Every finding on record at Fulton Center for Rehabilitation LLC

Based on observations, staff interviews, record review, and review of the facility's policies titled, Handwashing/ Hand Hygiene and [facility name] for Rehabilitation Infection Control Policy and Procedure, the facility failed to ensure that staff follow proper infection control techniques when administering medications, performing wound care, and providing residents care needs. The facility also failed to ensure a clean sanitary environment in the laundry room, with one of two washers inoperable. The facility failed to ensure staff practiced proper infection control measures by keeping oxygen tubing covered and in a clean sanitary area. The facility census was 96. Findings include: Review of the undated facility's policy titled Handwashing/ Hand Hygiene revealed under Policy Interpretation and Implementation: . 2. All personnel shall be trained and regularly in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; . h. Before moving from a contaminated body site to a clean body site during resident care; .k. After handling used dressings, contaminated equipment, etc., and . p. Before and after assisting a resident with meals. A review of the facility's policy titled [name of facility] for Rehabilitation Infection Control Policy and Procedure under Purpose: To help prevent the development and transmission of communicable diseases and infections in the Facility. Under Policy revealed: It is [name of facility] policy to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for all. Under Procedure: Infection Prevention and Control Program revealed: The Facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: .VI. Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. Observation on 4/29/2025 at 10:55 am revealed Licensed Practical Nurse (LPN) CC, Wound Care Nurse performing wound care. LPN CC was observed removing soiled dressing with the left hand and cleaning the wound with the right hand. No hand hygiene was performed, nor gloves changed between removing soiled dressing and cleaning the wound. LPN CC then removed gloves, sanitized hands and reapplied gloves to apply clean dressing. Interview on 4/29/2025 at 11:05 am with LPN/ Wound Care Nurse CC revealed him confirming that he did not change gloves in-between removing the soiled dressing and cleaning the wound. LPN CC stated that he used two different hands and washed his hands a million times. Observation on 4/30/2025 at 8:40 am with LPN AA revealed her administering morning medications. During the medication pass LPN AA revealed that three medications were missing from the medication cart and went to the medication room to remove it from the emergency medication box before returning to the medication cart to continue administration. No hand hygiene was performed. Interview on 4/30/2025 at 9:37 am with LPN AA revealed her confirming not performing any hand hygiene during the medication pass and stated that none was available on the medication cart (hand sanitizer). During an interview on 5/1/2025 at 9:53 am with the Director of Nursing (DON) revealed that it was her expectation that all staff were following the infection control policies and procedures of the facility. The DON also stated that she was not made aware that the hand sanitizing stations were broken and that some were empty. She revealed addressing the issues yesterday when it was brought to her attention. During an interview on 5/1/2025 at 10:48 am with the Infection Preventionist (IP)/ Staff Development Coordinator revealed that it was her expectation that staff were following proper infection control procedures. She revealed that in-services on hand hygiene and infection control were completed on 4/2/2025 with over 50% of the nursing staff in attendance. The IP admitted that hand sanitizing stations needed fixing and filling, but she was not aware until today. The IP revealed that all medication carts were supposed to have hand sanitizer available and that some of the staff were intentionally not performing hand hygiene and were now facing disciplinary actions. The IP also stated that staff also completed hand washing education with Covid-19 teachings and donning (putting on) and doffing (removing) of PPE (personal protective equipment) on 3/19/2025. 49138 2. Observation on 4/30/2025 at 12:08 pm of the laundry area revealed a staff member's personal items were observed on the folding table located in the clean linen area. A clean linen item was observed in direct contact with the floor. Interview on 5/1/2025 at 12:08 pm with Laundry Aide (LA) EE revealed she did not wear PPE when processing soiled laundry, due to the heat and a medical condition. Interview on 5/1/2025 at 10:48 am with the Infection Preventionist (IP) revealed that it was her expectation that staff were following proper infection control procedures. She revealed that in-services on hand hygiene and infection control were completed on 4/2/2025 with over 50% (percent) of the nursing staff attending.

