nursing staff to continue to monitor psychosocial needs q shift. Trauma assessment completed 11/21/2023. 11/21/2023 Regional Nurse Consultant provided training to DCO and ADCO on policy on abuse/neglect, reporting of suspected abuse/neglect, types of abuse including, but not limited to involuntary seclusion/punishment, verbal threats to residents. Abuse and neglect in-servicing was initiated on 11/21/2023 by the ADCO for all staff regarding reporting any suspected abuse/neglect to Abuse Coordinator immediately, 24 hours/day. Review of types of abuse including, but not limited to involuntary seclusion/punishment of residents. Staff inserviced on taking measures to intervene immediately to protect residents from inappropriate/suspicious behavior, abuse or potential abuse toward a resident. This training will be provided to all staff prior to the start of their next shift until all staff have had the training. Completion date 11/22/2023. This training will also be part of new staff orientation. Administrator was in-serviced on 11/21/23 by the RVP on policy and procedure for abuse/neglect and reporting parameters for abuse/neglect allegations, including immediate removal of AP from the facility to protect all residents. Safe surveys conducted with all alert and oriented residents to assess for abuse/neglect. 5 alert and interviewable residents will be interviewed weekly to assess for abuse/neglect x 4weeks, then weekly in Standards of Care Meeting. Administrator will review findings. Will evaluate findings in the monthly QAPI meeting until resolved. On 11/22/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 11/22/23 from 02:15 PM to 2:41 PM with (LVN D, E, Hospitality Aide F, and CNA G & H)) revealed that they could identify all five types of abuse (mental, physical, emotional/mental, sexual, and financial). They all explained that they had been trained and understood that depriving a resident of things was unacceptable to get them to complete a task. They all could define their roles and responsibilities if they witness or suspect abuse. They could state that they would report any allegations, whether they believed it occurred or would occur, to the Administrator Immediately. They all explained that it was important to protect the residents, including ensuring that the residents were not around any perpetrators and that the perpetrator was not putting other residents at risk. LVN D & E explained their role in ensuring they follow up with any abuse allegations, including reporting immediately to the ADM and removing any alleged perpetrators from the facility. Record review of 17 completed abuse and resident rights quizzes completed by multiple staff on various shifts between 11/21/23 &11/22/23 revealed the Resident rights quiz covered the residents right to refuse treatments, care and or services. The abuse quiz discussed types of abuse to include threatening a resident and refusing care. It covered alleged perpetrators not being allowed to work with residents and that abuse needed to be reported immediately. Record review of the facility QAPI meeting signature sheet indicating that an ad hoc meeting occurred on 11/21/23. Record review of the facility Inservice dated 11/21/23 revealed the ADM being the facility's abuse coordinator and her contact number. The inservice explained that she can be reached at anytime and that abuse and neglect must be reported immediately. The inservices specified that if staff see or hear anything they must report what they have seen or heard immediately. The inservice specified that staff must report all allegation of abuse even if they feel it will not happen. The inservice specified that staff may not punish or threaten residents by isolating them or withholding their rights or their privileges. The abuse policy revised 01/01/23 was also attached. 22 staff member signatures were reviewed. The ADM was informed the Immediate Jeopardy was removed on 11/22/23 at 2:48 PM the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure residents were free from verbal, sexual physical and mental abuse, corporal punishment, and involuntary seclusion for 1 of 5 residents (Resident #1) reviewed for abuse in that: The AP made Resident #1 clean up his own excrement from the floor and the toilet on 11/13/23. The AP threatened Resident #1 that if he did not clean up his excrement, he would not be able to go and smoke during the evening smoke break. LVN B failed to follow up and ensure that Resident #1 was free from abuse after the AP verbalize that she was going to make Resident #1 clean up his own excrement. The AP worked the remainder of her shift on 11/13/23-11/14/23 from 6:00 AM-6:00 PM after verbalizing that she verbalized that she would make Resident #1 clean his own excrement and after making Resident #1 clean his own excrement from the floor and the toilet. An IJ was identified on 11/21/23 at 4:50 PM. The IJ template was provided to the facility on [DATE] at 4:40 PM. While the IJ was removed on 11/22/23 at 02:58 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated because all staff had not been trained on 11/22/23. This failure could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings Included: Record review of Resident #1's face sheet, dated 11/21/23, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (brain disorder), schizophrenia (mental illness), dementia (impaired memory), cognitive communication deficit (difficulty paying attention), history of falling, difficulty walking, unsteadiness on feet and lack of coordination. Record review of Resident #1's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section G Functional status I. Toilet use: provide supervision with one person to physically assist. J. Personal Hygiene: Limited assistance with one person to physically assist. Mobility Devices B. [NAME] Section H Bladder and Bowel Bowel Continence Frequently incontinent Section I Active Diagnoses Anxiety Disorder, depression, and Schizophrenia Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 was incontinent of: Bladder Record review of Resident #1 care plan dated 09/05/21 revealed the following: Focus Resident #1 was at Risk for Falls as evidenced By: History of Falls, Cognitive Impairment, Unsteady Gait, Medication use. Record review of Resident #1 care plan dated 07/29/21 revealed the following: Focus Resident #1 had impaired Visual Functioning and was at Risk for a decrease in ADLs and Injuries r/t Disease Process Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 had an ADL self-care performance deficit r/t disease processes. Intervention TOILET USE: Resident requires supervision set up assistance with one person assistance at times Record review of Resident #1 care plan dated 12/15/21 revealed the following: Focus Resident #1 had a diagnosis of Depression. Resident #1 was at risk for self-care deficit, ineffective coping, deficient diversional activity, and insomnia. During an interview on 11/21/23 at 9:54 AM, the ADM stated Resident #1 had a bowel movement and was given a laxative. She said Resident #1 had feces on the toilet and the floor. She said Housekeeper C came and told the AP that she would disinfect after she (the AP) had cleaned up the feces. She said the AP refused. She said the AP refused and then said Resident #1 would clean up his mess. She said this verbal interaction occurred in front of the charge nurse (LVN A and LVN B). She said after the charge nurse (LVN B) told her she could not make him, the AP still took Resident #1 down to his room with cleaner, and the resident cleaned up his floor and the bathroom. She said the AP told Resident #1 that he could not smoke until it was cleaned. She said the AP did complete her entire shift on this date. She said she did not learn about the incident until the following day (11/14/23) when LVN A reported it to her at 8:30 AM. She said at that time, she spoke with Resident #1, and he could recall the incident and that it did happen. She said Resident #1 was concerned about the AP being fired and did not want the AP fired because she had children to care for. She said that the AP was terminated because of the incident. The ADM stated that she was notified of the incident the next day 11/14/23 by LVN A. During an interview on 11/21/23 at 9:54 AM, the DON stated LVN A was leaving, and LVN B took over the shift when the incident occurred. She said both charge nurses (LVN A and LVN B) told the AP that she could not do this and that it was not okay. She said this incident occurred around 6 PM on 11/13/23. She said the AP was not referred because they wanted to wait to see what the state would do. During an interview on 11/21/23 at 10:30 AM, Resident #1 stated he did not know the date of the incident, but he remembered what happened. He said that he was supposed to get a shower. He said he was really sorry for using the restroom on the floor and the toilet. He said the staff told him he could not leave his room until he cleaned up his mess. He said he did not know her name. He said she was mad at him, he was nervous, and it made him feel bad. He said he cleaned it up the best he could. He said he did not have any more toilet paper, so he did his best with paper towels. He said no one came in to help him clean. He said that he was told that he could not smoke that day. He said he did not get to smoke that day. He said he was able to smoke the next day. He said no one came to talk to him or check on him. He said no one had done anything like that to him before. During an interview on 11/21/23 at 11:07 AM, LVN B stated that she was unsure of the exact date and time of the incident with the AP and Resident #1. She said Resident #1 had feces on the toilet. She said she told the AP that she would have to clean it. She said the AP told her that she would not clean it up. She said she had Resident #1 clean it up. She said she was aware of this the following day when the investigation was started. She said she was busy and remembered them (Resident #1 and the AP) going down the hall. She said she assumed that the AP would take Resident #1 down the hall to his room and check him to ensure he had no feces on him. She said she did not think anything of it. She said she did not report this to anyone. She said she assumed that she would not have him clean the feces. She said she was mad when she told her that she (the AP) would have to clean it. She said she could tell she was angry because of her facial expression. She said the AP thought cleaning the feces was the housekeeper's job. She said it was her understanding that no one followed up with Resident #1. She said she believed Resident #1 went to his smoke break because she saw him coming down the hallway but did not physically see him smoke. She said smoking was Resident #1 favorite part of his day. She said LVN A was present for the verbal altercation. She said she was coming in for her shift, and LVN A was leaving for the day. She said she was unsure if the AP was having a bad day or moment. She said the AP does what she was typically told. She said she should have reported it as soon as she heard it, but the reason why she did not report it was because she was busy with her other nursing duties, and she did not think that she would make Resident #1 clean up his own excrement. During an interview on 11/21/23 at 11:28 AM, the Activity Director stated she was unsure when the AP made Resident #1 clean up his fecal matter off the floor and the toilet. Still, she remembered she stayed past her shift to help with the evening shift. She said she heard the AP tell Resident #1 directly that he was going to have to clean up his mess. Resident #1 said he could not clean it up, and the AP kept yelling yes, you can, yes, you can. She said she heard LVN B tell her no that she (the AP) could not do that. She said after LVN B told her no, she left to do medications for the other residents. She said she saw Resident #1 going to his room. She said she did not see the AP at that time. She said 20 minutes later, she went down the hall, and Resident #1 attempted to leave his room. She said she then saw the AP tell Resident #1 no that he could not come out and that she needed to check his room first to ensure it was done right. She said when the AP came out, she told Resident #1, Good job, and then he was allowed to go. She said that after she saw that, she went to LVN B and told her what she saw. She told LVN B, Did you know she made him (Resident #1 clean that up? She said LVN B responded, No, but the DON had been notified, and she had already called. She said she witnessed the AP yelling at one of the laundry ladies, stating that she was not paid to clean that up. She said that she supervised smoking that evening, and Resident #1 was allowed to smoke. She said that after the incident, she was told to report it to the ADM immediately. During an interview on 11/21/23 at 11:38 AM, the DON stated the incident occurred on the 12th of November. She said she was notified the morning that she came in on 11/13/23. She said she was notified by LVN A the night before. She said that she was told that the AP was griping about having to clean up the mess. She said she followed up with LVN B to see if the mess had been cleaned and handled. She said LVN B told her it had been handled and the mess had been cleaned. The DON said, I just left it there. She said she never followed up to see who cleaned up the feces. During an interview on 11/21/23 at 11:45 AM, LVN B stated that she could not remember who reported that Resident #1 had cleaned up the fecal matter. She said she had so much going on the night of the incident. She said she was trying to remember if it was the activity director or who it was because she was busy. She said she was busy with passing medications and was the only nurse in the evening. She said the AP worked her entire shift that evening. She said that the incident happened at shift change around 6:00 PM. She said she received a text from the DON asking if the mess had been cleaned up. She said she did not know how the DON knew about the incident. She said she assumed LVN A told her about it. She said the potential negative outcome was the comment about making Resident #1 clean his poop would make him feel bad. She said Resident #1 needs assistance. She said that was why he was at the facility. She said Resident #1 may have been confused and felt he had done something wrong. She said the AP would have been sent home if this had been reported. She said that the AP not being sent home would have placed Resident #1 and the other residents at risk for abuse. During an interview on 11/21/23 at 11:28 AM, Housekeeper C stated that on 11/13/23, she was on Hall 4 when she was told by the AP, Hey, look what Resident #1 did to you. She said the AP told her, You are the housekeeper, and you can clean it. She told the AP, No, you have to clean, then I come and disinfect. She said she told the AP she could not contaminate the housekeeping cart. She said the AP then was yelling where everyone could hear, saying that she would not clean it but that he (Resident # 1) would do it. She said the AP was screaming, upset and mad. She said the AP told her that she told Resident #1 that he better do it because she would not do it. She said the AP told her that she told Resident #1 that if he didn't clean the mess, then Resident #1 would not go out and smoke. She said the AP told Resident #1 that even if he went outside, he would not get a cigarette if he did not clean up the mess. She said even after Resident #1 cleaned the poop, there was still some on the toilet. She said she did not see Resident #1 cleaning but did see Resident #1 following the AP saying, I will clean it, I will clean it. She said the AP told her Resident #1 was cleaning the toilet. She said she did not see him personally cleaning the toilet She said the AP was mad and could tell because she was screaming at her. She said she was screaming so loud that everyone could hear. During an interview on 11/21/23 at 2:24 PM, the ADM stated once she was made aware of the incident, by LVN A she started educating staff on ANE. She said they educated staff on housekeeping and staff responsibilities regarding cleaning up body fluids. She said this incident was not covered in their QAPI meeting. She said this was not covered in their QAPI meeting because they had their meeting on 11/07 or 11/08 of November, and the incident occurred on the 13th. She said the QAPI meetings were on the 2nd Wednesday of the month. She said there was never a time that they deviated outside of the scheduled QAPI meetings. She said regarding the incident, she expected that the AP would have been removed from the facility immediately. She said it was abuse. She said it was a form of shaming and degrading Resident #1. She said when the AP threatened to withhold Resident #1's smoke break, this was a form of punishment. She said she was unaware that any of the nurses had reported the information to the DON. She said she was unaware that the DON was aware of the information until after LVN A wrote her statement. She said the AP worked the incident date from 6:00 AM to 6:00 PM. During an interview on 11/21/23 at 4:50 PM, the DON stated that she did not consider what the AP said verbal abuse because the AP did not tell the statement directly to Resident #1. She called and asked about the mess being cleaned but did not follow up with who cleaned it. During an interview on 11/22/23 at 12:00 PM, LVN A stated that on 11/13/23 she worked from 6 AM to 6 PM. She said Resident #1 had come to her and asked where his room was. She said she told Resident #1 where his room was. She said while giving LVN B a report that the AP found excrement on the toilet and the floor, she overheard the AP say she would make Resident #1 clean it. She told the AP she could not do that and would not make Resident #1 clean it. She said Resident #1 was seated at the nurse's station. She said she was not sure if he heard what was being said. She said he may not understand what was happening even if he did hear. She said Resident #1 was very forgetful and needed constant reminders. She said the incident occurred around 6:15 or 6:20 PM. After giving the report, she told LVN B she needed to leave because her shift was over. She said the AP had not made Resident #1 clean up the excrement before she left. She said after leaving work, she went to the DON's home and reported that the AP said she would make Resident #1 clean up her mess. She said the DON's initial response was, What? She repeated what she had told her. She said the DON stated, She cannot do that. She said that the DON told her she would call the facility. She said the DON had called to ask if the body fluids had been cleaned. She said she was unsure if LVN B knew who had cleaned it up at the time. The following day (11/14/23), LVN A said the Activity Director told her during a smoke break that Resident #1 had cleaned up the mess. LVN A said that she reported it to the DON again because anything could have happened. She said the DON at that time did not know that the AP had followed through with making Resident #1 clean up his mess. LVN A said she did not follow up the day before because she did not think she would do it. She said Resident #1 could have potentially consumed the chemical, the fumes could have made him sick, and he would not do well with cleaning because of his cognitive state. She said Resident #1 could have spilled the chemical on himself or even fallen. She said this could also be considered emotional abuse because being incontinent is embarrassing, and this entire incident could have embarrassed him and caused him to lose his dignity. She said even if a person was lower level cognitively, they should not be subject to abuse. She said she would not want this done to her loved one because it could hurt your feelings. She said the AP has a strong personality, and LVN B does not. She said this may have been why LVN B did nothing. During an interview on 11/22/23 at 01:13 PM, the AP stated that the excrement was left from the previous shift. She said the excrement was on the floor and the toilet. She said she had Resident #1 clean up the mess because she did not know she was not allowed to do so. She said she never received an in-service or training and could not have them cleaned. She said she thought it was okay because she was encouraging independence. She said she reported to housekeeping that they had to clean it up, and when housekeeping got upset, she went and retrieved a nurse. She said she (the AP) told Resident #1 that he would clean up his mess and was very capable of doing it. She said she helped him clean it up. She said she did not feel like what she did was abuse. She said no one ever told her that she could not do it. She said she was not told by LVN B, LVN A, or anyone that she could not do it. She said if she was doing wrong, she should have been told. She said she did tell him if he did not clean it up, then he could not smoke. She said she only told him this because he said no when she first told him he had to clean it up. She said she did not consider what she said a threat or a punishment at the time. She said this was okay because she had seen others tell other residents things like that. She said she had seen staff tell residents that if they did not get up, they would not get a food tray, so she thought this was okay. She said she had not done this with any other residents. Record review of the facility's video surveillance revealed the following occurred on 11/13/23 at 6:45 PM (The video surveillance did not have any sound): Observed Resident #1 walking by himself using a walker towards his room. The AP was walking quickly in front of him. She enters a room on the right, obtains a trash can and something unidentifiable in her left hand, and takes it in his room. She comes out. Resident #1 enters the room. The AP walked in and out of multiple rooms, talking with staff in the hallway. Resident #1 comes out of the room, the AP appears to say something, and Resident #1 returns to his room. After 2 minutes, Resident #1 came back out of the room. The AP exits another room and goes back into Resident #1 room, and Resident #1 goes back into the room. The AP returns to Resident #1's room and exits with the trash can. Resident #1 left his bedroom and walked down the hall. Record review of the AP employee file revealed the following: Termination Recommendation dated 11/14/23 based off of her having a resident clean his bathroom after soiling it. The termination recommendation revealed that she had a disciplinary on 04/15/23 for failure to complete assigned tasks and 04/25/23 for failure to report suspected abuse. All Staff Memo dated 04/18/23 stated that all calls to the DON and the ADM should be for emergency only. Community Orientation Checklist (undated) indicated the resident received the Resident abuse test. Abuse test dated 12/15/22 indicated that hitting a resident, refusing care and threatening a residents all constituted abuse. It also indicated that if a confused resident reports abuse that the staff has to report it. It indicated that any team member that is alleged to have abused was not allowed to work until the investigation is complete. The test stated allegations of abuse must be reported immediately. The test stated all allegations of abuse must be investigated. Record review of the facility policy, on Abuse (Revised 01/01/2023), revealed the following: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, involuntary Seclusion/Confinement, and or Misappropriation of property. Abuse isa willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, caretakers, friends, or other individuals. This includes physical, verbal, sexual, physical/chemical restraint. Procedure The administrator in or designee are responsible for maintaining all facility policies that prohibit abuse, neglect, and misappropriation of funds personal belongings, involuntary seclusion, or corporal punishment. Identification of possible problems that need investigation investigating all allegations reporting incidents, investigations, and facility response to results of investigation within mandated time frames. Protecting residents during investigation Reporting/Investigation: The law requires the abuse coordinator or designee or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statements summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate, and any staff who worked prior to and during the time of the incident. Interviews may include employees of various departments and ships. A thorough physical assessment will be conducted on residents involved in the allegation of abuse neglect. Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential causes. Protection: it is utmost important that the residents suspected of being abused, and all other residents must be protected during the initial identification, an investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Upon notification of the allegation, the abuse coordinator or designee will perform the following: identify the perpetrator that is identified by eyewitness or during the investigation and remove the perpetrator from further contact with the resident pending outcome of the investigation. Record review of the facility job description for Licensed Vocational Nurses (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct Resident Care and Support functions. Essential Functions Identifies problems and guides personnel to their solution Pursue more specific investigation as needed. Consistently follows established standards, policies, and procedures in providing nursing care Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Responds appropriately in urgent and/ or emergency situations. Record review of the facility job description for Housekeeper Supervisor (dated 11/2020) revealed the following: Position Summary Perform scheduled housekeeping tasks that may be assigned by the housekeeper supervisor. Incumbents may mop, sweep, dusts, wash window, shampoo and vacuum carpets, arrange furniture and generally clean furniture, equipment, fixtures and hardware. Essential Functions: Clean and sanitize residences and contents, including, but not limited to, vacuuming, dusting, cleaning kitchen and bath fixtures, turning mattresses, moving light furniture, emptying trash receptacles Record review of the facility job description for Certified Nurse Aide (dated 11/2020) revealed the following: Position Summary Responsible for assisting residents with activities of daily living to promote resident independence and dignity. Essential Functions: To assure resident safety Keep residents clean and dry, toileting or providing incontinent care. Others duties as assigned Record review of the facility job description for Director of Nursing (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct resident care and support functions. Essential Functions To assure resident safety Identifies problems and guides personnel to their solutions. Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Supports standards of nursing care through adherence to existence policies and procedures. Record review of the facility policy, Resident Rights (12/2016), revealed the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity Policy Interpretation and Implementation dignified existence Be treated with respect, kindness and dignity Be free from abuse, neglect, misappropriation of property, and exploitation; Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints Perform services for the facility if he chooses or refuses to perform services for the facility Record review of the AP's time sheet revealed that on 11/13/23 she worked from 6:00 PM until 11/14/23 6:07 AM. The ADM and the DON were notified on 11/21/23 at 4:50 PM and IJ situation was identified due to the above failures and the ID template was provided. The following Plan of Removal submitted by the facility was accepted on 11/22/23 at 01:50 PM: F600 Plan of Removal Any allegation of abuse/neglect will be investigated immediately by EDO/designee, and residents will be protected immediately. EDO/designee will review daily all incidents and accidents and grievances for potential allegations of abuse/neglect in the standup meeting, and will investigate immediately, and residents will be immediately protected. All incontinent residents have the potential to be affected by this alleged deficient practice. No other residents were identified to have been affected by this alleged deficient practice. Abuse/Neglect inservices for all staff in the community completed 11/22/2023 and ongoing. Alleged Perpetrator terminated 11/14/2023 following the incident that occurred 11/13/2023. DON has been suspended pending further investigation effective 11/21/2023. Ad hoc QAPI conducted 11/21/2023 to discuss IJ with Medical Director. LVN B suspended pending further investigation effective 11/21/2023. Resident #1 had a Psychiatric evaluation by the NP on 11/20/2023. No new orders or changes in treatment after this evaluation. A follow-up telehealth psychiatric assessment was completed 11/22/2023. No new orders or changes to plan of care recommended. Nursing staff to continue to monitor psychosocial needs q shift. Trauma assessment completed 11/21/2023. 11/21/2023 Regional Nurse Consultant provided training to DCO and ADCO on policy on abuse/neglect, reporting of suspected abuse/neglect, types of abuse including, but not limited to involuntary seclusion/punishment, verbal threats to residents. Abuse and neglect in-servicing was initiated on 11/21/2023 by the ADCO for all staff regarding reporting any suspected abuse/neglect to Abuse Coordinator immediately, 24 hours/day. Review of types of abuse including, but not limited to involuntary seclusion/punishment of residents. Staff inserviced on taking measures to intervene immediately to protect residents from inappropriate/suspicious behavior, abuse or potential abuse toward a resident. This training will be provided to all staff prior to the start of their next shift until all staff have had the training. Completion date 11/22/2023. This training will also be part of new staff orientation. Administrator was in-serviced on 11/21/23 by the RVP on policy and procedure for abuse/neglect and reporting parameters for abuse/neglect allegations, including immediate removal of AP from the facility to protect all residents. Safe surveys conducted with all alert and oriented residents to assess for abuse/neglect. 5 alert and interviewable residents will be interviewed weekly to assess for abuse/neglect x 4weeks, then weekly in Standards of Care Meeting. Administrator will review findings. Will evaluate findings in the monthly QAPI meeting until resolved. On 11/22/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 11/22/23 from 02:15 PM to 2:41 PM with (LVN D, E, Hospitality Aide F, and CNA G & H) revealed that they could identify all five types of abuse (mental, physical, emotional/mental, sexual, and financial). They all explained that they had been trained and understood that depriving a resident of things was unacceptable to get them to complete a task. They all could define their roles and responsibilities if they witness or suspect abuse. They could state that they would report any allegations, whether they believed it occurred or would occur to the Administrator Immediately. They all explained that it was important to protect the residents, including ensuring that the residents were not around any perpetrators and that the perpetrator was not putting other residents at risk. LVN D & E explained their role in ensuring they follow up with any abuse allegations, including reporting immediately to the ADM and removing any alleged perpetrators from the facility. Record review of 17 completed abuse and resident rights quizzes completed by multiple staff on various shifts between 11/21/23 &11/22/23 revealed the Resident rights quiz covered the Resident rights quiz covered the residents right to refuse treatments, care and or services. The abuse quiz discussed types of abuse to include threatening a resident and refusing care. It covered alleged perpetrators not being allowed to work with residents and that abuse needed to be reported immediately. Record review of the facility QAPI meeting signature sheet indicated that an ad hoc meeting occurred on 11/21/23. Record review of the facility Inservice dated 11/21/23 revealed the ADM being the facility's abuse coordinator and her contact number. The inservice explained that she can be reached at anytime and that abuse and neglect must be reported immediately. The inservices specified that if staff see or hear anything they must report what they have seen or heard immediately. The inservice specified that staff must report all allegation of abuse even if they feel it will not happen. The inservice specified that staff may not punish or threaten residents by isolating them or withholding their rights or their privileges. The abuse policy revised 01/01/23 was also attached. 22 staff member signatures were reviewed. The ADM was informed the Immediate Jeopardy was removed on 11/22/23 at 2:48 PM the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the current Administrator V and previous Administrator W failed to implement their policies and procedures, failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 4 of 13 residents (Resident #3, #4, #7 and #9) in that: · Administrator V and Administrator W failed to implement the Abuse/Neglect policies when they failed to investigate allegations of abuse when reported to them by the facility staff. · Administrator V failed to implement the Abuse/Neglect policies when he failed to protect Resident #4 and Resident #7 from ongoing sexual abuse by Residents #8 and #11. · Administrator V failed to implement the Abuse/Neglect policies when they failed to protect Resident ' s #3 and #9 from further abuse by CNA ' s G and I. Administrator V failed to remove CNA ' s G and I when allegations of abuse were brought to his attention regarding the 2 CNA ' s. · Administrator V failed to implement the Abuse/Neglect policies when they failed to investigate allegations of verbal and physical abuse toward Resident #3 and Resident #9 by Certified Nurse Aide (CNA) G and CNA I. · Administrator V failed to follow up on allegations regarding abuse and allegedly retaliated against staff for reporting abuse to him and the Department of Aging and Disability Services (DADS). An Immediate Jeopardy (IJ) was identified on 10/05/16. The IJ was removed on 10/10/16 but the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor its corrective action for effectiveness. The facility's failure to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical and psychosocial well-being could place 60 residents at risk for poor quality of life, neglect, abuse and mistreatment. Findings included: Record review of Resident #4's face sheet dated 09/24/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #4's MDS dated [DATE] indicated in part: · Speech clarity: No speech. · Cognitive skills for daily decision making = severely impaired - never/rarely made decisions. · Functional status: Transfer =total dependence, Locomotion on unit = total dependence, Dressing = total dependence, Eating = total dependence and Personal hygiene= total dependence. · Functional limitation in range of motion: Upper and lower extremities = impairment on both sides. During an interview on 09/27/16 at 2:00 p.m. Staff F said she observed an incident on or around 09/10/16 at about 5:00 p.m. involving CNA G and Resident #4. Staff F said she observed and heard CNA G stating, Look at Resident #4 raising her shirt and her tits are showing, and then they're going around saying they're molesting her. Staff F said she then observed CNA G hit Resident #4 on the wrist 3 times with an open hand. Staff F said she was standing approximately 20 feet away and the hits sounded loud. Staff F said she shook her head as CNA G looked at her. Staff F said CNA G then roughly pulled Resident #4's shirt down. Staff F said Resident #7 was sitting in the lobby and witnessed what happened. Staff F said Resident #7 pointed at CNA G and tried to tell her not to do that but could not express what she was trying to say. Staff F said at that time CNA G looked at Resident #7 and told her and what are you going to do, there you are sitting down all pissed and full of[***] well come on if you want to do something about it. Staff F said she did not report the incident right away because she did not know exactly what to report and was afraid of reporting it. Staff F said she felt horrible about it so, on 09/20/16, ten days after the observation, she told Staff D about it. Staff F said Staff D told her she needed to report what she observed. Staff F said she then reported it to Staff C, who then told Administrator V about it, at that time. Staff F said on 09/24/16 the Administrator approached her to get her statement. Staff F said the Administrator told her that CNA G was currently suspended for something else and was due to return back that day 09/24/16. Staff F said Administrator V told her that he would not allow CNA G to return back, but then she later saw CNA G working at the facility that day, 09/24/16. Staff F said when CNA G saw her CNA G told her I'm back. Staff F said she felt uncomfortable the way CNA G talked to her. Staff F said Housekeeper M was a witness to the incident as she was there when CNA G said what she did. During an interview on 09/27/16 at 3:22 p.m. Staff C said on 09/20/16 Staff F told her she had witnessed CNA G abuse Resident #4 about 3 weeks ago on 09/10/16 Staff C said she asked Staff F why she was just now reporting it. Staff C said Staff F told her she had not reported it because she was afraid of CNA G. Staff C said she went and told Administrator V right away after she found out about it. Staff C said when she told the Administrator he responded, That was 3 weeks ago? Staff C said the Administrator told her to tell Staff F to keep hush, hush about it and he would work on it. Staff C said on 09/23/16 the Administrator told her to write a statement regarding CNA G hitting Resident #4 but to indicate that she forgot to tell him earlier and to date it 09/23/16 instead of 09/20/16 when it actually happened. Review of Staff C's written statement dated 09/26/16 indicated, in part: · On Tuesday 09/20/16 Staff F told me she had witnessed CNA G hit Resident #4 three times and pulled her shirt down forcefully. I asked her when it happened and she said she saw it 3 weeks ago. I asked her why she didn't report it sooner. She said she was afraid to report it. She said that another witness, Resident #7 saw the situation. Resident #7 tried to get off the couch to stop CNA G from hitting Resident #4 but CNA G said, What are you gonna do you're full of[***]and piss. I told her I'm going to report it right now. I went inside and I knocked on the door to Administrator V's office. I told him we need to talk. I told him there was a report that CNA G was hitting Resident #4 three times. He asked, when was this and who told you. I said 3 weeks ago and Staff F told me. He said, Well tell her to hush hush. I asked him what he meant by that because this was serious and he stated I will take care of it. On Friday 09/23/16 administrator called the nursing home around 10:00 p.m. for all staff to remain in the building because he needed statements for a report of abuse on a resident. He arrived and started questioning all the CNA's one by one. When it was my turn he closed the door and told me that he needed a statement from me but not to put the date. He told me to say that I forgot to report it to him because I was overworked from working a triple shift on Thursday. He told me to write on the statement that I had reported it on Friday 09/23/16 when in actuality I had reported it on the Tuesday I found out, 09/20/16. He informed me that I would not get in trouble and that everything was going to be ok. On Saturday, 09/24/16 Staff F called me and informed me that CNA G was working. I called the administrator and asked why CNA G was working after he told me he would take care of it. I thought she would not be at work until after the investigation. He replied, I'm the boss here, I'm the administrator, do you want to be in charge? I said that I was aware of that but I'm worried about the residents. Record review of Staff C's statement dated 09/30/16 indicated in part: · On Wednesday 09/28/16 Administrator V said to me, if I find out it was one of my staff that called State I promise they'll be looking for another damn job. The RNC K (Regional Nurse Consultant) also has been asking everyone at the facility for information about me. During an interview on 09/29/16 at 10:39 a.m. Staff E said that on 09/20/16 Staff D came and told her that Staff F had told him that some weeks ago she had witnessed CNA G hit Resident #4. Staff E said she then went and reported this to Administrator V right away. Staff E said the Administrator stated, I told Staff F to keep it hush and that Staff C had already reported it to him. Staff E said the Administrator told her to keep it hush and to tell Staff D to keep it quiet because he wanted to work the investigation quietly. Staff E said she wrote the report on a grievance form and kept it with her. Staff E said recently the Administrator told her that he did not want her documenting anymore grievances and that he would be the only one writing the grievances from now on. During an interview on 09/29/16 at 11:17 a.m. Staff D said on 09/20/16 Staff F told him she had witnessed CNA G hit Resident #4 sometime ago. Staff D said he then went and told Staff E about it, who in return reported it to Administrator V. Staff D said after Staff E reported it to the Administrator she came back and told him that the Administrator told her to tell him to keep his mouth quiet about it. Staff D said he told Staff E on 09/20/16 around 4:00 p.m. Record review of Staff D's statement dated 09/29/16 indicated in part: · It's been approximately 3 or 4 months that I reported to Administrator V that Resident #8 was touching Resident #4's breasts. The Administrator said well they're adults and he did not investigate anything. Staff E was a witness because she interpreted to the administrator what I said. Also about 3 weeks ago, I again told the administrator that Resident #8 was molesting Resident #4. The administrator told me to tell CNA H; the administrator stayed sitting down and he did not even come check to see what was going on. I then told CNA H about it and then I don't know what happened after that since it was time for me to go home. (Note: this statement was written in Spanish and surveyor translated into English). During an interview on 09/29/16 at 3:14 p.m., CNA G said the incident with Resident #4 happened a long time ago. CNA G said she was getting Resident #4 from the lobby to take her to the dining room. CNA G said she remembered seeing Staff F standing there. CNA G said Resident #4 had her shirt tangled up in her arm exposing her breast. CNA G said she untangled her shirt and told the resident to not be picking up her shirt. CNA G said she never hit the resident nor told her that her tits were showing. CNA G said she remembered Resident #7 being close by but she never told her anything inappropriate. CNA G said Administrator V called her on the morning of 09/24/16 before she was scheduled to come in to work. CNA G said the Administrator told her he was working on an investigation that had occurred three weeks ago regarding Resident #4. CNA G said the Administrator told her he would call her later to see if she could return to work. CNA G said the Administrator called her later that same day at 12:30 pm and said it was ok for her to come to work. CNA G said the Administrator had asked her if she had hit Resident #4 to which she answered no. CNA G said when she came to work on 09/24/16 she saw Staff F but she did not say anything to her. (Note: At the time of this interview CNA G was currently still employed at the facility but was later terminated by the facility during this investigation). During an interview on 09/27/16 at 4:35 p.m. Administrator V said he had not called the State regarding the allegation that CNA G physically abused Resident #4 because there was no corroboration evidence found that it had occurred. The Administrator said that he had discussed his findings with the Regional Director of Operations (RDO) and they both agreed there was no need to do a self-report. The Administrator said CNA G was currently suspended for a different allegation when this new allegation came up and saw no need to reinvestigate CNA G since he had already investigated her. Review of the Customer Service Intakes on 10/25/16 revealed Administrator V reported this allegation to DADS on 9/27/16 at 9:41 p.m. Record review of the facility's PIR (Provider Investigation Report) related to Resident #4's alleged abuse by CNA G dated 09/29/16 indicated in part: · After completion of resident interviews, I spoke with my RDO about the findings and the fact that there was no corroborating evidence. Advised to close investigation, document findings and create an investigation file and that there was nothing to report. · Provider action taken post-investigation. After all interviews completed, Administrator V spoke with Regional Director about the investigation and the findings. RDO agreed with Administrator that there was no corroborating evidence. Advised to close investigation, document findings and agreed to bring CNA G back to work on her next scheduled shift, which was that day. · Signed and dated by Administrator V on 09/29/16. During an interview on 10/11/16 at 4:10 p.m. the RDO said he had not clearly told Administrator V to not report it or otherwise. The RDO said the Administrator should have reported it to the State. RESIDENT #3 and #9 Record review of Resident #3's face sheet dated 09/19/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5. (5 severe impairment). · Transfer = limited assistance - 2 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. Record review of Resident #9's face sheet dated 09/27/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #9's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5. (5 severe impairment). · Transfer = extensive assistance - 1 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. Review of Staff C's written statement dated 09/26/16 indicated, in part: · On Wednesday 09/21/16 Resident #9 began to cry so I asked her what was wrong, she answered that CNA G and CNA I were mistreating her daughter (Resident #3). I asked her how and she responded they were throwing her on the bed. Her exact words were I know I cannot see but I can hear my daughter telling them not to throw her in the bed that way. Resident #9 also stated that she could hear CNA G and CNA I cursing at her daughter. They would roll her out of the room so she would not hear them but she could still hear them from the hallway. Resident #9 said they don't have any [MEDICATION NAME] for us. After Resident #9 told me this I went to Administrator V's office and reported the situation. He stated that it was already taken care of. During an interview on 09/27/16 at 3:22 p.m. Staff C said on 09/21/16 she was assisting Resident #9 when the resident started to cry. Staff C said she asked the resident what was wrong and she told her that CNA G and CNA I were mean to her and would take her out of her room so she could not hear them being ugly to her daughter and roommate, Resident #3. Staff C said Resident #9 told her she could hear CNA G and CNA I throwing her daughter, Resident #3 on her bed because she could hear her daughter telling the CNA's not to throw her on the bed. Staff C said Resident #9 said she could hear the same CNA's cursing at Resident #3 as well. Staff C said she reported this to Administrator V on 09/21/16 and he told her he had already taken care of it because the 2 CNA's were currently suspended. (Note: CNA G and CNA I were currently suspended but for a different reason). Staff C said she was afraid of reporting this because she was afraid of losing her job and believed the Administrator would see to it that she lost her job. During an interview on 09/30/16 at 9:27 a.m. Resident #3 said CNA G and CNA I had thrown her in her bed from her wheelchair. Resident #3 said CNA I would talk ugly to her when she would change her brief and say things like look at all that[***] you're full of[***] and that would make her feel bad (embarrassed). Resident #3 said CNA G would also be mean to her and that she did not feel comfortable when CNA G and CNA I provided care for her and her mother, Resident #9. During an interview on 09/30/16 at 9:39 a.m. Resident #9 said she heard CNA G and CNA I telling her daughter Resident #3 that she had a rash and had crap on her bottom in a rude way. Resident #9 said she was blind but could hear very well and that it made her feel very bad when CNA G and CNA I would talk ugly to her daughter, Resident #3 because she could not help herself. Resident #9 became emotional and started to cry as she recalled the events. Resident #9 said CNA G and CNA I would place her in the hall on purpose so she could not hear them being verbally abusive to her daughter Resident #3. During an interview on 10/03/16 at 9:57 a.m. Staff O said Staff N told him that Resident #3 told her that CNA G and CNA I had been abusive to her on 09/18/16 at 7pm. Staff O said he reported it to Administrator V and the Administrator told him that it had already being taken care of. Staff O said he told Staff N that he had reported it to the Administrator and it was up to her to leave it at that or report it to the State if she felt she needed to. Staff O said the next day Staff P came and told him that Staff N had a phone call from Department of Aging and Disability Services (DADS). Staff O said within the minute the Administrator came down the hall and told him, What the hell is this about Staff N filing a self-report? During an interview on 09/29/16 at 12:00 p.m. Staff N said on 09/18/16 Resident #3 told her that CNA G and CNA I threw her in bed and placed her wheelchair in the hall so she could not have access to it. Staff N said Resident #3 told her that the same CNA's would take her mother, Resident #9 and place her in another room so she could not hear what they were doing to her. Staff N said she reported this to Staff O who in return reported it to Administrator V. Staff N said she also called in the complaint to the State hotline. Staff N said she called it in because she had heard the Administrator was known for not following up on complaints brought to his attention. Staff N said later the Administrator came and asked her if she had called in a complaint to the State. Staff N said she told him that she had and that he became upset about it and told her my license is on the line and that I had blind-sided him. Staff N said the Administrator appeared to be upset and was trying to intimidate her for calling in the complaint to the State. Staff N said she had never called in a complaint to the State before and had left the facility's phone number as a call back and that was probably how the Administrator found out she had called the State. During an interview on 09/29/16 at 4:08 p.m. CNA I said on 09/18/16 she and CNA G assisted Resident #3 to her bed. CNA I said when they put her to bed the resident became upset and started cursing at them because she did not want to go to bed. CNA I said the resident was full of stool so they cleaned her up. CNA I said she had never been abusive to Resident #3 or her mother, Resident #9. CNA I said her voice was kind of loud which the residents might interpret as being mean. During an interview on 09/29/16 at 3:14 p.m. CNA G said she had never rough-handled or verbally abused any of the residents at the facility. CNA G said she had never cursed or rough-handled Resident #3 or Resident #9. CNA G denied that she nor CNA I wheeled Resident #9 out of her room on purpose while they provided care for her daughter, Resident #3. Review of the Customer Service Intakes on 10/25/16 revealed the facility reported this allegation to DADS on 10/06/16 at 3:58 p.m. SEXUAL ABUSE RESIDENT #4 During a telephone interview on 10/03/16 at 10:43 a.m. Licensed Vocational Nurse (LVN) B said when Staff A reported to her that Resident #8 was messing (inappropriately touching) with Resident #4. LVN B said she told Staff A to write a statement and they both signed it. LVN B said she did not remember if she or Staff A posted the statement on Administrator V's door. LVN B said the Administrator never came and talked to her about the statement. LVN B said she did not document the allegation anywhere as she did not know she was supposed to. Record review of Resident #8's face sheet dated 09/30/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #8's care plan dated 08/17/15 indicated in part; · Goal: Will have no evidence of behavior problems by review date. · Approach: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. · Approach: Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Record review of Resident #8's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 14. (14 indicates cognitively intact). · Functional limitation in range of motion: upper extremity and lower extremity = no impairment. · Mobility devices: Wheelchair. During an interview on 09/29/16 at 11:17 a.m. Staff D said some time ago he told Staff E to tell Administrator V that he had witnessed Resident #8 touching Resident #4's breasts. Staff D said he accompanied Staff E to the Administrator's office to report this. Staff D said when Staff E told the Administrator what he had witnessed, the Administrator said that Resident's #8 and #4 were both adults. Staff D said Staff E told the Administrator that Resident #4 could not consent to that but the Administrator just blew her off. Staff D said about 15 days later he again witnessed Resident #8 touching Resident #4 in her private parts. Staff D said he went right away to the Administrator's office and told him about it. Staff D said the Administrator told him to go tell CNA H about it. Staff D said he went and told CNA H about it and she came and told Resident #8 to get away from Resident #4. Staff D said the Administrator never intervened when he reported the allegations nor investigated it as far as he knew. During an interview on 09/30/16 at 3:09 p.m. CNA H said about 2 or 3 weeks ago Staff D came and told her that Resident #8 was touching Resident #4 in appropriately. CNA H said she went and moved Resident #8 away from Resident #4 and told him to get away from her. CNA H said Resident #8 told her he was not doing anything wrong to Resident #4. During an interview on 10/05/16 at 11:30 a.m. Resident #8 said that a few months ago he was sitting in the lobby by Resident #4. Resident #8 said Resident #4 grabbed his beard and pulled him towards her. Resident #8 said when he tried to push himself away he unintentionally grabbed her breasts. Resident #8 said that Administrator V had talked to him and told him that could be perceived as sexual harassment and to get away from Resident #4. Resident #8 denied he ever touched Resident #4 inappropriately on purpose and that he would go and sit by her to talk to her about God. During an interview on 10/03/16 at 9:18 a.m. Staff A said on Sunday 08/21/16 she witnessed Resident #8 touching Resident #4's breasts in the lobby. Staff A said she told Resident #8 to get away from Resident #4 and not be doing that. Staff A said Resident #8 denied doing anything wrong, became upset and went outside. Staff A said she reported it to LVN B and then wrote a statement. Staff A said she and LVN B signed the statement and posted it on Administrator V's door. Staff A said on Monday morning she noticed the statement was still on the Administrator's door and then shortly after the Administrator arrived the statement was no longer there. Staff A said the Administrator never called her to talk to her regarding her statement nor did she go ask him if he had any questions regarding her statement. Staff A said she did not make a copy of the statement and felt bad for not following up since the rumors continued that Resident #8 was fondling Resident #4. Record review of Staff A's statement dated 10/03/16 indicated in part: · I, staff A saw Resident #8 on 08/21/16 with Resident #4 and I saw him rubbing her breast at 11:30 a.m. and I told him to get away from her. I told LVN B and she said to write a statement so I did and signed it and the nurse signed it also and I taped it on the door of the administrator V. During an interview on 09/29/16 at 4:40 p.m. Administrator V said he recalled Staff D telling him that Resident #4 had her shirt up and that Resident #8 was in the area. The Administrator said he told Resident #8 to move from there. The Administrator said he never saw Resident #8 touching Resident #4 inappropriately. The Administrator said he was never told Resident #8 had touched Resident #4's private parts. The Administrator said he never said Resident #8 touching Resident #4 was consensual. The Administrator said he did not know why staff were saying all these allegations about him not doing anything when supposedly they complained to him about abuse. Review of the Customer Service Intakes on 10/25/16 revealed the facility reported this allegation to DADS on 10/10/16 at 5:07 p.m. During an interview on 10/11/16 at 9:44 a.m. Staff E said sometime last year around November 2015, Staff D told her that he had witnessed Resident #8 touching Resident #4's breasts. Staff E said Staff D told her that he told Resident #8 to stop doing that and he became hostile with him. Staff E said she accompanied Staff D into Administrator W's office to translate for him. Staff E said the Administrator told them she would talk to Resident #8 and that was it. Staff E said the next day during the stand-up meeting the Administrator said she spoke to Resident #8 and his mom, and that if it occurred again she would discharge Resident #8. Record review of Staff E's statement dated 09/29/16 indicated in part: · Around 3 to 4 months ago Staff D came to my office reporting Resident #8 was touching Resident #4's breasts. Staff D told Resident #8 to stop and Resident #8 started arguing with Staff D. We went to Administrator V ' s office and I interpreted for Staff D. Administrator said maybe it was consensual but he would look into it. During an interview on 10/11/16 at 9:58 a.m. Staff U said sometime in November 2015, Staff D reported to her that Resident #8 was touching Resident #4's breasts. Staff U said she reported it to Administrator W and that Administrator W told her she would address it. Staff U said a couple of days later she witnessed Resident #8 and his mom going into the Administrator's office. Staff U said the Administrator later said she had talked to Resident #8 and his mom and that Resident #8 had denied the allegations. During a telephone interview on 10/10/16 at 4:25 p.m. Administrator W said her last day working at the facility was in mid February 2016. Administrator W said she recalled Resident #8 because she was the one who helped the resident get admitted to the facility from the community. The Administrator said she believed Resident #8 liked Resident #4 but not in an inappropriate way. The Administrator said no one ever reported any allegations to her regarding Resident #8 being inappropriate towards Resident #4. Record review of Resident #11's face sheet dated 10/11/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #11's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 3. (3 indicates severe impairment). · Functional limitation in range of motion: upper extremity and lower extremity = no impairment. · Mobility devices: Cane. During an interview on 10/05/16 at 9:09 a.m. Staff C said approximately one month ago she witnessed Resident #11 grabbing Resident #4's breast. Staff C said she told Resident #11 to get away from her and that Resident #4 was trying to scratch Resident #11 to get him away from her. Staff C said she went and told Administrator V about it and the Administrator said, She probably likes it. Staff C said as far as she knew the Administrator never did anything about it. During an interview on 10/05/16 at 10:22 a.m. Administrator V said no one ever reported to him that Resident #11 had grabbed Resident #4's breast. When asked if he ever stated that She probably likes it referring to Resident #11 touching Resident #4, the Administrator said, That's BS, I would never say that. The Administrator said he never saw a note posted on his door indicating Resident #8 had touched Resident #4's breasts. The Administrator said he had never retaliated against staff for reporting abuse. During an interview on 10/10/16 at 9:15 a.m. Resident #11 said he had never been inappropriate with any of the resident's at the facility. Resident #11 said it was all gossip. Record review of Resident #13's face sheet dated 10/11/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #13's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 11. (11 indicates moderately impaired). During an interview on 10/07/16 at 3:30 p.m. Resident #13 said he had observed Resident #8 kissing Resident #4 in the lobby. Resident #13 said he reported it to Administrator V and the Administrator told him that he knew about it and that was all he said. RESIDENT #7 Record review of Resident #7's face sheet dated 09/30/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #7's MDS dated [DATE] indicated in part: · Speech clarity: Unclear speech - slurred or mumbled words. · Cognitive skills for daily decision making = severely impaired - never/rarely made decisions. · Bed mobility = total dependence and 2 person physical assist. · Dressing = total dependence and 2 person physical assist. · Upper and lower extremities = no impairment. · Balance during transitions and walking: Walking - not steady but able to stabilize without staff assistance. During an interview on 10/11/16 at 10:20 a.m. Staff D said on two occasions he witnessed Resident #8 inappropriately touch the residents in the month of November 2015. Staff D said on the first observation, he witnessed Resident #8 touch Resident #4's breast. Staff D said the second time he witnessed Resident #8 he was in Resident #7's room and he could see them because the door was open. Staff D said Resident #7 was in her bed and she had her pants and panties pulled down and Resident #8 was touching her private parts. Staff D said he reported both observations to Administrator W who just stated, I'll take care of it. Staff D said he did not believe the Administrator did anything because Resident #8 continued to fondle the residents. During an interview on 09/30/16 at 9:15 a.m. the surveyor asked Resident #7 if she ha

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for 3 of 13 residents (Residents #3, #4 and #7) reviewed for abuse or neglect. The facility failed in that: · Resident #3 was verbally and physically abused by Certified Nurse Aide (CNA) G and CNA I. The administrator did not thoroughly investigate or report the allegation, or protect residents from further potential abuse. · Resident #4 was verbally and physically abused by CNA G. CNA G hit Resident #4 on her wrist and told her to stop showing her breasts. The administrator did not thoroughly investigate or report the allegation, or protect residents from further potential abuse. · Resident #4 was inappropriately touched by Resident # 11 on one occasion and touched inappropriately on several occasions by Resident #8. The administrator did not thoroughly investigate or report the allegation, or protect residents from further potential abuse. · Resident #7 was verbally abused by CNA G and was inappropriately touched by Resident #8. The administrator did not thoroughly investigate or report the allegation, or protect residents from further potential abuse. An Immediate Jeopardy (IJ) was identified on 10/05/16. The IJ was removed on 10/10/16 but the facility remained out of compliance at pattern of actual harm due to the facility's need to monitor its corrective action for effectiveness. This deficient practice placed 60 residents at risk for verbal, physical and sexual abuse due to the facility not thoroughly investigating allegations of abuse immediately and reporting to the State as required. Findings include: Review of the facility's February 2014 policy and procedure on Abuse Investigations documented, in part: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 1. Should an incident of suspected resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee will appoint a member of management to investigate the alleged incident. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The individual conducting the investigation will, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident); h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up the alleged incident. Record review of the facility's policy and procedure abuse prevention program dated 08/2006 indicated in part: · Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. · Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Record review of Resident #4's face sheet dated 09/24/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #4's Minimal Data Set ((MDS) dated [DATE] indicated in part: · Speech clarity: No speech. · Cognitive skills for daily decision making = severely impaired - never/rarely made decisions. · Functional status: Transfer =total dependence, Locomotion on unit = total dependence, Dressing = total dependence, Eating = total dependence and Personal hygiene= total dependence. · Functional limitation in range of motion: Upper and lower extremities = impairment on both sides. During an interview on 09/27/16 at 2:00 p.m. Staff F said she observed an incident on or around 09/10/16 at about 5:00 p.m. involving CNA G and Resident #4. Staff F said she observed and heard CNA G stating, Look at Resident #4 raising her shirt and her tits are showing, and then they're going around saying they're molesting her. Staff F said she then observed CNA G hit Resident #4 on the wrist 3 times with an open hand. Staff F said she was standing approximately 20 feet away and the hits sounded loud. Staff F said she shook her head as CNA G looked at her. Staff F said CNA G then roughly pulled Resident #4's shirt down. Staff F said Resident #7 was sitting in the lobby and witnessed what happened. Staff F said Resident #7 pointed at CNA G and tried to tell her not to do that but could not express what she was trying to say. Staff F said at that time CNA G looked at Resident #7 and told her and what are you going to do, there you are sitting down all pissed and full of[***] well come on if you want to do something about it. Staff F said she did not report the incident right away because she did not know exactly what to report and was afraid of reporting it. Staff F said she felt horrible about it so, on 09/20/16, ten days after the observation, she told Staff D about it. Staff F said Staff D told her she needed to report what she observed. Staff F said she then reported it to Staff C, who then told Administrator V about it, at that time. Staff F said on 09/24/16 Administrator V approached her to get her statement. Staff F said Administrator V told her that CNA G was currently suspended for something else and was due to return back that day 09/24/16. Staff F said Administrator V told her that he would not allow CNA G to return back, but then she later saw CNA G working at the facility that day, 09/24/16. Staff F said when CNA G saw her CNA G told her I'm back. Staff F said she felt uncomfortable the way CNA G talked to her. Staff F said Housekeeper M was a witness to the incident as she was there when CNA G said what she did. During an interview on 09/27/16 at 3:22 p.m. Staff C said on 09/20/16 Staff F told her she had witnessed CNA G abuse Resident #4 about 3 weeks ago on 09/10/16 Staff C said she asked Staff F why she was just now reporting it. Staff C said Staff F told her she had not reported it because she was afraid of CNA G. Staff C said she went and told Administrator V right away after she found out about it. Staff C said when she told the Administrator he responded, That was 3 weeks ago? Staff C said Administrator V told her to tell Staff F to keep hush, hush about it and he would work on it. Staff C said on 09/23/16 Administrator V told her to write a statement regarding CNA G hitting Resident #4 but to indicate that she forgot to tell him earlier and to date it 09/23/16 instead of 09/20/16 when it actually happened. Review of Staff C's written statement dated 09/26/16 indicated, in part: · On Tuesday 09/20/16 Staff F told me she had witnessed CNA G hit Resident #4 three times and pulled her shirt down forcefully. I asked her when it happened and she said she saw it 3 weeks ago. I asked her why she didn't report it sooner. She said she was afraid to report it. She said that another witness, Resident #7 saw the situation. Resident #7 tried to get off the couch to stop CNA G from hitting Resident #4 but CNA G said, What are you gonna do you're full of[***]and piss. I told her I'm going to report it right now. I went inside and I knocked on the door to administrator's V office. I told him we need to talk. I told him there was a report that CNA G was hitting Resident #4 three times. He asked, when was this and who told you. I said 3 weeks ago and Staff F told me. He said, Well tell her to hush hush. I asked him what he meant by that because this was serious and he stated I will take care of it. On Friday 09/23/16 administrator V called the nursing home around 10:00 p.m. for all staff to remain in the building because he needed statements for a report of abuse on a resident. He arrived and started questioning all the CNA's one by one. When it was my turn he closed the door and told me that he needed a statement from me but not to put the date. He told me to say that I forgot to report it to him because I was overworked from working a triple shift on Thursday. He told me to write on the statement that I had reported it on Friday 09/23/16 when in actuality I had reported it on the Tuesday I found out, 09/20/16. He informed me that I would not get in trouble and that everything was going to be ok. On Saturday, 09/24/16 Staff F called me and informed me that CNA G was working. I called administrator V and asked why CNA G was working after he told me he would take care of it. I thought she would not be at work until after the investigation. He replied, I'm the boss here, I'm the administrator, do you want to be in charge? I said that I was aware of that but I'm worried about the residents. Record review of Staff C's statement dated 09/30/16 indicated in part: · On Wednesday 09/28/16 administrator V said to me, if I find out it was one of my staff that called State I promise they'll be looking for another damn job. The RNC K (Regional Nurse Consultant) also has been asking everyone at the facility for information about me. During an interview on 09/29/16 at 10:39 a.m. Staff E said that on 09/20/16 Staff D came and told her that Staff F had told him that some weeks ago she had witnessed CNA G hit Resident #4. Staff E said she then went and reported this to Administrator V right away. Staff E said Administrator V stated, I told Staff F to keep it hush and that Staff C had already reported it to him. Staff E said Administrator V told her to keep it hush and to tell Staff D to keep it quiet because he wanted to work the investigation quietly. Staff E said she wrote the report on a grievance form and kept it with her. Staff E said recently Administrator V told her that he did not want her documenting anymore grievances and that he would be the only one writing the grievances from now on. During an interview on 09/29/16 at 11:17 a.m. Staff D said on 09/20/16 Staff F told him she had witnessed CNA G hit Resident #4 sometime ago. Staff D said he then went and told Staff E about it, who in return reported it to Administrator V. Staff D said after Staff E reported it to Administrator V she came back and told him that Administrator V told her to tell him to keep his mouth quiet about it. Staff D said he told Staff E on 09/20/16 around 4:00 p.m. Record review of Staff D's statement dated 09/29/16 indicated in part: · It's been approximately 3 or 4 months that I reported to administrator V that Resident #8 was touching Resident #4's breasts. The Administrator said well they're adults and he did not investigate anything. Staff E was a witness because she interpreted to the administrator what I said. Also about 3 weeks ago, I again told the administrator that Resident #8 was molesting Resident #4. The administrator told me to tell CNA H; the administrator stayed sitting down and he did not even come check to see what was going on. I then told CNA H about it and then I don't know what happened after that since it was time for me to go home. (Note: this statement was written in Spanish and surveyor translated into English). During an interview on 09/29/16 at 3:14 p.m., CNA G said the incident with Resident #4 happened a long time ago. CNA G said she was getting Resident #4 from the lobby to take her to the dining room. CNA G said she remembered seeing Staff F standing there. CNA G said Resident #4 had her shirt tangled up in her arm exposing her breast. CNA G said she untangled her shirt and told the resident to not be picking up her shirt. CNA G said she never hit the resident nor told her that her tits were showing. CNA G said she remembered Resident #7 being close by but she never told her anything inappropriate. CNA G said Administrator V called her on the morning of 09/24/16 before she was scheduled to come in to work. CNA G said Administrator V told her he was working on an investigation that had occurred three weeks ago regarding Resident #4. CNA G said Administrator V told her he would call her later to see if she could return to work. CNA G said Administrator V called her later that same day at 12:30 pm and said it was ok for her to come to work. CNA G said Administrator V had asked her if she had hit Resident #4 to which she answered no. CNA G said when she came to work on 09/24/16 she saw Staff F but she did not say anything to her. (Note: At the time of this interview CNA G was currently still employed at the facility but was later terminated by the facility during this investigation). During an interview on 09/27/16 at 4:35 p.m. Administrator V said he had not called the State regarding the allegation that CNA G physically abused Resident #4 because there was no corroboration evidence found that it had occurred. Administrator V said that he had discussed his findings with the Regional Director of Operations (RDO) and they both agreed there was no need to do a self-report. Administrator V said CNA G was currently suspended for a different allegation when this new allegation came up and saw no need to reinvestigate CNA G since he had already investigated her. Review of the Customer Service Intakes on 10/25/16 revealed Administrator V reported this allegation to DADS on 9/27/16 at 9:41 p.m. Record review of the facility's PIR (Provider Investigation Report) related to Resident #4's alleged abuse by CNA G dated 09/29/16 indicated in part: · After completion of resident interviews, I spoke with my RDO about the findings and the fact that there was no corroborating evidence. Advised to close investigation, document findings and create an investigation file and that there was nothing to report. · Provider action taken post-investigation. After all interviews completed, Administrator V spoke with Regional Director about the investigation and the findings. RDO agreed with Administrator that there was no corroborating evidence. Advised to close investigation, document findings and agreed to bring CNA G back to work on her next scheduled shift, which was that day. · Signed and dated by Administrator V on 09/29/16. During an interview on 10/11/16 at 4:10 p.m. the RDO said he had not clearly told Administrator V to not report it or otherwise. The RDO said the Administrator should have reported it to the State. RESIDENT #3 and #9 Record review of Resident #3's face sheet dated 09/19/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5. (5 severe impairment). · Transfer = limited assistance - 2 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. Record review of Resident #9's face sheet dated 09/27/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #9's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5. (5 severe impairment). · Transfer = extensive assistance - 1 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. Review of Staff C's written statement dated 09/26/16 indicated, in part: · On Wednesday 09/21/16 Resident #9 began to cry so I asked her what was wrong, she answered that CNA G and CNA I were mistreating her daughter (Resident #3). I asked her how and she responded they were throwing her on the bed. Her exact words were I know I cannot see but I can hear my daughter telling them not to throw her in the bed that way. Resident #9 also stated that she could hear CNA G and CNA I cursing at her daughter. They would roll her out of the room so she would not hear them but she could still hear them from the hallway. Resident #9 said they don't have any [MEDICATION NAME] for us. After Resident #9 told me this I went to administrator V's office and reported the situation. He stated that it was already taken care of. During an interview on 09/27/16 at 3:22 p.m. Staff C said on 09/21/16 she was assisting Resident #9 when the resident started to cry. Staff C said she asked the resident what was wrong and she told her that CNA G and CNA I were mean to her and would take her out of her room so she could not hear them being ugly to her daughter and roommate, Resident #3. Staff C said Resident #9 told her she could hear CNA G and CNA I throwing her daughter, Resident #3 on her bed because she could hear her daughter telling the CNA's not to throw her on the bed. Staff C said Resident #9 said she could hear the same CNA's cursing at Resident #3 as well. Staff C said she reported this to Administrator V on 09/21/16 and he told her he had already taken care of it because the 2 CNA's were currently suspended. (Note: CNA G and CNA I were currently suspended but for a different reason). Staff C said she was afraid of reporting this because she was afraid of losing her job and believed Administrator V would see to it that she lost her job. During an interview on 09/30/16 at 9:27 a.m. Resident #3 said CNA G and CNA I had thrown her in her bed from her wheelchair. Resident #3 said CNA I would talk ugly to her when she would change her brief and say things like look at all that[***] you're full of[***] and that would make her feel bad (embarrassed). Resident #3 said CNA G would also be mean to her and that she did not feel comfortable when CNA G and CNA I provided care for her and her mother, Resident #9. During an interview on 09/30/16 at 9:39 a.m. Resident #9 said she heard CNA G and CNA I telling her daughter Resident #3 that she had a rash and had crap on her bottom in a rude way. Resident #9 said she was blind but could hear very well and that it made her feel very bad when CNA G and CNA I would talk ugly to her daughter, Resident #3 because she could not help herself. Resident #9 became emotional and started to cry as she recalled the events. Resident #9 said CNA G and CNA I would place her in the hall on purpose so she could not hear them being verbally abusive to her daughter Resident #3. During an interview on 10/03/16 at 9:57 a.m. Staff O said Staff N told him that Resident #3 told her that CNA G and CNA I had been abusive to her on 09/18/16 at 7pm. Staff O said he reported it to Administrator V and the Administrator told him that it had already being taken care of. Staff O said he told Staff N that he had reported it to Administrator V and it was up to her to leave it at that or report it to the State if she felt she needed to. Staff O said the next day Staff P came and told him that Staff N had a phone call from Department of Aging and Disability Services (DADS). Staff O said within the minute Administrator V came down the hall and told him, What the hell is this about Staff N filing a self-report? During an interview on 09/29/16 at 12:00 p.m. Staff N said on 09/18/16 Resident #3 told her that CNA G and CNA I threw her in bed and placed her wheelchair in the hall so she could not have access to it. Staff N said Resident #3 told her that the same CNA's would take her mother, Resident #9 and place her in another room so she could not hear what they were doing to her. Staff N said she reported this to Staff O who in return reported it to Administrator V. Staff N said she also called in the complaint to the State hotline. Staff N said she called it in because she had heard Administrator V was known for not following up on complaints brought to his attention. Staff N said later Administrator V came and asked her if she had called in a complaint to the State. Staff N said she told him that she had and that he became upset about it and told her my license is on the line and that I had blind-sided him. Staff N said Administrator V appeared to be upset and was trying to intimidate her for calling in the complaint to the State. Staff N said she had never called in a complaint to the State before and had left the facility's phone number as a call back and that was probably how the Administrator found out she had called the State. During an interview on 09/29/16 at 4:08 p.m. CNA I said on 09/18/16 she and CNA G assisted Resident #3 to her bed. CNA I said when they put her to bed the resident became upset and started cursing at them because she did not want to go to bed. CNA I said the resident was full of stool so they cleaned her up. CNA I said she had never been abusive to Resident #3 or her mother, Resident #9. CNA I said her voice was kind of loud which the residents might interpret as being mean. During an interview on 09/29/16 at 3:14 p.m. CNA G said she had never rough-handled or verbally abused any of the residents at the facility. CNA G said she had never cursed or rough-handled Resident #3 or Resident #9. CNA G denied that she nor CNA I wheeled Resident #9 out of her room on purpose while they provided care for her daughter, Resident #3. Review of the Customer Service Intakes on 10/25/16 revealed the facility reported this allegation to DADS on 10/06/16 at 3:58 p.m. SEXUAL ABUSE RESIDENT #4 During a telephone interview on 10/03/16 at 10:43 a.m. Licensed Vocational Nurse (LVN) B said when Staff A reported to her that Resident #8 was messing (inappropriately touching) with Resident #4. LVN B said she told Staff A to write a statement and they both signed it. LVN B said she did not remember if she or Staff A posted the statement on Administrator V's door. LVN B said the Administrator never came and talked to her about the statement. LVN B said she did not document the allegation anywhere as she did not know she was supposed to. Record review of Resident #8's face sheet dated 09/30/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #8's care plan dated 08/17/15 indicated in part; · Goal: Will have no evidence of behavior problems by review date. · Approach: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. · Approach: Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Record review of Resident #8's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 14. (14 indicates cognitively intact). · Functional limitation in range of motion: upper extremity and lower extremity = no impairment. · Mobility devices: Wheelchair. During an interview on 09/29/16 at 11:17 a.m. Staff D said some time ago he told Staff E to tell Administrator V that he had witnessed Resident #8 touching Resident #4's breasts. Staff D said he accompanied Staff E to Administrator V's office to report this. Staff D said when Staff E told the Administrator what he had witnessed, the Administrator said that Resident's #8 and #4 were both adults. Staff D said Staff E told the Administrator that Resident #4 could not consent to that but the Administrator just blew her off. Staff D said about 15 days later he again witnessed Resident #8 touching Resident #4 in her private parts. Staff D said he went right away to the Administrator's office and told him about it. Staff D said the Administrator told him to go tell CNA H about it. Staff D said he went and told CNA H about it and she came and told Resident #8 to get away from Resident #4. Staff D said the Administrator never intervened when he reported the allegations nor investigated it as far as he knew. During an interview on 09/30/16 at 3:09 p.m. CNA H said about 2 or 3 weeks ago Staff D came and told her that Resident #8 was touching Resident #4 in appropriately. CNA H said she went and moved Resident #8 away from Resident #4 and told him to get away from her. CNA H said Resident #8 told her he was not doing anything wrong to Resident #4. During an interview on 10/05/16 at 11:30 a.m. Resident #8 said that a few months ago he was sitting in the lobby by Resident #4. Resident #8 said Resident #4 grabbed his beard and pulled him towards her. Resident #8 said when he tried to push himself away he unintentionally grabbed her breasts. Resident #8 said that Administrator V had talked to him and told him that could be perceived as sexual harassment and to get away from Resident #4. Resident #8 denied he ever touched Resident #4 inappropriately on purpose and that he would go and sit by her to talk to her about God. During an interview on 10/03/16 at 9:18 a.m. Staff A said on Sunday 08/21/16 she witnessed Resident #8 touching Resident #4's breasts in the lobby. Staff A said she told Resident #8 to get away from Resident #4 and not be doing that. Staff A said Resident #8 denied doing anything wrong, became upset and went outside. Staff A said she reported it to LVN B and then wrote a statement. Staff A said she and LVN B signed the statement and posted it on Administrator V's door. Staff A said on Monday morning she noticed the statement was still on the Administrator's door and then shortly after the Administrator arrived the statement was no longer there. Staff A said Administrator V never called her to talk to her regarding her statement nor did she go ask him if he had any questions regarding her statement. Staff A said she did not make a copy of the statement and felt bad for not following up since the rumors continued that Resident #8 was fondling Resident #4. Record review of Staff A's statement dated 10/03/16 indicated in part: · I, staff A saw Resident #8 on 08/21/16 with Resident #4 and I saw him rubbing her breast at 11:30 a.m. and I told him to get away from her. I told LVN B and she said to write a statement so I did and signed it and the nurse signed it also and I taped it on the door of administrator V. During an interview on 09/29/16 at 4:40 p.m. Administrator V said he recalled Staff D telling him that Resident #4 had her shirt up and that Resident #8 was in the area. Administrator V said he told Resident #8 to move from there. The Administrator said he never saw Resident #8 touching Resident #4 inappropriately. The Administrator said he was never told Resident #8 had touched Resident #4's private parts. The Administrator said he never said Resident #8 touching Resident #4 was consensual. The Administrator said he did not know why staff were saying all these allegations about him not doing anything when supposedly they complained to him about abuse. Review of the Customer Service Intakes on 10/25/16 revealed the facility reported this allegation to DADS on 10/10/16 at 5:07 p.m. During an interview on 10/11/16 at 9:44 a.m. Staff E said sometime last year around November 2015, Staff D told her that he had witnessed Resident #8 touching Resident #4's breasts. Staff E said Staff D told her that he told Resident #8 to stop doing that and he became hostile with him. Staff E said she accompanied Staff D into Administrator W's office to translate for him. Staff E said Administrator W used to be the Administrator at that time and left the facility around February 2016. Staff E said Administrator W told them she would talk to Resident #8 and that was it. Staff E said the next day during the stand-up meeting Administrator W stated she had spoken to Resident #8 and his mom, and that if it occurred again she would discharge Resident #8. Record review of Staff E's statement dated 09/29/16 indicated in part: · Around 3 to 4 months ago Staff D came to my office reporting Resident #8 was touching Resident #4's breasts. Staff D told Resident #8 to stop and Resident #8 started arguing with Staff D. We went to administrator V ' s office and I interpreted for Staff D. Administrator V said maybe it was consensual but he would look into it. During an interview on 10/11/16 at 9:58 a.m. Staff U said sometime in November 2015, Staff D reported to her that Resident #8 was touching Resident #4's breasts. Staff U said she reported it to Administrator W and that Administrator W told her she would address it. Staff U said a couple of days later she witnessed Resident #8 and his mom going into the Administrator's office. Staff U said the Administrator later said she had talked to Resident #8 and his mom and that Resident #8 had denied the allegations. During a telephone interview on 10/10/16 at 4:25 p.m. Administrator W said her last day working at the facility was in mid February 2016. Administrator W said she recalled Resident #8 because she was the one who helped the resident get admitted to the facility from the community. The Administrator said she believed Resident #8 liked Resident #4 but not in an inappropriate way. The Administrator said no one ever reported any allegations to her regarding Resident #8 being inappropriate towards Resident #4. Record review of Resident #11's face sheet dated 10/11/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #11's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 3. (3 indicates severe impairment). · Functional limitation in range of motion: upper extremity and lower extremity = no impairment. · Mobility devices: Cane. During an interview on 10/05/16 at 9:09 a.m. Staff C said approximately one month ago she witnessed Resident #11 grabbing Resident #4's breast. Staff C said she told Resident #11 to get away from her and that Resident #4 was trying to scratch Resident #11 to get him away from her. Staff C said she went and told Administrator V about it and the Administrator said, She probably likes it. Staff C said as far as she knew the Administrator never did anything about it. During an interview on 10/05/16 at 10:22 a.m. Administrator V said no one ever reported to him that Resident #11 had grabbed Resident #4's breast. When asked if he ever stated that She probably likes it referring to Resident #11 touching Resident #4, the Administrator said, That's BS, I would never say that. The Administrator said he never saw a note posted on his door indicating Resident #8 had touched Resident #4's breasts. The Administrator said he had never retaliated against staff for reporting abuse. During an interview on 10/10/16 at 9:15 a.m. Resident #11 said he had never been inappropriate with any of the resident's at the facility. Resident #11 said it was all gossip. Record review of Resident #13's face sheet dated 10/11/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or sexual abuse were thoroughly investigated to prevent further potential abuse and reported immediately to officials in accordance with State law for 3 of 13 residents (Residents #3, #4 and #7) reviewed for abuse or neglect. The facility failed in that: · Resident #4 was verbally and physically abused by CNA G. CNA G hit Resident #4 on her wrist and told her to stop showing her breasts. The administrator did not thoroughly investigate or report the allegation, or protect residents from further potential abuse. · Resident #3 was verbally and physically abused by Certified Nurse Aide (CNA) G and CNA I. The administrator did not thoroughly investigate or report the allegation, or protect residents from further potential abuse. · Resident #4 was inappropriately touched by Resident # 11 on one occasion and touched inappropriately on several occasions by Resident #8. The administrator did not thoroughly investigate or report the allegation, or protect residents from further potential abuse. · Resident #7 was verbally abused by CNA G and was inappropriately touched by Resident #8. The administrator did not thoroughly investigate or report the allegations, or protect residents from further potential abuse. An Immediate Jeopardy (IJ) was identified on 10/05/16. The IJ was removed on 10/10/16 but the facility remained out of compliance at pattern of actual harm due to the facility's need to monitor its corrective action for effectiveness. This deficient practice placed 60 residents at risk for verbal, physical and sexual abuse due to the facility not thoroughly investigating allegations of abuse immediately and reporting to the State as required. Findings include: PHYSICAL AND VERBAL ABUSE Record review of Resident #4's face sheet dated 09/24/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #4's Minimal Data Set ((MDS) dated [DATE] indicated in part: · Speech clarity: No speech. · Cognitive skills for daily decision making = severely impaired - never/rarely made decisions. · Functional status: Transfer =total dependence, Locomotion on unit = total dependence, Dressing = total dependence, Eating = total dependence and Personal hygiene= total dependence. · Functional limitation in range of motion: Upper and lower extremities = impairment on both sides. During an interview on 09/27/16 at 2:00 p.m. Staff F said she observed an incident on or around 09/10/16 at about 5:00 p.m. involving CNA G and Resident #4. Staff F said she observed and heard CNA G stating, Look at Resident #4 raising her shirt and her tits are showing, and then they're going around saying they're molesting her. Staff F said she then observed CNA G hit Resident #4 on the wrist 3 times with an open hand. Staff F said she was standing approximately 20 feet away and the hits sounded loud. Staff F said she shook her head as CNA G looked at her. Staff F said CNA G then roughly pulled Resident #4's shirt down. Staff F said Resident #7 was sitting in the lobby and witnessed what happened. Staff F said Resident #7 pointed at CNA G and tried to tell her not to do that but could not express what she was trying to say. Staff F said at that time CNA G looked at Resident #7 and told her and what are you going to do, there you are sitting down all pissed and full of[***] well come on if you want to do something about it. Staff F said she did not report the incident right away because she did not know exactly what to report and was afraid of reporting it. Staff F said she felt horrible about it so, on 09/20/16, ten days after the observation, she told Staff D about it. Staff F said Staff D told her she needed to report what she observed. Staff F said she then reported it to Staff C, who then told the Administrator V about it, at that time. Staff F said on 09/24/16 the Administrator approached her to get her statement. Staff F said the Administrator told her that CNA G was currently suspended for something else and was due to return back that day 09/24/16. Staff F said the Administrator told her that he would not allow CNA G to return back, but then she later saw CNA G working at the facility that day, 09/24/16. Staff F said when CNA G saw her CNA G told her I'm back. Staff F said she felt uncomfortable the way CNA G talked to her. Staff F said Housekeeper M was a witness to the incident as she was there when CNA G said what she did. During an interview on 09/27/16 at 3:22 p.m. Staff C said on 09/20/16 Staff F told her she had witnessed CNA G abuse Resident #4 about 3 weeks ago on 09/10/16 Staff C said she asked Staff F why she was just now reporting it. Staff C said Staff F told her she had not reported it because she was afraid of CNA G. Staff C said she went and told Administrator V right away after she found out about it. Staff C said when she told the Administrator he responded, That was 3 weeks ago? Staff C said the Administrator told her to tell Staff F to keep hush, hush about it and he would work on it. Staff C said on 09/23/16 the Administrator told her to write a statement regarding CNA G hitting Resident #4 but to indicate that she forgot to tell him earlier and to date it 09/23/16 instead of 09/20/16 when it actually happened. Review of Staff C's written statement dated 09/26/16 indicated, in part: · On Tuesday 09/20/16 Staff F told me she had witnessed CNA G hit Resident #4 three times and pulled her shirt down forcefully. I asked her when it happened and she said she saw it 3 weeks ago. I asked her why she didn't report it sooner. She said she was afraid to report it. She said that another witness, Resident #7 saw the situation. Resident #7 tried to get off the couch to stop CNA G from hitting Resident #4 but CNA G said, What are you gonna do you're full of[***]and piss. I told her I'm going to report it right now. I went inside and I knocked on the door to Administrator V's office. I told him we need to talk. I told him there was a report that CNA G was hitting Resident #4 three times. He asked, when was this and who told you. I said 3 weeks ago and Staff F told me. He said, Well tell her to hush hush. I asked him what he meant by that because this was serious and he stated I will take care of it. On Friday 09/23/16 administrator called the nursing home around 10:00 p.m. for all staff to remain in the building because he needed statements for a report of abuse on a resident. He arrived and started questioning all the CNA's one by one. When it was my turn he closed the door and told me that he needed a statement from me but not to put the date. He told me to say that I forgot to report it to him because I was overworked from working a triple shift on Thursday. He told me to write on the statement that I had reported it on Friday 09/23/16 when in actuality I had reported it on the Tuesday I found out, 09/20/16. He informed me that I would not get in trouble and that everything was going to be ok. On Saturday, 09/24/16 Staff F called me and informed me that CNA G was working. I called the administrator and asked why CNA G was working after he told me he would take care of it. I thought she would not be at work until after the investigation. He replied, I'm the boss here, I'm the administrator, do you want to be in charge? I said that I was aware of that but I'm worried about the residents. Record review of Staff C's statement dated 09/30/16 indicated in part: · On Wednesday 09/28/16 Administrator V said to me, if I find out it was one of my staff that called State I promise they'll be looking for another damn job. The RNC K (Regional Nurse Consultant) also has been asking everyone at the facility for information about me. During an interview on 09/29/16 at 10:39 a.m. Staff E said that on 09/20/16 Staff D came and told her that Staff F had told him that some weeks ago she had witnessed CNA G hit Resident #4. Staff E said she then went and reported this to Administrator V right away. Staff E said the Administrator stated, I told Staff F to keep it hush and that Staff C had already reported it to him. Staff E said the Administrator told her to keep it hush and to tell Staff D to keep it quiet because he wanted to work the investigation quietly. Staff E said she wrote the report on a grievance form and kept it with her. Staff E said recently the Administrator told her that he did not want her documenting anymore grievances and that he would be the only one writing the grievances from now on. During an interview on 09/29/16 at 11:17 a.m. Staff D said on 09/20/16 Staff F told him she had witnessed CNA G hit Resident #4 sometime ago. Staff D said he then went and told Staff E about it, who in return reported it to Administrator V. Staff D said after Staff E reported it to the Administrator she came back and told him that the Administrator told her to tell him to keep his mouth quiet about it. Staff D said he told Staff E on 09/20/16 around 4:00 p.m. Record review of Staff D's statement dated 09/29/16 indicated in part: · It's been approximately 3 or 4 months that I reported to Administrator V that Resident #8 was touching Resident #4's breasts. The Administrator said well they're adults and he did not investigate anything. Staff E was a witness because she interpreted to the administrator what I said. Also about 3 weeks ago, I again told the administrator that Resident #8 was molesting Resident #4. The administrator told me to tell CNA H; the administrator stayed sitting down and he did not even come check to see what was going on. I then told CNA H about it and then I don't know what happened after that since it was time for me to go home. (Note: this statement was written in Spanish and surveyor translated into English). During an interview on 09/29/16 at 3:14 p.m., CNA G said the incident with Resident #4 happened a long time ago. CNA G said she was getting Resident #4 from the lobby to take her to the dining room. CNA G said she remembered seeing Staff F standing there. CNA G said Resident #4 had her shirt tangled up in her arm exposing her breast. CNA G said she untangled her shirt and told the resident to not be picking up her shirt. CNA G said she never hit the resident nor told her that her tits were showing. CNA G said she remembered Resident #7 being close by but she never told her anything inappropriate. CNA G said Administrator V called her on the morning of 09/24/16 before she was scheduled to come in to work. CNA G said the Administrator told her he was working on an investigation that had occurred three weeks ago regarding Resident #4. CNA G said the Administrator told her he would call her later to see if she could return to work. CNA G said the Administrator called her later that same day at 12:30 pm and said it was ok for her to come to work. CNA G said the Administrator had asked her if she had hit Resident #4 to which she answered no. CNA G said when she came to work on 09/24/16 she saw Staff F but she did not say anything to her. (Note: At the time of this interview CNA G was currently still employed at the facility but was later terminated by the facility during this investigation). During an interview on 09/27/16 at 4:35 p.m. Administrator V said he had not called the State regarding the allegation that CNA G physically abused Resident #4 because there was no corroboration evidence found that it had occurred. The Administrator said that he had discussed his findings with the Regional Director of Operations (RDO) and they both agreed there was no need to do a self-report. The Administrator said CNA G was currently suspended for a different allegation when this new allegation came up and saw no need to reinvestigate CNA G since he had already investigated her. Review of the Customer Service Intakes on 10/25/16 revealed Administrator V reported this allegation to DADS on 9/27/16 at 9:41 p.m. Record review of the facility's PIR (Provider Investigation Report) related to Resident #4's alleged abuse by CNA G dated 09/29/16 indicated in part: · After completion of resident interviews, I spoke with my RDO about the findings and the fact that there was no corroborating evidence. Advised to close investigation, document findings and create an investigation file and that there was nothing to report. · Provider action taken post-investigation. After all interviews completed, Administrator V spoke with Regional Director about the investigation and the findings. RDO agreed with Administrator that there was no corroborating evidence. Advised to close investigation, document findings and agreed to bring CNA G back to work on her next scheduled shift, which was that day. · Signed and dated by Administrator V on 09/29/16. During an interview on 10/11/16 at 4:10 p.m. the RDO said he had not clearly told Administrator V to not report it or otherwise. The RDO said the Administrator should have reported it to the State. RESIDENT #3 and #9 Record review of Resident #3's face sheet dated 09/19/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5 (severe impairment). · Transfer = limited assistance - 2 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. Record review of Resident #9's face sheet dated 09/27/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #9's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5. (5 severe impairment). · Transfer = extensive assistance - 1 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. Review of Staff C's written statement dated 09/26/16 indicated, in part: · On Wednesday 09/21/16 Resident #9 began to cry so I asked her what was wrong, she answered that CNA G and CNA I were mistreating her daughter (Resident #3). I asked her how and she responded they were throwing her on the bed. Her exact words were I know I cannot see but I can hear my daughter telling them not to throw her in the bed that way. Resident #9 also stated that she could hear CNA G and CNA I cursing at her daughter. They would roll her out of the room so she would not hear them but she could still hear them from the hallway. Resident #9 said they don't have any [MEDICATION NAME] for us. After Resident #9 told me this I went to Administrator V's office and reported the situation. He stated that it was already taken care of. During an interview on 09/27/16 at 3:22 p.m. Staff C said on 09/21/16 she was assisting Resident #9 when the resident started to cry. Staff C said she asked the resident what was wrong and she told her that CNA G and CNA I were mean to her and would take her out of her room so she could not hear them being ugly to her daughter and roommate, Resident #3. Staff C said Resident #9 told her she could hear CNA G and CNA I throwing her daughter, Resident #3 on her bed because she could hear her daughter telling the CNA's not to throw her on the bed. Staff C said Resident #9 said she could hear the same CNA's cursing at Resident #3 as well. Staff C said she reported this to Administrator V on 09/21/16 and he told her he had already taken care of it because the 2 CNA's were currently suspended. (Note: CNA G and CNA I were currently suspended but for a different reason). Staff C said she was afraid of reporting this because she was afraid of losing her job and believed the Administrator would see to it that she lost her job. During an interview on 09/30/16 at 9:27 a.m. Resident #3 said CNA G and CNA I had thrown her in her bed from her wheelchair. Resident #3 said CNA I would talk ugly to her when she would change her brief and say things like look at all that[***] you're full of[***] and that would make her feel bad (embarrassed). Resident #3 said CNA G would also be mean to her and that she did not feel comfortable when CNA G and CNA I provided care for her and her mother, Resident #9. During an interview on 09/30/16 at 9:39 a.m. Resident #9 said she heard CNA G and CNA I telling her daughter Resident #3 that she had a rash and had crap on her bottom in a rude way. Resident #9 said she was blind but could hear very well and that it made her feel very bad when CNA G and CNA I would talk ugly to her daughter, Resident #3 because she could not help herself. Resident #9 became emotional and started to cry as she recalled the events. Resident #9 said CNA G and CNA I would place her in the hall on purpose so she could not hear them being verbally abusive to her daughter Resident #3. During an interview on 10/03/16 at 9:57 a.m. Staff O said Staff N told him that Resident #3 told her that CNA G and CNA I had been abusive to her on 09/18/16 at 7pm. Staff O said he reported it to Administrator V and the Administrator told him that it had already being taken care of. Staff O said he told Staff N that he had reported it to the Administrator and it was up to her to leave it at that or report it to the State if she felt she needed to. Staff O said the next day Staff P came and told him that Staff N had a phone call from Department of Aging and Disability Services (DADS). Staff O said within the minute the Administrator came down the hall and told him, What the hell is this about Staff N filing a self-report? During an interview on 09/29/16 at 12:00 p.m. Staff N said on 09/18/16 Resident #3 told her that CNA G and CNA I threw her in bed and placed her wheelchair in the hall so she could not have access to it. Staff N said Resident #3 told her that the same CNA's would take her mother, Resident #9 and place her in another room so she could not hear what they were doing to her. Staff N said she reported this to Staff O who in return reported it to Administrator V. Staff N said she also called in the complaint to the State hotline. Staff N said she called it in because she had heard the Administrator was known for not following up on complaints brought to his attention. Staff N said later the Administrator came and asked her if she had called in a complaint to the State. Staff N said she told him that she had and that he became upset about it and told her my license is on the line and that I had blind-sided him. Staff N said the Administrator appeared to be upset and was trying to intimidate her for calling in the complaint to the State. Staff N said she had never called in a complaint to the State before and had left the facility's phone number as a call back and that was probably how the Administrator found out she had called the State. During an interview on 09/29/16 at 4:08 p.m. CNA I said on 09/18/16 she and CNA G assisted Resident #3 to her bed. CNA I said when they put her to bed the resident became upset and started cursing at them because she did not want to go to bed. CNA I said the resident was full of stool so they cleaned her up. CNA I said she had never been abusive to Resident #3 or her mother, Resident #9. CNA I said her voice was kind of loud which the residents might interpret as being mean. During an interview on 09/29/16 at 3:14 p.m. CNA G said she had never rough-handled or verbally abused any of the residents at the facility. CNA G said she had never cursed or rough-handled Resident #3 or Resident #9. CNA G denied that she nor CNA I wheeled Resident #9 out of her room on purpose while they provided care for her daughter, Resident #3. Review of the Customer Service Intakes on 10/25/16 revealed the facility reported this allegation to DADS on 10/06/16 at 3:58 p.m. SEXUAL ABUSE RESIDENT #4 During a telephone interview on 10/03/16 at 10:43 a.m. Licensed Vocational Nurse (LVN) B said Staff A reported to her that Resident #8 was messing (inappropriately touching) with Resident #4. LVN B said she told Staff A to write a statement and they both signed it. LVN B said she did not remember if she or Staff A posted the statement on the Administrator V's door. LVN B said the Administrator never came and talked to her about the statement. LVN B said she did not document the allegation anywhere as she did not know she was supposed to. Record review of Resident #8's face sheet dated 09/30/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #8's care plan dated 08/17/15 indicated in part; · Goal: Will have no evidence of behavior problems by review date. · Approach: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. · Approach: Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Record review of Resident #8's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 14. (14 indicates cognitively intact). · Functional limitation in range of motion: upper extremity and lower extremity = no impairment. · Mobility devices: Wheelchair. During an interview on 09/29/16 at 11:17 a.m. Staff D said some time ago he told Staff E to tell Administrator V that he had witnessed Resident #8 touching Resident #4's breasts. Staff D said he accompanied Staff E to the Administrator's office to report this. Staff D said when Staff E told the Administrator what he had witnessed, the Administrator said that Resident's #8 and #4 were both adults. Staff D said Staff E told the Administrator that Resident #4 could not consent to that but the Administrator just blew her off. Staff D said about 15 days later he again witnessed Resident #8 touching Resident #4 in her private parts. Staff D said he went right away to the Administrator's office and told him about it. Staff D said the Administrator told him to go tell CNA H about it. Staff D said he went and told CNA H about it and she came and told Resident #8 to get away from Resident #4. Staff D said the Administrator never intervened when he reported the allegations nor investigated it as far as he knew. During an interview on 09/30/16 at 3:09 p.m. CNA H said about 2 or 3 weeks ago Staff D came and told her that Resident #8 was touching Resident #4 in appropriately. CNA H said she went and moved Resident #8 away from Resident #4 and told him to get away from her. CNA H said Resident #8 told her he was not doing anything wrong to Resident #4. During an interview on 10/05/16 at 11:30 a.m. Resident #8 said that a few months ago he was sitting in the lobby by Resident #4. Resident #8 said Resident #4 grabbed his beard and pulled him towards her. Resident #8 said when he tried to push himself away he unintentionally grabbed her breasts. Resident #8 said that Administrator V had talked to him and told him that could be perceived as sexual harassment and to get away from Resident #4. Resident #8 denied he ever touched Resident #4 inappropriately on purpose and that he would go and sit by her to talk to her about God. During an interview on 10/03/16 at 9:18 a.m. Staff A said on Sunday 08/21/16 she witnessed Resident #8 touching Resident #4's breasts in the lobby. Staff A said she told Resident #8 to get away from Resident #4 and not be doing that. Staff A said Resident #8 denied doing anything wrong, became upset and went outside. Staff A said she reported it to LVN B and then wrote a statement. Staff A said she and LVN B signed the statement and posted it on Administrator V's door. Staff A said on Monday morning she noticed the statement was still on the Administrator's door and then shortly after the Administrator arrived the statement was no longer there. Staff A said the Administrator never called her to talk to her regarding her statement nor did she go ask him if he had any questions regarding her statement. Staff A said she did not make a copy of the statement and felt bad for not following up since the rumors continued that Resident #8 was fondling Resident #4. Record review of Staff A's statement dated 10/03/16 indicated in part: · I, staff A saw Resident #8 on 08/21/16 with Resident #4 and I saw him rubbing her breast at 11:30 a.m. and I told him to get away from her. I told LVN B and she said to write a statement so I did and signed it and the nurse signed it also and I taped it on the door of the administrator V. During an interview on 09/29/16 at 4:40 p.m. Administrator V said he recalled Staff D telling him that Resident #4 had her shirt up and that Resident #8 was in the area. The Administrator said he told Resident #8 to move from there. The Administrator said he never saw Resident #8 touching Resident #4 inappropriately. The Administrator said he was never told Resident #8 had touched Resident #4's private parts. The Administrator said he never said Resident #8 touching Resident #4 was consensual. The Administrator said he did not know why staff were saying all these allegations about him not doing anything when supposedly they complained to him about abuse. Review of the Customer Service Intakes on 10/25/16 revealed the facility reported this allegation to DADS on 10/10/16 at 5:07 p.m. During an interview on 10/11/16 at 9:44 a.m. Staff E said sometime last year around November 2015, Staff D told her that he had witnessed Resident #8 touching Resident #4's breasts. Staff E said Staff D told her that he told Resident #8 to stop doing that and he became hostile with him. Staff E said she accompanied Staff D into Administrator W's office to translate for him. Staff E said Administrator W used to be the Administrator at that time and left the facility around February 2016. Staff E said Administrator W told them she would talk to Resident #8 and that was it. Staff E said the next day during the stand-up meeting Administrator W stated she had spoken to Resident #8 and his mom, and that if it occurred again she would discharge Resident #8. Record review of Staff E's statement dated 09/29/16 indicated in part: · Around 3 to 4 months ago Staff D came to my office reporting Resident #8 was touching Resident #4's breasts. Staff D told Resident #8 to stop and Resident #8 started arguing with Staff D. We went to Administrator V ' s office and I interpreted for Staff D. Administrator said maybe it was consensual but he would look into it. During an interview on 10/11/16 at 9:58 a.m. Staff U said sometime in November 2015, Staff D reported to her that Resident #8 was touching Resident #4's breasts. Staff U said she reported it to Administrator W and that Administrator W told her she would address it. Staff U said a couple of days later she witnessed Resident #8 and his mom going into the Administrator's office. Staff U said the Administrator later said she had talked to Resident #8 and his mom and that Resident #8 had denied the allegations. During a telephone interview on 10/10/16 at 4:25 p.m. Administrator W said her last day working at the facility was in mid February 2016. The Administrator said she recalled Resident #8 because she was the one who helped the resident get admitted to the facility from the community. The Administrator said she believed Resident #8 liked Resident #4 but not in an inappropriate way. The Administrator said no one ever reported any allegations to her regarding Resident #8 being inappropriate towards Resident #4. Record review of Resident #11's face sheet dated 10/11/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #11's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 3. (3 indicates severe impairment). · Functional limitation in range of motion: upper extremity and lower extremity = no impairment. · Mobility devices: Cane. During an interview on 10/05/16 at 9:09 a.m. Staff C said approximately one month ago she witnessed Resident #11 grabbing Resident #4's breast. Staff C said she told Resident #11 to get away from her and that Resident #4 was trying to scratch Resident #11 to get him away from her. Staff C said she went and told Administrator V about it and the Administrator said, She probably likes it. Staff C said as far as she knew the Administrator never did anything about it. During an interview on 10/05/16 at 10:22 a.m. Administrator V said no one ever reported to him that Resident #11 had grabbed Resident #4's breast. When asked if he ever stated that She probably likes it referring to Resident #11 touching Resident #4, the Administrator said, That's BS, I would never say that. The Administrator said he never saw a note posted on his door indicating Resident #8 had touched Resident #4's breasts. The Administrator said he had never retaliated against staff for reporting abuse. During an interview on 10/10/16 at 9:15 a.m. Resident #11 said he had never been inappropriate with any of the resident's at the facility. Resident #11 said it was all gossip. Record review of Resident #13's face sheet dated 10/11/2016 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #13's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 11. (11 indicates moderately impaired). During an interview on 10/07/16 at 3:30 p.m. Resident #13 said he had observed Resident #8 kissing Resident #4 in the lobby. Resident #13 said he reported it to Administrator V and the Administrator told him that he knew about it and that was all he said. RESIDENT #7 Record review of Resident #7's face sheet dated 09/30/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #7's MDS dated [DATE] indicated in part: · Speech clarity: Unclear speech - slurred or mumbled words. · Cognitive skills for daily decision making = severely impaired - never/rarely made decisions. · Bed mobility = total dependence and 2 person physical assist. · Dressing = total dependence and 2 person physical assist. · Upper and lower extremities = no impairment. · Balance during transitions and walking: Walking - not steady but able to stabilize without staff assistance. During an interview on 10/11/16 at 10:20 a.m. Staff D said on two occasions he witnessed Resident #8 inappropriately touch the residents in the month of November 2015. Staff D said on the first observation, he witnessed Resident #8 touch Resident #4's breast. Staff D said the second time he witnessed Resident #8 he was in Resident #7's room and he could see them because the door was open. Staff D said Resident #7 was in her bed and she had her pants and panties pulled down and Resident #8 was touching her private parts. Staff D said he reported both observations to Administrator W who just stated, I'll take care of it. Staff D said he did not believe the Administrator did anything because Resident #8 continued to fondle the residents. During an interview on 09/30/16 at 9:15 a.m. the surveyor asked Resident #7 if she had ever seen staff be abusive to any of th

Based on interview and record review, the facility failed to care for residents in a manner to maintain or enhance dignity for 2 of 13 (Resident #3 and #9) reviewed for dignity. · Certified Nurse Aide (CNA) G and CNA I spoke ugly to Resident #3 by saying things such as you are full of[***]which made her feel bad. · Resident #9 said that CNA ' s G and I spoke ugly to her daughter Resident #3 by telling her she was full of[***]and that made her feel bad. This failure could place 18 interviewable residents who required assistance with ADL's at risk for loss of self-esteem and self-worth. Findings include: Record review of Resident #3's face sheet dated 09/19/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5. (5 severe impairment). · Transfer = limited assistance - 2 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. · Incontinent of bladder/bowel. Record review of Resident #9's face sheet dated 09/27/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #9's MDS dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 5. (5 severe impairment). · Transfer = extensive assistance - 1 person physical assist. · Functional limitation in range of motion: lower extremity = impairment on both sides. · Mobility devices: Wheelchair. During an interview on 09/27/16 at 3:22 p.m. Staff C said on 09/21/16 she was assisting Resident #9 when the resident started to cry. Staff C said she asked the resident what was wrong and she told her that CNA G and CNA I were mean to her and would take her out of her room so she could not hear them being ugly to her daughter, Resident #3. Staff C said Resident #9 said she could hear the same CNA's cursing at Resident #3 as well. During an interview on 09/29/16 at 12:00 p.m. Staff N said Resident #3 told her that CNA ' s G and I would take her mother, Resident #9 and place her in another room so she could not hear what they were doing to her. During an interview on 09/29/16 at 3:14 p.m. CNA G said she had never verbally abused any of the residents at the facility. CNA G denied she ever cursed Resident #3 or Resident #9. CNA G said CNA I and her never wheeled Resident #9 out of her room on purpose while they provided care for her daughter, Resident #3. During an interview on 09/29/16 at 4:08 p.m. CNA I said on 09/18/16 she and CNA G assisted Resident #3 to her bed. CNA I said when they put her to bed the resident became upset and started cursing at them because she did not want to go to bed. CNA I said the resident was full of stool so they cleaned her up. CNA I said she had never been abusive to Resident #3 or her mother, Resident #9. CNA I said her voice was kind of loud which the residents might interpret as being mean. During an interview on 09/30/16 at 9:27 a.m. Resident #3 said CNA I would talk ugly to her when she would change her brief and say things like look at all that[***] you're full of[***] and that would make her feel bad. Resident #3 said CNA G would also be mean to her and that she did not feel comfortable when CNA G and CNA I provided care for her and her mother, Resident #9. During an interview on 09/30/16 at 9:39 a.m. Resident #9 said she heard CNA G and CNA I tell her daughter, Resident #3 that she had a rash and had crap on her bottom in a rude way. Resident #9 said she was blind but could hear very well and that it made her feel very bad when CNA G and CNA I would talk ugly to her daughter, Resident #3 because she could not help herself. Resident #9 was emotional and crying during the interview. Resident #9 said CNA G and CNA I would place her in the hall on purpose so she could not hear them being verbally abusive to her daughter, Resident #3. During an interview on 09/30/16 at 4:00 p.m. Administrator V said they would follow their policy on abuse if any abuse was reported. The Administrator said he was not aware of the verbal abuse regarding Resident's #3 and #9. The Administrator said if he had been told about it he would have looked into it as this is not acceptable behavior. Record review of the facility's policy titled dignity dated 10/2009 indicated in part: · Policy statement. Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. · Residents shall be treated with dignity and respect at all times. · Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. · Staff shall speak respectfully to residents at all times. Record review of a report provided by the Administrator on 10/11/16 indicated there were 18 residents that were interviewable.

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accidents, hazards, and provided adequate supervision for 1 of 13 residents (Resident #1) reviewed for safety. The facility failed to ensure: · To have a system in place to prevent Resident #1 from getting burned by hot coffee. Resident #1 had a burn with blisters to her upper inner thighs after coffee was spilled on her lap. · To initiate and/or implement any new interventions or safety measures to prevent further coffee burns. Failure to provide adequate supervision or preventive measures could place 21 residents that drank coffee regularly at a chance of getting burned. Findings Included: Record review of Resident #1's face sheet dated 09/19/2016 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] indicated in part: · BIMS (Brief Interview for Mental Status) summary score = 1. (1 indicates severe impairment). · Eating how resident eats and drinks: Supervision-oversight, encouragement or cueing. Setup help only. · Mobility devices: Wheelchair. Record review of Resident #1 ' s care plan indicated in part: · Problem: Resident at risk of burning self with coffee. Goal: Resident to utilize lidded coffee cup when drinking coffee. Approach: Staff to provide resident with lidded coffee sup, Staff to encourage resident to use lidded coffee cup. Start date 09/21/16. · Problem: Cognitive loss/dementia or alteration on thought process related to dementia aeb (as evidence by): impaired decision making, short and/or long term memory loss. Goal: Will maintain current level of cognitive function through review date. Approach: Observe, document, report to MD PRN, dementia signs and symptoms, decision making problem, memory problem, difficulty expressing self or understanding others. Start date: 03/11/16. Record review of Resident #1's event report dated 09/16/16 indicated in part: · Description: Upon skin assessment noted resident to have reddened area bilaterally to upper inner thighs with several small scattered blisters with this area. · Progress note: This nurse was doing routine skin assessment and resident complained of pain to top of thighs upon assessment noted redness and several scattered small blisters to bilateral upper inside of thighs. Questioned resident if she knew what happened, she stated I spilled my coffee. FNP notified received order to apply Silvadene 1% ointment to burn area BID until healed. (FNP=Family Nurse Practitioner. Silvadene is used with other treatments to help prevent and treat wound infections in patients with serious burns. BID = twice a day). · Signed and dated by Licensed Vocational Nurse (LVN) J on 09/16/16. During an interview on 09/23/16 at 9:42 a.m. Resident #1 said one of her tablemates in the dining room had spilled a cup of coffee and it landed on her lap. Resident #1 said it burned her really bad and she had gone to her room and changed her pants. During an interview on 09/23/16 at 3:55 p.m. LVN J said on 09/16/16 she assessed Resident #1's skin and noted some redness to her inner thighs. LVN J said she asked Resident #1 what happened and she told her coffee had spilled on her. LVN J said she called the doctor, who then ordered some ointment for it and ordered the resident be sent to the hospital. During an observation on 09/29/16 at 12:15 p.m. Resident #1 was eating lunch in her room alone. Resident #1 had a regular cup of coffee on her tray, not a Styrofoam cup with a lid. During an interview on 10/03/16 at 11:20 a.m. Dietary Aide Q said she was not aware they were supposed to be using temporary Styrofoam cups with lids for the coffee. During an interview on 10/03/16 at 11:39 a.m. Certified Nurse Aide (CNA) R said she was not aware they were supposed to be using temporary Styrofoam cups with lids for the coffee. CNA R said they were just using the regular cups when they served coffee to the residents. During an interview on 10/03/16 at 11:45 a.m. CNA S said she had not seen any Styrofoam cups with lids to use for the coffee. CNA S said she had not been told about them and that they used the regular cups when they served the resident's their coffee. During an interview on 10/03/16 at 12:06 p.m. the Administrator said they currently had Styrofoam cups with lids in the kitchen, and that staff was supposed to be using them. The Administrator said the kitchen staff were aware and were using them to serve the coffee. The Administrator was made aware that the staff interviewed did not know about these cups and there were no observations of the staff using them. The Administrator shook his head and said they were supposed to be using them. During an interview on 10/03/16 at 12:10 p.m. Dietary Aide T said they would use the regular coffee cups to serve resident's their coffee. Dietary Aide T said she did not know about any special cups with lids to use for the coffee. During an interview on 10/03/16 at 1:50 p.m. the FSS (Food Service Supervisor) said they started using Styrofoam cups with lids since last week. The FSS said they were supposed to place the cups by the coffee pots that are in the dining room. The FSS said he forgot to in-service the staff about using the Styrofoam cups and was just now doing the training. The FSS said the Styrofoam cups and the lids were now located by the coffee pots in the dining room. Record review of the facility's PIR (Provider Investigation Report) related to Resident #1's coffee burn dated 09/23/16 indicated in part: · Provider action taken post-investigation. Temporary coffee cups with lids ordered for those determined to be at risk for spilling coffee on themselves. · Signed and dated by Administrator. 09/23/16. During an observation on 09/23/16 at 3:42 p.m. the temperature of the coffee, in the dining room coffee pot, was 137 degrees Fahrenheit. Resident #1 was in the dining room playing activities and drinking coffee along with other residents. There were no observations of residents using the Styrofoam cups with lids. Record review of the facility's policy titled safety and supervision of resident dated 12/2007 indicated in part: · Policy statement: Our facility strives to make the environment as free from accident hazards as possible resident safety and supervision and assistance to prevent accidents are facility-wide priorities. · Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. Document provided by the Regional Director of Operations (RDO) on 10/11/16 indicated there were 21 residents at the facility that had a risk of spilling coffee on themselves.

Based on interview, observation and record review, the Administrator failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 3 of 16 residents (Resident #1, #2 and #5) in that: · The Administrator failed to ensure the residents were supervised and transferred safely in the van. · The Administrator failed to develop and implement a policy for transporting residents in the van and to include screening van drivers for a valid driver's license and training for the van drivers. · The Administrator failed to supervise the Maintenance supervisor/FSS (Food Service Supervisor) to ensure he was training and overseeing staff to ensure staff were securing the wheelchairs in the facility's van during transportation. An Immediate Jeopardy (IJ) was identified on 08/30/16. The IJ was removed on 08/31/16 but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. The failure of Administrative Staff to effectively manage the resources of the facility could place 15 residents identified by the facility as being wheelchair bound and used the facility van for transportation at risk for serious injury or death if not secured properly in the van. Findings: During an interview on 08/26/16 at 3:22 p.m. the Maintenance Supervisor/FSS (Food Service Supervisor) said he was in charge of training the staff on how to secure the wheelchairs in the van. The Maintenance Supervisor/FSS said he basically would show them how to tie down the wheelchair and have them do a return demonstration. The Maintenance Supervisor/FSS said he did not have a specific document indicating what or how he trained them regarding securing the wheelchairs in the van. The Maintenance Supervisor/FSS said as far as he knew there was no specific manual for the way to secure the wheelchairs in the van. During an interview on 08/29/16 at 2:01 p.m. the Administrator said he believed the Maintenance Supervisor/FSS did the training on securing the wheelchairs in the van. The Administrator said he believed the wheelchairs were supposed to be facing forward when placed in the transportation van, but was not sure. During an interview on 08/29/16 at 5:04 p.m. the Administrator said they had never submited any driver's license to corporate when asked if they had found any evidence that CNA H had a valid driver's license. During an interview on 08/30/16 at 1:20 p.m. the Maintenance Supervisor/FSS said the facility had purchased the current used van several years ago. The Maintenance Supervisor/FSS said he had been trained to secure the wheelchairs in the van by the person who had sold them the van. The Maintenance Supervisor/FSS said he was trained to place the wheelchairs sideways and not facing forward. The Maintenance Supervisor/FSS said he was trained to place 4 tie downs on the wheelchair. The Maintenance Supervisor/FSS said he would place 2 tie downs on the front wheels and 2 tie downs on the back wheels. The Maintenance Supervisor/FSS said he did not recall seeing the pamphlet on securing wheelchairs in the van that the surveyor reviewed. Record review of Resident #1's face sheet dated 06/19/16 documented he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's MDS (Minimum Data Set) dated 07/25/16 indicated in part: · BIMS (Brief Interview for Mental Status) = 10 indicating moderately impaired. · Functional status: Transfer= Total dependence and 2 person physical assistance. · Mobility Devices: Wheelchair. During an interview on 08/19/16 at 11:34 a.m. Licensed Vocational Nurse (LVN) G said on 03/18/16 van driver/CNA H called the facility stating that Resident #1's wheelchair had broken while they were on their way back to the facility, in the van, and the resident had fallen. LVN G said she assessed Resident #1 and he had a laceration on his leg. LVN G said the resident told her that he had fallen out of the wheelchair. LVN G said she asked the van driver/CNA H when they arrived at the facility, I thought you said the wheelchair had broken? but the van driver did not respond. Record review of Resident #1's incident/accident report dated 03/18/16 indicated in part: · Date of incident: 03/18/16, time: 12:15pm. · Was first aid administered?: Yes, Cleaned skin tear to left chin. · Describe exactly what you observed or heard. (This area was left blank and concluded information found in incident report). · Signed by LVN G and dated 03/18/16. During a telephone interview on 08/19/16 at 5:15 p.m. CNA I said on 03/18/16 she had accompanied van driver/CNA H and Resident #1 to the wound care clinic. CNA I said on the way back from the clinic, Resident #1 complained that he did not feel his wheelchair was secure and that he was sliding down. CNA I said the resident slid out of the wheelchair onto the floor so they pulled the van over but could not put him back in the chair. CNA I said they had to call 911 to come help place Resident #1 back in the wheelchair. CNA I said they had not been trained on how to secure the wheelchair while in the van. CNA I said she believed van driver/CNA H did not even have a driver's license because she had told her they had not even checked her for one. During a telephone interview on 08/26/16 at 4:36 p.m. Resident #1 said on 03/18/16 two facility female staff members had taken him to the clinic in the facility van. Resident #1 said when the doctor's visit was over the two females placed him back in the van and tied his wheelchair down. Resident #1 said as soon as the van took off he felt that his wheelchair was not secure. Resident #1 said he told the girls that he felt the wheelchair was loose. Resident #1 said the girls ignored him and were not even paying attention to him because they were on their cell phones. Resident #1 said as soon as they came to the first stop, he fell out of the chair and the chair landed on him. Resident #1 said the girls pulled the van over and tried to get him in the wheelchair again, but they could not. Resident #1 said the ambulance people came and helped place him back in the wheelchair. During an interview on 08/29/16 at 9:20 a.m. the BOM (Business Office Manager) said they had initially hired CNA H as a floor aide and not as a transportation aide. The BOM said later on the previous DON (Director of Nurses) had offered CNA H the position of transportation aide. The BOM said she did not recall asking CNA H for a copy of her driver's license. The BOM said she had looked through CNA H's employee file and was not able to find a copy of her driver's license. During a telephone interview on 08/30/16 at 7:31 p.m. van driver/CNA H said some time ago while she was still employed at the facility the DON (Director of Nurses) had called her and offered her the van driver job. Van driver/CNA H said she took the position and started driving the van since then. Van driver/CNA H said she had never been trained on how to secure the wheelchairs in the van. Van driver/CNA H said she was the driver when Resident #1 fell out of his wheelchair on 03/18/16. Van driver/CNA H said the facility never even checked if she had a driver's license. Van driver/CNA H said she did not have a driver's license. Record review of CNA H's employee file, there was no proof or copy of her driver's license found. CNA H worked as a transport driver at the facility from 03/07/16 till 04/15/16. Record review of van driver/CNA H's record of employee counseling indicated in part: · Date: 03/21/16. · Position: Transportation aide. · Details of interview: Resident #1 during transport from wound care to facility were not strapped in appropriately for approximately 1 block. Resident #1 had fall with a skin tear. No other injuries noted. Resident also complained of phone use . · Employee signature: van driver/CNA H. Date: 03/21/16. RESIDENT #2 Record review of Resident #2's face sheet dated 09/01/16 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #2's MDS (Minimum Data Set) dated 08/26/16 indicated in part: · BIMS (Brief Interview for Mental Status) = 14 indicating cognitively intact. · Functional status: Transfer= Extensive assistance and 2 person physical assistance. · Mobility Devices: Wheelchair. Record review of Resident #2's incident/accident report dated 08/16/16 indicated in part: · Event date: 08/16/16, 5:11pm. · Description: Brought to writer attention by van driver E at 1:30 pm of van having to come to an abrupt stop causing resident to tilt Geri-chair to the left hitting left side of head and left arm. With no visible injury noted by van driver. 1:35 pm FNP (Family Nurse Practioner) called and notified of incident with orders to transport resident to ER (emergency room ) due to resident was stable. Record review of Resident #2's hospital records related to the van incident and dated 08/16/16 indicated in part: · Shoulder contusion and shoulder sprain. · Prescriptions:[MEDICATION NAME] (milligrams) oral tablet take 1 tablet by oral route every 6 hours as needed. (Soma is a medication used to relax muscles and help alleviate pain from muscle spasms). · Prescriptions: [MEDICATION NAME] 50mg oral tablet take 1 tablet by oral route every 8 hours as needed. ([MEDICATION NAME] is a narcotic medication used to treat moderate to severe pain). During an interview on 08/29/16 at 10:43 a.m. van driver E said she was initially hired as a PRN (as needed) CNA then in April 2016 she was hired as the fulltime van driver. Van driver E said she had not been trained on how to secure the wheelchair while working at the facility. Van driver E said she used to be the van driver at a different facility and that was where she learned to secure the wheelchairs. Van driver E said this van was different from the one at the other facility. Van driver E said on 08/16/16 she was transporting Resident #2 to a doctor's appointment at a nearby town. Van driver E said they had to place Resident #2 on a Geri-chair because he was too tall in his regular wheelchair and would not fit in the van. Van driver E said she had placed the Geri-chair facing forward and had tied down each of the 4 wheels with a strap. Van driver E said she was driving behind 2 other vehicles on the highway. Van driver E said the vehicle in front of her made an abrupt stop so she had to also stop suddenly. Van driver E said this caused Resident #2's Geri-chair to tilt and bump his head and shoulder on the side of the van. Van driver E said the Geri-chair tilted left and rose up from the floor about 5 inches. Van driver E said she called the facility and LVN F told her to turn around and take the resident to the emergency room . Van driver E said the Administrator said they were going to retrain her on how to properly secure the wheelchairs when the incident occurred, but it never happened. Van driver E said she was never trained or in-serviced on how to properly secure the Geri-chair or wheelchairs at this facility. RESIDENT #5 Record review of Resident #5's face sheet dated 09/01/16 documented she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #5's MDS (Minimum Data Set) dated 08/16/16 indicated in part: · BIMS (Brief Interview for Mental Status) = 5 indicating severe impairment. · Mobility Devices: Wheelchair. During an observation on 08/29/16 at 10:45 a.m. Van driver E wheeled Resident #5 to the van for a doctor's appointment. Van driver E placed Resident #5 on the van lift and then wheeled the resident into the van, facing sideways. Van driver E then secured the wheelchair's front wheels by placing 1 tie down/strap on the left front wheel and then 1 tie down/strap to the right front wheel. Van driver E then placed a lap seat belt around the resident. Van driver E did not secure the back wheels of the wheelchair. There were extra tie downs/strap observed in the floor of the van. During an interview on 08/29/16 at 10:46 a.m. Van driver E said she was finished securing Resident #5 by placing the 2 tie downs on the front wheels and the lap seat belt. Van driver E said the back wheels of the wheelchair could not be secured as there was not enough room to get behind the wheelchair to place the tie downs/straps. Van driver E said that was the way she always secured the wheelchairs. Van driver E said she would always place the wheelchairs facing sideways and not facing forward. During an interview on 08/26/16 at 3:37 p.m. CNA J said the previous housekeeper supervisor had trained her on how to secure the wheelchairs in the van and not the FSS. CNA J said she had been trained to place the wheelchairs facing forward, secure them with the straps and that she would drive the van only as needed. During an interview on 08/26/16 at 3:40 p.m. CNA K said the previous housekeeper supervisor had trained her on how to secure the wheelchairs in the van and not the FSS. CNA K said she would place the wheelchair facing sideways and secure the front wheels of the wheelchair and that she would drive the van only as needed. During an interview on 08/29/16 at 10:00 a.m. CNA L said she would help with transportation on the weekends. CNA L said she had been trained on securing a wheelchair by the previous housekeeping supervisor. CNA L said she would position the wheelchair in the van facing sideways and not forward. CNA L said she would secure the wheelchair by placing 1 tie down/ strap on the front right wheel and 1 tie down/strap on the front left wheel. CNA L said they would not tie down the back part of wheelchair as she had not been instructed to do it that way. During an interview on 08/31/16 at 2:45 p.m. the Administrator said they did not have a specific policy and procedure on transportation or training for van drivers. Review of the facility's undated transportation pamphlet on securing a wheelchair, found in the van, indicated in part: · Positioning the chair: Facing forward. · Front tie downs: Anchor the tie downs to the floor approximately 3-8 inches outside the front wheels; Tighten the front tie downs. · Rear tie downs: Anchor the tie downs to the floor just inside of the rear back wheels of the chair; Tighten the rear tie downs. During an interview on 08/30/16 at 2:16 p.m. the Administrator was informed of the IJ based on the lack of staff training to secure the wheelchairs in the van and prevent accidents. The Administrator said he well get on it and make sure the wheelchairs were being secured properly. Plan of removal was submitted and accepted on 08/31/16 at 12:30 p.m.: · Wheelchair Van Restraint: The Regional Director of Operations conducted an in-service with return demonstration on properly restraining residents for transportation in the facility van with all staff currently assisting with transportation. Any other employees who may assist with transportation will be in-serviced on the proper procedure before transporting any residents. (08/30/16). · Staff education related to wheelchair van restraints: All residents will be secured in a forward facing manner only. The larger (rear) straps will be used in the rear position to secure the back of the wheelchair. The front of the wheelchair will be secured using the front straps. The lap restraint will go under the side rails and fasten in the center as to secure the waist and hips of the resident. Only one wheelchair resident will be transported at a time. (08/30/16). · Monitoring of wheelchair van restraints: The Maintenance Supervisor/FSS will monitor the procedures at least daily for 2 weeks then once a week there after for 4 weeks to ensure that residents are restrained appropriately. The Maintenance Supervisor will document his findings in a weekly restraint log. (08/30/16). · On-going management system: The Administrator will monitor the procedures at least twice a month to ensure that residents are restrained appropriately. The Administrator will document findings in a weekly restraint log. Findings will be presented to the QA & A (Quality Assessment and Assurance) committee at least monthly for review and recommendations until compliance with this regulatory requirement is met. The Administrator will ensure that all candidates for van driver have a current and valid driver's license and will have a check of candidates driving record prior to staff member driving the facility van. This will be done annually for all van drivers. (08/30/16). a) In-service training report: 08/30/16, 4:55 p.m. presented by the Regional Director of Operations. b) Subject: Proper positioning of wheelchairs in van and proper securing of wheelchairs in the van. c) Instructor: RDO (Regional Director of Operations). d) In-serviced staff on how to position wheelchair in van, how to properly secure wheelchair in van including which straps to use on front and back of wheelchair. Also in-serviced on how to properly place lap belt (seat belt) so resident is secure. Resident will be forward facing during transport. Plan of removal verification completed 08/31/16: · Interviews were conducted with staff (the 1 full time van driver, 3 CNAs, Maintenance Supervisor/FSS) regarding the training they had received regarding securing the wheelchairs in the van. The staff were able to explain the correct way to secure the wheelchairs. Staff were observed to correctly secure a wheelchair as indicated in the 08/30/16 in-service. During an interview on 08/31/16 at 4:00 p.m. the RNC (Regional Nurse Consultant) and the Administrator were informed the IJ was removed but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. A daily census report provided by the Administrator on 09/01/16 indicated there were 15 residents with wheelchairs and Geri-chairs that used the facility van for transportation.

Based on observation, interview and record review the facility failed to ensure that residents remained as free of accidents as possible for 3 of 16 residents (#1, #2 and #5) reviewed for accidents and assistance devices. a) The facility failed to secure Resident #2's Geri-chair while being transported in the facility's van on 08/16/16. Resident #2's Geri-chair tilted on its side causing him to hit his head and shoulder and sustaining a contusion and a sprain to his left shoulder; b) The facility failed to secure Resident #1's wheelchair while being transported in the facility's van on 03/18/16. Due to that Resident #1 fell out of his wheelchair and sustained a laceration to his leg; c) Van driver E improperly secured Resident #5's wheelchair to the facility's van by attaching two tie downs to the front wheels and no tie downs to the back wheels. Van driver E then drove Resident #5 to the doctor ' s office without securing the back wheels; d) The facility failed to train the staff on how to place and properly secure the wheelchairs and Geri-chairs in the van; e) The facility failed to verify Certified Nurse Aide (CNA) H had a valid driver's license before she was employed as the facility's van driver. CNA H transported the facility's residents to and from doctor's appointments on a regular basis without having a driver's license. An Immediate Jeopardy (IJ) was identified on 08/30/16. The IJ was removed on 08/31/16 but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. These failures could affect any of the 15 residents identified by the facility that used a wheelchair or a Geri-chair and used the facility van for transportation at risk for serious injury or death if not secured properly in the van. Findings Include: RESIDENT #1 Record review of Resident #1's face sheet dated 06/19/16 documented he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's MDS (Minimum Data Set) dated 07/25/16 indicated in part: · BIMS (Brief Interview for Mental Status) = 10 indicating moderately impaired. · Functional status: Transfer= Total dependence and 2 person physical assistance. · Mobility Devices: Wheelchair. During an interview on 08/19/16 at 11:34 a.m. Licensed Vocational Nurse (LVN) G said on 03/18/16 van driver/CNA H called the facility stating that Resident #1's wheelchair had broken while they were on their way back to the facility, in the van, and the resident had fallen. LVN G said she assessed Resident #1 and he had a laceration on his leg. LVN G said the resident told her that he had fallen out of the wheelchair. LVN G said she asked the van driver/CNA H when they arrived at the facility, I thought you said the wheelchair had broken? but the van driver did not respond. Record review of Resident #1's incident/accident report dated 03/18/16 indicated in part: · Date of incident: 03/18/16, time: 12:15pm. · Was first aid administered?: Yes, Cleaned skin tear to left chin. · Describe exactly what you observed or heard. (This area was left blank and concluded information found in incident report). · Signed by LVN G and dated 03/18/16. During a telephone interview on 08/19/16 at 5:15 p.m. CNA I said on 03/18/16 she had accompanied van driver/CNA H and Resident #1 to the wound care clinic. CNA I said on the way back from the clinic, Resident #1 complained that he did not feel his wheelchair was secure and that he was sliding down. CNA I said the resident slid out of the wheelchair onto the floor so they pulled the van over but could not put him back in the chair. CNA I said they had to call 911 to come help place Resident #1 back in the wheelchair. CNA I said they had not been trained on how to secure the wheelchair while in the van. CNA I said she believed van driver/CNA H did not even have a driver's license because she had told her they had not even checked her for one. During a telephone interview on 08/26/16 at 4:36 p.m. Resident #1 said on 03/18/16 two facility female staff members had taken him to the clinic in the facility van. Resident #1 said when the doctor's visit was over the two females placed him back in the van and tied his wheelchair down. Resident #1 said as soon as the van took off he felt that his wheelchair was not secure. Resident #1 said he told the girls that he felt the wheelchair was loose. Resident #1 said the girls ignored him and were not even paying attention to him because they were on their cell phones. Resident #1 said as soon as they came to the first stop, he fell out of the chair and the chair landed on him. Resident #1 said the girls pulled the van over and tried to get him in the wheelchair again, but they could not. Resident #1 said the ambulance people came and helped place him back in the wheelchair. During an interview on 08/29/16 at 9:20 a.m. the BOM (Business Office Manager) said they had initially hired CNA H as a floor aide and not as a transportation aide. The BOM said later on the previous DON (Director of Nurses) had offered CNA H the position of transportation aide. The BOM said she did not recall asking CNA H for a copy of her driver's license. The BOM said she had looked through CNA H's employee file and was not able to find a copy of her driver's license. During an interview on 08/29/16 at 5:04 p.m. the Administrator said they had never submited any driver's license to corporate when asked if they had found any evidence that CNA H had a valid driver's license. During a telephone interview on 08/30/16 at 7:31 p.m. van driver/CNA H said some time ago while she was still employed at the facility the DON (Director of Nurses) had called her and offered her the van driver job. Van driver/CNA H said she took the position and started driving the van since then. Van driver/CNA H said she had never been trained on how to secure the wheelchairs in the van. Van driver/CNA H said she was the driver when Resident #1 fell out of his wheelchair on 03/18/16. Van driver/CNA H said the facility never even checked if she had a driver's license. Van driver/CNA H said she did not have a driver's license. Record review of van driver/CNA H's record of employee counseling indicated in part: · Date: 03/21/16. · Position: Transportation aide. · Details of interview: Resident #1 during transport from wound care to facility were not strapped in appropriately for approximately 1 block. Resident #1 had fall with a skin tear. No other injuries noted. Resident also complained of phone use . · Employee signature: van driver/CNA H. Date: 03/21/16. Record review of CNA H's employee file, there was no proof or copy of her driver's license found. CNA H worked as a transport driver at the facility from 03/07/16 till 04/15/16. RESIDENT #2 Record review of Resident #2's face sheet dated 09/01/16 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #2's MDS (Minimum Data Set) dated 08/26/16 indicated in part: · BIMS (Brief Interview for Mental Status) = 14 indicating cognitively intact. · Functional status: Transfer= Extensive assistance and 2 person physical assistance. · Mobility Devices: Wheelchair. Record review of Resident #2's incident/accident report dated 08/16/16 indicated in part: · Event date: 08/16/16, 5:11pm. · Description: Brought to writer attention by van driver E at 1:30 pm of van having to come to an abrupt stop causing resident to tilt Geri-chair to the left hitting left side of head and left arm. With no visible injury noted by van driver. 1:35 pm FNP (Family Nurse Practioner) called and notified of incident with orders to transport resident to ER (emergency room ) due to resident was stable. Record review of Resident #2's hospital records related to the van incident and dated 08/16/16 indicated in part: · Shoulder contusion and shoulder sprain. · Prescriptions: Soma 350mg (milligrams) oral tablet take 1 tablet by oral route every 6 hours as needed. (Soma is a medication used to relax muscles and help alleviate pain from muscle spasms). · Prescriptions: Tramadol 50mg oral tablet take 1 tablet by oral route every 8 hours as needed. (Tramadol is a narcotic medication used to treat moderate to severe pain). During an interview on 08/29/16 at 10:43 a.m. van driver E said she was initially hired as a PRN (as needed) CNA then in April 2016 she was hired as the fulltime van driver. Van driver E said she had not been trained on how to secure the wheelchair while working at the facility. Van driver E said she used to be the van driver at a different facility and that was where she learned to secure the wheelchairs. Van driver E said this van was different from the one at the other facility. Van driver E said on 08/16/16 she was transporting Resident #2 to a doctor's appointment at a nearby town. Van driver E said they had to place Resident #2 on a Geri-chair because he was too tall in his regular wheelchair and would not fit in the van. Van driver E said she had placed the Geri-chair facing forward and had tied down each of the 4 wheels with a strap. Van driver E said she was driving behind 2 other vehicles on the highway. Van driver E said the vehicle in front of her made an abrupt stop so she had to also stop suddenly. Van driver E said this caused Resident #2's Geri-chair to tilt and bump his head and shoulder on the side of the van. Van driver E said the Geri-chair tilted left and rose up from the floor about 5 inches. Van driver E said she called the facility and LVN F told her to turn around and take the resident to the emergency room . Van driver E said the Administrator said they were going to retrain her on how to properly secure the wheelchairs when the incident occurred, but it never happened. Van driver E said she was never trained or in-serviced on how to properly secure the Geri-chair or wheelchairs at this facility. RESIDENT #5 Record review of Resident #5's face sheet dated 09/01/16 documented she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #5's MDS (Minimum Data Set) dated 08/16/16 indicated in part: · BIMS (Brief Interview for Mental Status) = 5 indicating severe impairment. · Mobility Devices: Wheelchair. During an observation on 08/29/16 at 10:45 a.m. Van driver E wheeled Resident #5 to the van for a doctor's appointment. Van driver E placed Resident #5 on the van lift and then wheeled the resident into the van, facing sideways. Van driver E then secured the wheelchair's front wheels by placing 1 tie down/strap on the left front wheel and then 1 tie down/strap to the right front wheel. Van driver E then placed a lap seat belt around the resident. Van driver E did not secure the back wheels of the wheelchair. There were extra tie downs/strap observed in the floor of the van. During an interview on 08/29/16 at 10:46 a.m. Van driver E said she was finished securing Resident #5 by placing the 2 tie downs on the front wheels and the lap seat belt. Van driver E said the back wheels of the wheelchair could not be secured as there was not enough room to get behind the wheelchair to place the tie downs/straps. Van driver E said that was the way she always secured the wheelchairs. Van driver E said she would always place the wheelchairs facing sideways and not facing forward. During an interview on 08/26/16 at 3:22 p.m. the Maintenance Supervisor/FSS (Food Service Supervisor) said he was in charge of training the staff on how to secure the wheelchairs in the van. The Maintenance Supervisor/FSS said he basically would show them how to tie down the wheelchair and have them do a return demonstration. The Maintenance Supervisor/FSS said he did not have a specific document indicating what or how he trained them regarding securing the wheelchairs in the van. The Maintenance Supervisor/FSS said as far as he knew there was no specific manual for the way to secure the wheelchairs in the van. During an interview on 08/26/16 at 3:37 p.m. CNA J said the previous housekeeper supervisor had trained her on how to secure the wheelchairs in the van and not the FSS. CNA J said she had been trained to place the wheelchairs facing forward, secure them with the straps and that she would drive the van only as needed. During an interview on 08/26/16 at 3:40 p.m. CNA K said the previous housekeeper supervisor had trained her on how to secure the wheelchairs in the van and not the FSS. CNA K said she would place the wheelchair facing sideways and secure the front wheels of the wheelchair and that she would drive the van only as needed. During an interview on 08/29/16 at 10:00 a.m. CNA L said she would help with transportation on the weekends. CNA L said she had been trained on securing a wheelchair by the previous housekeeping supervisor. CNA L said she would position the wheelchair in the van facing sideways and not forward. CNA L said she would secure the wheelchair by placing 1 tie down/ strap on the front right wheel and 1 tie down/strap on the front left wheel. CNA L said they would not tie down the back part of wheelchair as she had not been instructed to do it that way. During an interview on 08/29/16 at 2:01 p.m. the Administrator said he believed the Maintenance Supervisor/FSS did the training on securing the wheelchairs in the van. The Administrator said he believed the wheelchairs were supposed to be facing forward when placed in the transportation van, but was not sure. During an interview on 08/30/16 at 1:20 p.m. the Maintenance Supervisor/FSS said the facility had purchased the current used van several years ago. The Maintenance Supervisor/FSS said he had been trained to secure the wheelchairs in the van by the person who had sold them the van. The Maintenance Supervisor/FSS said he was trained to place the wheelchairs sideways and not facing forward. The Maintenance Supervisor/FSS said he was trained to place 4 tie downs on the wheelchair. The Maintenance Supervisor/FSS said he would place 2 tie downs on the front wheels and 2 tie downs on the back wheels. The Maintenance Supervisor/FSS said he did not recall seeing the pamphlet on securing wheelchairs in the van that the surveyor reviewed. During an interview on 08/31/16 at 2:45 p.m. the Administrator said they did not have a specific policy and procedure on transportation or training for van drivers. Review of the facility's undated transportation pamphlet on securing a wheelchair, found in the van, indicated in part: · Positioning the chair: Facing forward. · Front tie downs: Anchor the tie downs to the floor approximately 3-8 inches outside the front wheels; Tighten the front tie downs. · Rear tie downs: Anchor the tie downs to the floor just inside of the rear back wheels of the chair; Tighten the rear tie downs. During an interview on 08/30/16 at 2:16 p.m. the Administrator was informed of the IJ based on the lack of staff training to secure the wheelchairs in the van and prevent accidents. The Administrator said he well get on it and make sure the wheelchairs were being secured properly. Plan of removal was submitted and accepted on 08/31/16 at 12:30 p.m.: · Wheelchair Van Restraint: The Regional Director of Operations conducted an in-service with return demonstration on properly restraining residents for transportation in the facility van with all staff currently assisting with transportation. Any other employees who may assist with transportation will be in-serviced on the proper procedure before transporting any residents. (08/30/16). · Staff education related to wheelchair van restraints: All residents will be secured in a forward facing manner only. The larger (rear) straps will be used in the rear position to secure the back of the wheelchair. The front of the wheelchair will be secured using the front straps. The lap restraint will go under the side rails and fasten in the center as to secure the waist and hips of the resident. Only one wheelchair resident will be transported at a time. (08/30/16). · Monitoring of wheelchair van restraints: The Maintenance Supervisor/FSS will monitor the procedures at least daily for 2 weeks then once a week there after for 4 weeks to ensure that residents are restrained appropriately. The Maintenance Supervisor will document his findings in a weekly restraint log. (08/30/16). · On-going management system: The Administrator will monitor the procedures at least twice a month to ensure that residents are restrained appropriately. The Administrator will document findings in a weekly restraint log. Findings will be presented to the QA & A (Quality Assessment and Assurance) committee at least monthly for review and recommendations until compliance with this regulatory requirement is met. The Administrator will ensure that all candidates for van driver have a current and valid driver's license and will have a check of candidates driving record prior to staff member driving the facility van. This will be done annually for all van drivers. (08/30/16). a) In-service training report: 08/30/16, 4:55 p.m. presented by the Regional Director of Operations. b) Subject: Proper positioning of wheelchairs in van and proper securing of wheelchairs in the van. c) Instructor: RDO (Regional Director of Operations). d) In-serviced staff on how to position wheelchair in van, how to properly secure wheelchair in van including which straps to use on front and back of wheelchair. Also in-serviced on how to properly place lap belt (seat belt) so resident is secure. Resident will be forward facing during transport. Plan of removal verification completed 08/31/16: · Interviews were conducted with staff (the 1 full time van driver, 3 CNAs, Maintenance Supervisor/FSS) regarding the training they had received regarding securing the wheelchairs in the van. The staff were able to explain the correct way to secure the wheelchairs. Staff were observed to correctly secure a wheelchair as indicated in the 08/30/16 in-service. During an interview on 08/31/16 at 4:00 p.m. the RNC (Regional Nurse Consultant) and the Administrator were informed the IJ was removed but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. A daily census report provided by the Administrator on 09/01/16 indicated there were 15 residents with wheelchairs and Geri-chairs that used the facility van for transportation.

Based on observation, interview, and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for elopement risk (Resident #1) as evidenced by: a) failure to place a RoamAlert bracelet on Resident #1, who was confused, and prevent her elopement from the facility on 12/14/13 after she made multiple attempts to exit the facility; b) failure to educate facility staff about the new RoamAlert system prior to Resident #1's elopement and following Resident #1's elopement; and c) failure to have a process of monitoring the RoamAlert bracelets worn by residents who were an elopement risk to check the functionality of the bracelets with the alarms on the doors. On 12/19/13 an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to deficient practice with the potential for more than minimal harm at a pattern on 12/20/13 at 12:25 p.m. The facility remained out of compliance as they had not yet monitored their plan for effectiveness. These failures resulted in Resident #1's elopement from the facility on 12/14/13. Resident #1 then crossed a busy four lane street which placed her at risk for harm. These failures could place the four residents the facility identified as wanderers at risk for leaving the facility unsupervised and place them in situations that could result in harm or death. Findings included: 1. Admitting physician orders [REDACTED].#1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] documented Resident #1 had moderately impaired cognitive skills, short-term memory problems, wandered, had uncorrected vision problems, had limited range of motion in both lower extremities, had involuntary movements, and had a lack of coordination. The assessment documented that Resident #1 had depression and anxiety, and she was resistant to being placed in the nursing facility. An admission Care Plan for Resident #1 dated 12/13/13 included problem #11: "Falls/Safety Risk/Elopement Risk. Goal: Resident will remain free of injuries and falls." Under this goal was a list of interventions with a check mark beside them. One intervention addressed elopement, which was, "WanderGuard." On 12/14/13, an additional intervention was handwritten into the care plan. It stated, "Modification: Q (every) 15 minute checks for 72 hours." 2. Observation of Resident #1 on 12/19/13 at 10:50 a.m. revealed she was sitting in a recliner in the front lobby. LVN (licensed vocational nurse) B was observed to help Resident #1 from the recliner to stand with her walker. LVN B provided considerable assistance as Resident #1 had difficulty standing. Resident #1 used a rolling walker. She then walked unassisted with the walker but did not appear steady. Resident #1 was not interviewable. Resident #1 was wearing a RoamAlert bracelet. 3. Nurse's notes revealed Resident #1 was admitted on [DATE] and was tearful and crying on admission. At 11:50 p.m., Resident #1 was still awake and the nurse documented that she accused the 2:00 p.m. - 10:00 p.m. shift CNA (certified nurse's aide) of trying to kill her with an axe. The CNA said that she was only trying to redirect the resident from the wrong room when the resident began yelling at her. 4. During an interview on 12/19/13 at 2:10 p.m., Police Officer (PO) A said that he was dispatched on 12/14/13 to find that Resident #1 had been picked up by a citizen at a local pharmacy parking lot and brought to the police department. He was not at his office and could not report the exact time of dispatch. He said the citizen witness explained he found the resident on the ground where she had fallen in the parking lot of the pharmacy. He said the resident could not get up, so he helped her to get up off the pavement and brought her to the police station. PO A said Resident #1 was confused and disoriented and could not tell them where she lived. He said he did not know how the resident safely crossed four lanes of traffic. PO A said that the facility called in a report of the missing resident about ten minutes after he was dispatched. He said the facility reported that the resident was only gone about ten minutes, but he found that difficult to believe, because the resident was approximately a half mile from the facility by his estimate. He said the EMS (emergency medical services) had already been dispatched to the police department to check her for injuries. He said that, by his estimation and taking into account the time it took Resident #1 to walk from the facility to the pharmacy, Resident #1 was likely missing from the facility at least a half hour or longer. A review of the Police Offense/Incident Report dated 12/14/13 revealed that on 12/14/13, PO A was dispatched at 0948 to the PD parking lot. Upon arrival PO A met with a citizen who advised that he was travelling north on the 1400 block of N Bryan Ave when he observed an elderly female laying on the road in front of the pharmacy. The citizen advsed that the elderly female was disoriented and was unsure of who she was or where she lived. The citizen advised that he then gave her a ride to the police department. EMS arrived and examined the female. At approximately 1001 hours dispatch received a 911 call from the facility that they had a missing person matching this person's description. POA A then transported the resident to the facility. LVN A advised PO A that she had last seen the resident 15 minutes prior to calling 911. 5. An attempt to contact the witness who picked Resident #1 up at the pharmacy and took her to the police department was unsuccessful. 6. Observation of the path from the facility to the pharmacy identified by the police officer revealed that Resident #1 travelled approximately two city blocks on the street occupied by the facility, crossed a busy four lane street, then went north another block to the pharmacy. Traffic on the four lane street was noted to be regular and busy. 7. Nursing notes dated 12/14/13 (no time identified), LVN A documented that Resident #1 said she wanted to go home and was trying to exit the facility. LVN A stated she notified the RN and the RN gave her a WanderGuard bracelet to place on the resident. At 8:15 a.m., LVN A documented the resident was sitting on a bench in front of the nurse's station. At 8:45 a.m., LVN A documented Resident #1 was going to exit doors on halls 3 and 4. At 9:15 a.m. she documented she saw the resident sitting back in front of the nurse's station. Resident #1 continued to say she needed to go home to her sister's house. At 9:30 a.m., Resident #1 was noted to be missing. LVN A documented notifications to the DON (Director of Nurses), a search of the premises, and a 911 call to the police department at 9:43 a.m. She documented Resident #1's return to the facility at 10:25 a.m. 8. During an interview on 12/19/13 at 9:20 a.m. the DON said that Resident #1 was admitted to the facility on [DATE]. The following day, Resident #1 eloped from the facility. She said the facility called 911 to report her missing and the PD (police department) informed them she was at the police station. The PD told them that a passer-by picked the resident up on the road and took her there. The DON said the resident was not gone very long. The DON said she determined that LVN A put a WanderGuard bracelet on the resident that morning because Resident #1 was anxious, pacing and going to the exit doors. The DON said the facility had installed a new system, called the "RoamAlert system " about a month prior which had replaced the older, WanderGuard system. She said the RoamAlert system was similar in that the resident wore a bracelet that would cause the door to lock when the resident went near the door and then if the resident stayed at the door and opened it, a loud alarm would sound. The DON said that LVN A put one of the WanderGuard bracelets on Resident #1 and that bracelet was not compatible with the RoamAlert system. She said the old bracelets had a beige/cream colored sensor on the bracelet and the new RoamAlert bracelets had a deep sapphire colored sensor. She said Resident #1 left out of the front door and the alarm did not sound since the bracelet did not work with the door. The DON said that it was her fault because she had never in-serviced any of the staff regarding the new system and the differences in the bracelets. She said she had not told them the old bracelets did not work anymore.When discussing whether she had in-serviced the staff regarding the system since Resident #1's elopement, she said she had talked to the staff, but had not done a full in-service and did not document anything. 9. A review of the facility's documentation regarding the incident revealed an incident/accident report dated 12/14/13 with no time. The writer documented that the incident occurred in the resident's room. Another place documented, "left facility." The description of the incident stated the resident left the front door of the facility, was found, and was taken to the police department. The writer documented she called 911 and was informed of same. She documented the resident was brought back and was not injured. Vital signs and notification to the physician and family were documented. Under the section, "Additional comments and/or steps taken to prevent recurrence," the space was blank. The document was signed by LVN A, the DON, and the Administrator. The nurse documented in nursing notes that a RoamAlert bracelet was placed on Resident #1 on her return. A separate checklist titled, "Missing Resident Policy Audit" completed by the facility documented the steps taken after Resident #1 was determined to have eloped. #23 of the checklist read, "Did NM (nurse manager)/charge nurse update CCP (care plan) to attempt to prevent further occurrences?" The writer documented, "A new bracelet was placed on resident." The checklist did not address testing or monitoring of the bracelet for Resident #1 or other residents. Resident #1's care plan dated 12/13/14 was not modified to address the change from "WanderGuard" to "RoamAlert" and did not include interventions to test or monitor the bracelet. 10. During an interview on 12/19/13 at 12:50 p.m., LVN A said that when she came on duty the morning of 12/14/13, she was told by the night shift staff that Resident #1 had been restless during the night, had talked about leaving, and had been lingering around the doors. LVN A said she decided that Resident #1 should be wearing a WanderGuard bracelet, so she talked to the RN supervisor, who agreed. LVN A said she and the RN began looking for a bracelet and finally found one in the DON's office and placed it on the resident. She said she did not test the bracelet with the door to see if it would work because that had never been their procedure. She said they had a remote tester that was used to test the bracelets and when she used that, it showed the bracelet was working. She said she knew the facility had the new RoamAlert system but had never been told it came with new bracelets or that the old bracelets would not work. LVN A said that it was not long after that when she noticed Resident #1 was missing and she sent the staff to search for her. LVN A said that she was very worried about Resident #1 because it was very cold outside that morning. She said she called the DON and then called 911 and found out Resident #1 was at the police department. 11. During an interview on 12/19/13 at 10:45 a.m., the Administrator said she had only been employed at the facility a short time (approximately a week and a half). She said she knew about the new RoamAlert system and knew the staff needed to be in-serviced about the system. She showed the investigator the in-service she had prepared, but stated she had not done it yet, because she was waiting on clarification from her corporate office regarding a piece of the in-service information. She said, "I had planned to do it next payday." 12. During interview on 12/19/13 at 10:50 a.m., LVN B said she was charge nurse for the day shift on this date. She said she had not received information regarding the RoamAlert bracelets. When discussing what color the new RoamAlert bracelets were, she said she thought they were white. She said she knew Resident #1 had eloped from the facility and that the door did not alarm, but she did not know why the door did not alarm since she thought the resident was wearing a WanderGuard bracelet at the time. 13. During observation and interview on 12/19/13 at 11:00 a.m., when discussing where the RoamAlert bracelets were kept if a nurse needed to access one, the DON said she was not sure. She said she would have to look or might have to call LVN A. She looked in the medication room in a drawer where she found a plastic bag that contained several old, WanderGuard sensors and one WanderGuard bracelet. She said those were the old ones that were not used anymore that had been cut off of the residents and replaced. There were no RoamAlert bracelets in the medication room. She then left to search and located a RoamAlert bracelet in a box in the Administrator's office. She said she would need to place the RoamAlert bracelets in the medication room, since staff could not get in the Administrator's office on weekends and evenings. 14. During an interview on 12/19/13 at 11:10 a.m., LVN B said she had never really checked the WanderGuard or RoamAlert bracelets on her shift (days). She said the night shift nurse had just told her at shift change this morning that she should be checking them. LVN B said the night shift was responsible to check the functioning of the bracelets and they documented these checks in a book at the nurse's station. She said she did not know how the night shift checked the bracelets. A review of the book at the nurse's station revealed a checksheet for daily night shift checks of the WanderGuard bracelets with a check mark in the date. Nurses had checked nightly checks of the bracelets every night in the months examined (November and December 2013). 15. During an interview on 12/19/13 at 11:30 a.m., the DON said that Resident #1's family told the facility at admission that she would likely try to elope. The DON said she told LVN C to put a RoamAlert bracelet on the resident on 12/13/13. When discussing what the facility's process was for checking the function of the new bracelets with the door to ensure they would set off an alarm, the DON said the night shift had just asked her the same question. She had a note in her hand and indicated it was from night shift staff. She said, "You might ask the Administrator." 16. During interview on 12/19/13 at 12:00 p.m., the Administrator joined the above interview. She had a remote tester that came with the RoamAlert system. She said a similar remote (hand-held) tester was what was used during the night shift to check the WanderGuard system. The tester would light up when placed in close proximity to the bracelet to show that the bracelet was active. She said the facility had not been using this method with the RoamAlert system. She had not provided this tester to the staff as she did not want them using it. The Administrator said that checking the bracelets with a remote tester did not prove the bracelets were working with the door, and so she would need to put a system in place to do this. She did not know how the RoamAlert bracelets had been being tested on the night shift, or if they had. 17. During interview on 12/19/13 at 3:10 p.m., LVN C said she worked the evening shift on 12/13/13 when Resident #1 was admitted . She said the DON never told her to place a RoamAlert bracelet on Resident #1. LVN C said she knew the facility installed a new alarm system about three weeks ago, but she was never given an in-service about the difference between this system and the WanderGuard system. 18. During an interview on 12/19/13 at 10:20 a.m., CNA A said Resident #1 was very confused. She said she had never been in-serviced about the RoamAlert system. When discussing the bracelets for the WanderGuard and RoamAlert systems, CNA A said, "They're the same." 19. During an interview on 12/19/13 at 10:55 a.m., CNA B said she was on duty when Resident #1 eloped on 12/14/13. She said Resident #1 was lingering around the side doors and she had re-directed the resident to the front lobby. She said a short time later, Resident #1 was missing when they went to take her vital signs. She said she thought Resident #1 was gone for about an hour. When discussing how Resident #1 eloped, CNA B said she did not know. She said she knew Resident #1 was wearing a bracelet, so she did not know why the alarm on the door did not sound. 20. During an interview on 12/19/13 at 3:00 p.m., CNA C said she was not informed about the RoamAlert bracelets until today. 21. During an interview on 12/20/13 at 5:10 a.m., LVN D said she worked the night shift. She said she was not in-serviced about the difference between the WanderGuard system and the RoamAlert system until after this investigation began yesterday. She said that the night shift staff had asked the DON how they were supposed to test the bracelets' function as they were supposed to document it, but the DON had told them she would have to get back with them. She said she had discussed this with another night shift nurse, who had told her that without the hand-held tester, the only way to test the bracelets was to get the residents out of bed and take them to the door, and that was not feasible. 22. A review of the facility's policies and procedures specific to elopement provided by the DON on 12/19/13 revealed policies that included a policy titled, "Elopements" dated with revision in December 2006. This policy did not include provisions to prevent elopements. It included only the statement, "Attempt to prevent the departure." The rest of the procedure addressed the facility's response to a missing resident. A second policy titled, "Missing Resident/Elopement" (no date) included policies and procedures the facility would implement following awareness that a resident was missing. There were no policies/procedures regarding the RoamAlert System or prevention of elopements. The facility's Abuse and Neglect Policy and Procedure dated 11-11-11 included the following under "Interpretation & Implementation": "-3. ...Supervision will be provided for those individuals with known special needs: ...Impaired individuals with known elopement risk". 23. On 12/19/13 at 1:20 p.m., the Administrator and DON were informed of the Immediate Jeopardy identified related to Resident #1. 24. The facility submitted the following action plan for removal on 12/20/13: a. Elopement Assessment to be done on admission, readmission, quarterly, and significant change. b. RoamAlert system check daily by taking the resident to the door to ensure the door locks. c. All staff in-serviced and trained on the RoamAlert bracelet and alarm on the doors. d. If RoamAlert bracelet does not work, a new bracelet will be immediately tested and applied. e. Maintain stock of RoamAlert bracelets in the Medication Room. f. All old WanderGuard bracelets removed from the building and thrown away. g. Quarterly review of the RoamAlert system monitoring effectiveness during Quality Assurance Meetings. 25. Plan of removal verification completed 12/20/13: -Interviews were conducted with direct care staff to verify knowledge of the RoamAlert system. -Observation of the four residents who were identified as elopement risks to ensure all residents were wearing the RoamAlert bracelets. -Observation and interview to verify that all RoamAlert bracelets were compatible with the doors and set off the alarms (Residents were brought to the door to ensure the bracelet set off the alarm). 26. During a conference on 12/20/13 at 1:25 p.m. the facility was notified that the Immediate Jeopardy was lowered to deficient practice with the potential for more than minimal harm when the action plan was fully implemented. 27. During an interview on 12/19/13 at 9:20 a.m., the DON said that the facility had four residents who were at risk for elopement.

Based on observation, interview, and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 5 of 5 residents (Residents #1, #2, #3, #4, #5) reviewed for elopement risk as evidenced by: a) failure to ensure the exit door (these doors are locked using a key code entry, there is no RoamAlert alarm on these doors) on Hall 3 located near the front of the hall was kept secure at all times; b) Failure to educate facility staff/vendors about keeping exit doors secure by not propping them open. The exit door on Hall 3 was propped open and not attended by staff on 03/11/14. Resident #1 resided on Hall 3 and had a previous elopement on 12/13/13, having been found a mile from the facility in a parking lot. Residents who were known wanders and had the Roam Alert alarm on were not accounted for until 2 hours after the Director of Nureses and the Administrator were made aware of the open door. On 03/11/14 an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to deficient practice with the potential for more than minimal harm at a pattern on 03/12/14. The facility remained out of compliance as they had not yet monitored their plan for effectiveness. These failures could place the five residents the facility identified as wanderers at risk for leaving the facility unsupervised and place them in situations that could result in harm or death. Findings included: Observation on 3/11/14 at 9:34 a.m. revealed the exit door at the front end of Hall 3, leading to the outside was open without any staff located in the hall or outside the door. There was no staff or repairmen observed within sight on the inside or outside the exit door. The Administrator and Director of Nurses were notified on 3/11/14 at 9:38 a.m. the door was propped open and no staff was observed in the area. The Administrator was informed by staff that a housekeeper had been outside and watching and monitoring the door as she swept. The Administrator said there was a water heater repair person at the facility and that was why the door was open. She said we don't usually prop it (the door) open. RESIDENT #1 Review of Resident #1's Admission Record, undated, documented she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 resided on Hall 3. Review of Resident #1's Elopement Risk assessment dated [DATE] documented Resident #1 is cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time), had dementia , Alzheimer's, and hallucinations, ambulates without assist, ambulated in the facility and was confused/disoriented. On 03/07/14 it was documented on Resident #1 Elopement Risk Assessment that the resident continues to be at risk for elopement from facility. Cont. (continue) with Roam Alert bracelet on. Has made no more attempts to leave facility. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] documented in part: -Mental status score of 09 (scores: 0-7 severe impairment, 8-12 moderately impaired 13-15 cognitively intact to determine the residents ability to remember, think coherently, and organize daily self-care activities). -Resident mood Interview- total severity level of 12 (feeling down, depressed or hopeless almost every day, feeling tired or having little energy almost every day, feeling bad about yourself-or that you are a failure or have let yourself or your family down almost every day and had trouble concentrating on things, such as reading the newspaper or watching television almost every day). -Behaviors: Wandering-Presence & Frequency 1. Behavior of this type occurred 1 to 3 days (Resident eloped on 12/14/13 from the facility according to previous investigation). Does the wandering place the resident at significant risk for getting to a potentially dangerous place (e.g. stairs, outside of the facility)? Yes -Functional Status: a one person limited assist with transfers, walked in room and corridor with limited assist, - Functional limitation in Range of Motion: no impairment to upper or lower extremities and used a walker for mobility. The Care Plan for Resident #1 dated 12/21/13 documented in part: Resident requires a wander guard device and is at risk for injury from wandering in a un-safe environment as evidenced by: Resident had a wander guard put in place early am by nurse. She (Resident #1) was trying to leave the facility. Resident is at risk for injury due to potential elopement-(wandering) confused as evidenced by: monitor her closely when up in the hall, follow wander guard system to prevent resident from leaving facility. (Care Plan updated 1/14/14) Resident has episodes of inappropriate behaviors as evidenced by: she wanders about in the facility and is very confused. She wears a wander guard due to hx (history) of elopement. She takes Risperdal 0.25 mg 1 po (by mouth) as needed (delusions). (Care Plan updated 1/14/14) Resident had impaired communication as evidenced by: Alzheimer's and she is very confused. She only speaks Spanish. (Care Plan updated 1/14/14) Resident has cognitive impairment as evidenced by: she has short term memory loss with impaired decision making skills. (Care Plan updated 1/14/14) Psychosocial well-being-little interest or pleasure doing things mood state-feels depressed or hopeless and feels tired or having little energy. Review of the Wander Risk Information, undated, documented Resident #1's family stated "sometimes you will find her trying to leave". In an interview on 03/11/14 at 11:40 a.m. (Cook A translating) Resident #1 said she was very sad (Resident #1 started to cry) because no one comes to visit her, that she was not crazy and does not need to be there (meaning at the facility). Resident #1 asked the surveyor when she would be able to leave the facility. In an interview on 3/11/14 at 11:40 a.m. MDS Coordinator said Resident #1 had gotten out of the facility before (note: This follow up visit was directly related to violations cited as a result of the elopement of Resident # 1 from the facility on 12/14/13. The Plan of Action for 12/19/14 docuemnted: Elopement Assessment to be done on admission, readmission, quarterly, and significant change, RoamAlert system check daily by taking the resident to the door to ensure the door locks, all staff in-serviced and trained on the RoamAlert bracelet and alarm on the doors, if RoamAlert bracelet does not work, a new bracelet will be immediately tested and applied, maintain stock of RoamAlert bracelets in the Medication Room, all old WanderGuard bracelets removed from the building and thrown away, and quarterly review of the RoamAlert system monitoring effectiveness during Quality Assurance Meetings). RESIDENT #2 Review of Resident #2's Admission Record, undated, documented he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 resided on Hall 3. Review of Resident 2's Elopement Risk assessment dated [DATE] documented Resident #2 is cognitively impaired with poor decision-making skills (i.e., intermittent confusion), lower extremities continue to be weak, wanders about in the facility aimlessly and not at risk for elopement at this time. Review of Resident #2's Monthly summary Assessment, dated 2/23/14 documented in Part: Memory: Short and Long memory problems. Decision Making: Moderately impaired-decisions poor, cues/supervision required. Behavior symptoms: Wandering (moves with no rational purpose, seemingly oblivious to needs or safety), verbally abusive behavioral symptoms (ex: others were threatened, screamed at, cursed at) and Rejection of Care (resist taking medication/injections, ADL (activities of daily living) assistance or eating) Review of Resident #2's MDS dated 02/19/14 documented in part: -Mental Status summary score-04 (scores: 0-7 severe impairment). -Delirium: Inattention that was continuously present does not fluctuate. -Functional Status: total dependence with one person with transfers, locomotion off unit is with a wheelchair and one person assist. -Functional Limitation in Range of Motion: no impairment of either of her lower or upper extremities. Mobility Devices: wheelchair for mobility. The Care Plan for Resident #2 dated 5/11/13, updated 3/01/14 documented in part: Resident is at risk for injury due to potential elopement he has a wander guard bracelet to alert staff as evidence by: he wanders about-confused at times. Resident requires a wander guard device and is at risk for injury from wandering in a un-safe environment as evidenced by: check his wander guard to be sure it is working and the door alarms is also working. Resident wanders-resident will be free of any problems related to wandering over the next 90 days. Resident has cognitive impairment as evidenced by: he has short and long term memory loss-poor decision making at this time. Psychosocial well-being-little interest or pleasure doing things mood state-feels depressed or hopeless and feels tired or having little energy. In an interview on 3/11/14 at 11:40 a.m. the MDS Coordinator said Resident #2 gets around the facility well by himself (resident uses a wheelchair for mobility). RESIDENT #3 Review of Resident #3's Admission Record, undated, documented she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 3's Elopement Risk assessment dated [DATE] documented Resident #3 is cognitively impaired with poor decision-making skills (i.e., disoriented all the time), resident ambulates without assist, ambulates in the facility is confused and disoriented. Documentation date 12/15/13 resident is not at risk for elopement at this time (resident has a Roam Alert bracelet on). Review of the Progress Notes dated 3/01/14 at 1800 documented in part: 1800 (6:00 p.m.) Per med aide, refused all pm meds-Verbally aggressive to another resident, kept going to front door as if looking for somebody. Son did not come to visit tonight. Review of Resident #3's physician's telephone orders dated 12/24/13 documented: may apply roam alert. Review of Resident #3's MDS dated [DATE] documented in part: Mental status score 04 (scores: 0-7 severe impairment). -Functional status: Locomotion off and on unit (how resident moves in his/her room and off unit-e.g., areas set aside for dining, activities or treatments) l with limited assist and one person physical assist. Resident #3 had no impairment of the lower or upper extremities and used a wheelchair for mobility. The Care Plan for Resident #3 dated 10/12/13, updated 1/04/14 documented in part: Resident is at risk for injury due to wandering as evidence by: she wanders about in facility- 12/24/13 Roam Alert put on resident to alert staff if resident tries to exit facility alone. Resident has cognitive impairment as evidenced by: she has short and long term memory loss. Mobility-at risk for falls as resident ambulates about the facility. Resident ADL functions: bed mobility, transfers, dressing, assist: self. Review of the Progress Notes dated 3/01/14 at 1800 documented in part: 1800 (6:00 p.m.) Per med aide, refused all PM meds-Verbally aggressive to another resident, kept going to front door as if looking for somebody. Son did not come to visit tonight. RESIDENT #4 Review of Resident #4's Admission Record, undated, and Care Plan dated 1/16/14 documented he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Progress notes dated 2/4/14 at 1510 (3:10 p.m.) documented Alert yet confused, looking for his truck. Review of Resident 4's Elopement Risk assessment dated [DATE] documented Resident #4 is cognitively impaired with poor decision-making skills (i.e., intermittent confusion), [DIAGNOSES REDACTED]. Resident #4 is at risk for elopement and wears a wander guard-staff, aware of the risk-tries to keep him within vision when up in his w/c (wheelchair). Review of Resident #4's Monthly summary Assessment, dated 02/17/14 documented in part: Memory: Short and Long memory problems Decision Making: Moderately impaired-decisions poor, cues/supervision required Behavior symptoms: Wandering (moves with no rational purpose, seemingly oblivious to needs or safety), physically abusive behavioral symptoms (ex: others were hit, shoved, scratched cursed at). Musculoskeletal: 1) Modes of locomotion-wheelchair-self-other 2) contractures/limited ROM (range of motion)-none. Review of Resident #4's MDS dated [DATE] documented in part: -Mental status summary score-05 (scores: 0-7 severe impairment). -Functional status: locomotion on and off unit (how resident moves in his/her room and in area out of room such as dining, activities or treatment)-limited assistance with one person physical assist. -Functional limitation in Range of Motion- no impairment with upper and lower extremities. Mobility Devices- wheelchair used for mobility. The Care Plan for Resident #4 dated 5/11/13, updated 3/01/14 documented in part: Resident is at risk for injury due to potential elopement he has a wander guard bracelet to alert staff as evidence by: he wanders about-confused at times. Resident requires a wander guard device and is at risk for injury from wandering in a un-safe environment as evidenced by: check his wonder guard to be sure it is working and the door alarms is also working. Resident wanders-resident will be free of any problems related to wandering over the next 90 days. Resident has cognitive impairment as evidenced by: he has short and long term memory loss-poor decision making at this time. Psychosocial well-being-little interest or pleasure doing things mood state-feels depressed or hopeless and feels tired or having little energy. RESIDENT #5 Review of Resident #5's Admission Record, dated 06/24/10, documented she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 5's Elopement Risk assessment dated [DATE] documented Resident #5 is cognitively impaired with poor decision-making skills (i.e., cognitive deficit or disoriented all the time), [DIAGNOSES REDACTED]. 3/11/14 Cont.(continue) with Roam Alert bracelet on wheels in w/c and needs help at this time. Occasionally ambulates with walker and gets close to door. Review of Resident #5's The MDS dated [DATE] documented in part: -Mental status summary: score-05 (scores: 0-7 severe impairment). -Delirium: Inattention-difficulty focusing attention. -Resident Mood Interview- score of 24 (little interest of pleasure In doing things, feeling down, depressed, or hopeless, trouble sleeping, poor appetite or overeating, feeling bad about self, trouble concentrating on things, moving or speaking and moving so slowly others notice). -Behavioral Symptoms: Verbal behavior symptoms directed toward other (threatening others, screaming at other, cursing at other). -Functional status: locomotion on and off unit (how resident moves in his/her room and in area out of room such as dining, activities or treatment)-limited assistance with one person physical assist. - Functional limitation in Range of Motion: no impairment with upper and lower extremities. Mobility Devices- wheelchair and walker used for mobility. The Care Plan for Resident #5 dated 10/06/13, updated 01/06/14 documented in part: Resident is at risk for injury due to potential elopement as evidenced by: she is wearing a wander guard so staff would be aware of her going to the door to go out of the facility. Resident has cognitive impairment as evidenced by: she has short and long term memory loss-unable to make decisions. INTERVIEWS During an interview on 3/11/14 at 10:15 a.m. the Administrator said the washer repairman was the one who left the door open. She said the housekeeper went out the door to sweep and he (the repairman) was the one that left the door open. The Administrator said she was going to call and tell the repairman to not prop the door open. In an interview on 3/11/14 at 10:40 a.m. The Administrator said she talked to the repairman and informed him he couldn't prop the door open. She said that he was glad to know that because he had not been aware he could not prop the door open. She said she was going to call the main office and have them inform all the repairmen. The Administrator said she did not ask him when he propped the opened door. During an interview on 3/11/14 at 11:25 a.m. the Administrator and the Director of Nurses (DON) said they had not checked to see if all resident were accounted for . The DON said "I guess I better do one now". In an interview on 3/11/14 at 10:50 a.m. Housekeeper B (she observed the door open and was sweeping the area) said the door had to have been opened around 9:30 to 10:00 a.m. and that she closed the door. She said she stepped outside to sweep but didn't know what time it was for sure, it could have been 10:00 or 10:10 a.m. The housekeeper said she did not see a repairman outside. She said it was only herself and another staff member (did not remember who it was). She said she went back to the dining room but made sure the door was locked. She said when she saw the repairman later, she informed the repairman not to keep the door open. She said she wasn't outside for very long, just long enough to sweep the entrance area of the door way. In an interview on 3/11/14 at 11:50 a.m. the Administrator said she did not know if there was a written policy for the doors being kept closed and locked. In an interview on 3/11/14 at 11:55 a.m. the DON said she should have done a head count and the one who saw the door opened should have closed it and reported it (the door being propped open was reported by the surveyor). I should have gone immediately to check on the residents. In an interview on 3/11/14 at 3:40 p.m. the nurse consultant said "I think the vendor had the key pad number to get in and propped it open. I wasn't here, I am just trying to fix the problem . I have changed the key lock pad numbers and I am not letting the vendors have the key pad numbers. I have posted signs at the doors to keep doors shut and to enter and exit out the front door only. I checked all the doors from inside and outside, they were all locked. I think the vendors having the numbers was the problem and I think this has it fixed." In an interview on 3/12/14 at 10:05 a.m. Cook A said she was working on Hall 3 and the repairman asked her to open the door and let him out. She said the repairman was coming in and out. Cook A said she saw housekeeper B prop the door open to sweep after sweeping, housekeeper B closed the door. Cook A said she had seen repairmen keep the door open in the past. She said groceries are delivered on Tuesday's and they (the delivery men) get mad when the door is closed. She said the delivery man said it was too much trouble to keep opening the door. She said she had only seen the plumber and the grocery delivery guy prop the door open. In an interview on 3/12/14 at 10:25 a.m. LVN C, the charge nurse for Hall 3, said she did not see the door open on Hall 3. She said she might have been at the nurse's desk or giving medications on Hall 2. She said she opened the door to the storage room for the repairman, not the exit door, and that was the only time she saw him. She said she did not know what time that was. She said she had been in the dining room and Hall 2 and did not see the door open to the outside. She said she went to the nurse's desk to chart and did not look that way (toward Hall 3/exit door). In an interview on 3/12/14 at 10:45 a.m. CNA D said she worked both Hall 3 and 4. She said she saw the plumbers coming in and out. She said the door was propped open. She said she went to the door and was going to close it when the plumber yelled no-no (for her not to shut the door) he was coming back in, so she left the door open. She said she didn't know she was going to get the facility in trouble or she would have shut the door. She said the people who deliver groceries would use that door and they would prop it open. She said she didn't know they couldn't leave the door open. She said she didn't know when the door was closed, maybe between 10:00 a.m. to 10:30 a.m. She said she went on break at 10:30 a.m. so it was somewhere around that time. POLICIES When asked for a policy for the doors on 3/12/14 at 12:50 p.m. the Nurse consultant said " we don't have anything that says anything specifically about keeping the doors locked, they have always been locked." A review of the facility's policies and procedures specific to elopement provided by the Administrator on 3/11/14 revealed policies that included a policy titled, "Elopements" dated with revision in December 2006. This policy did not include provisions to prevent elopements. It included only the statement, "Attempt to prevent the departure." The rest of the procedure addressed the facility's response to a missing resident. On 03/11/14 at 12:12 p.m.an Immediate Jeopardy was identified. Plan of Removal was submitted on 03/11/14. All vendors and facility staff will not use any door other that the front entrance door to enter and exit facility. An 8 X 10 notification (poster) will be posted on all doors to redirect to the front door for entrance and exit. Will be monitored by administrator, director of nurses and charge nurses. Maintenance man will monitor all locked doors three times a day, Monday thru Friday and charge nurses will monitor doors on the weekends to ensure they are locked and not propped open. This will be documented on the elopement book form labeled hall door monitor: located at the nurses station. Key pad codes have been changed by maintenance man and the vendors do not have this code to enter from any side doors and will not be given code. Inservice all staff on 03/11/14 and completed on 03/11/14 either in person or by phone on what to do when a door is found to be propped open, and not to give key pad codes to anyone other than staff, and to not use any other door but front door to enter and exit facility. Also inserviced on monitoring of doors. Elopement assessment to be done on all admissions, readmissions, quarterly and upon a significant change in condition. To be completed by nursing. Roam Alert checked daily by taking the resident to the door to ensure the doors lock as required. Roam Alert log kept at nurses station and will be monitored by the Managers and Administrator. Plan of removal verification completed 3/12/14: -Observation to verify that all doors were locked and signs were posted on all exit doors. -Interviews were conducted with staff (CNA, housekeepers, activity director, cooks, aide from hospice, laundry aide and nurses) regarding the training and knowledge of keeping the doors locked what to do for residents if a door is left open, and not giving codes to vendors. During the exit on 3/12/14 at 11:25 a.m. the facility was notified that the Immediate Jeopardy was lowered to deficient practice with the potential for more than minimal harm at a pattern. A list provided by the DON on 3/11/14 at 10:05 a.m. documented the facility had five residents who were at risk for elopement.