Based on observations, staff interviews, and review of the facility policy titled, Preventative Maintenance Program, the facility failed to maintain the resident rooms in a clean, comfortable, homelike environment in 10 of 32 occupied rooms. Specifically, observations of rooms 103, 106, 203, 202, and 120 revealed heating, ventilation, and air conditioning (HVAC) units with black and/or brown film, cracked drywall, loose door handles, loose call light plates, and worn furniture. These deficiencies had the potential to create health and safety hazards and diminish the quality of life for affected residents. Findings include: Review of the facility policy titled Preventative Maintenance Program reviewed/revised September 2023 revealed the following: Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Review of the Direct Supply TELS (maintenance work order system) Tasks in Use revealed the following: Category HVAC-Chillers: inspect condenser coils, clean as required (every two weeks/every three months). Category Facility Inspection: asset tagging-HVAC (monthly) Category HVAC-Air Handlers: inspect air filter, verify operation (every three months) Review of the Housekeeping Action Plan for Training New Hires and Transition, dated April 25, 2025, revealed no tasks related to HVAC units. Observation of resident rooms on 4/29/25 revealed the following: 4/29/2025 at 10:16 am, room [ROOM NUMBER]: HVAC unit grill (black film) 4/29/2025 at 10:40 am, room [ROOM NUMBER]: HVAC unit grill (brown film) 4/29/2025 at 11:14 am, room [ROOM NUMBER]: cracked drywall (window side), HVAC unit (black film) 4/29/2025 at 11:48 am, room [ROOM NUMBER]: HVAC unit (black film) 4/29/2025 at 11:51 am, room [ROOM NUMBER]: HVAC unit (black film); loose bathroom door handle; loose call light plate 4/29/2025 at 12:31 pm, room [ROOM NUMBER]-A: nightstand bottom drawer handle hanging on one screw Repeat observation of rooms 103, 106, 203, 202, 120, and 207 on 4/30/25 revealed the following same concerns: 4/29/2025 at11:00 am, room [ROOM NUMBER]: HVAC unit grill (black film) 4/29/2025 at 11:05 am, room [ROOM NUMBER]: HVAC unit grill (brown film) 4/29/2025 at 11:15 am, room [ROOM NUMBER]: HVAC unit (black film) 4/29/2025 at 11:20 am, room [ROOM NUMBER]: cracked drywall (window side), HVAC unit (black film) 4/29/2025 at 11:25 am, room [ROOM NUMBER]: HVAC unit (black film); loose bathroom door handle; loose call light plate 4/29/2025 at 11:30 am, room [ROOM NUMBER]-A: nightstand bottom drawer handle hanging on one screw During observations and interview with the Maintenance Director (MD) on 5/1/2025 at 4:05 pm, he confirmed the aforementioned observations. He stated he was only hired this past Tuesday and had yet to complete an assessment of the facility's maintenance needs. He stated the maintenance staff were responsible for keeping the HVAC units clean and well-maintained. He stated they are supposed to be trained to perform routine inspections, clean filters and ensure the units operated efficiently. The MD also stated that the environmental services department was responsible for deep cleaning twice a week and the air conditioning units were a part of each deep clean. He confirmed regular maintenance of the units was critical for residents who may be more vulnerable. He stated dirty or poorly maintained units can harbor dust, mold, and bacteria, increasing the risk of infections in the facility. In an interview with the Administrator on 5/1/2025 at 5:00 pm, she stated she had identified some tasks previously not done on time and terminated the previous Maintenance Director on 4/28/2025. The current Maintenance Director started on 4/29/2025. In addition, the housekeeping company was a newly contracted company that just started in March of 2025. She stated she expected the HVAC units to be cleaned regularly and would clarify the roles of the maintenance and housekeeping departments related to this.

Based on staff interview, record review, and review of the facility policy titled, Transfer and Discharge (including AMA), the facility failed to issue a written transfer notice and a bed hold policy to one of two residents (R) (R1), sampled for falls. Findings include: Review of the facility policy titled Transfer and Discharge (including AMA) reviewed/revised January 2023, revealed the following: Policy Explanation and Compliance Guidelines: .2. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met at the facility.4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for the transfer or discharge. b. The effective date of transfer or discharge. c. The specific location .to which the resident is to be transferred.12. Emergency Transfers/Discharges: initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. Review of the electronic medical record (EMR) for R1 revealed admission to the facility with diagnoses to include but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the dominant right side, repeated falls/history of falling, and vascular dementia. Review of the Care Plan revealed R1 was at risk for falls due to generalized weakness, highly impaired mobility, and psychotropic med use (Initiated/Created 1/22/2024). Continued review of the Care Plan revealed R1 was found lying on back at bedside with c/o (complaint of) pain on 8/14/2024 with an intervention to send to ER (emergency room ) for evaluation and treatment. Continued review of the EMR revealed no documentation to indicate that written transfer notification and bed hold policy were issued to R1 or his responsible party (RP) related to the hospital transfer on 8/14/2024. In an interview with the Director of Nursing (DON) on 5/1/2055 at 5:30 pm, she confirmed, after speaking with the Business Office Manager (BOM), that there was no documentation in the EMR or on file related to written transfer notification and bed hold policy issued to R1 or his RP, but should have been.

Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Comprehensive Assessments and the Care Delivery Process and Resident Smoking, the facility failed to ensure accurate and complete quarterly assessments related to smoking status and safety for two of 45 sampled residents (R) (R27 and R36). The deficient practice had the potential for R1 to have unmet needs and services. Findings include: Review of the facility policy titled Comprehensive Assessments and the Care Delivery Process revealed under Policy Statement: Comprehensive assessments will be conducted to assist in developing person-centered care plans. Under Policy Interpretation and Implementation: Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Review of the facility's policy titled, Resident Smoking revised December 2023, revealed in the Policy Explanation and Compliance Guidelines: . 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 6. Resident who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or of resident is safe to smoke at all.13. Smoking materials of residents (such as matches and lighters) will be maintained by nursing staff. 14. Residents that have shown the ability to safely store and follow facility safe smoking rules can keep their own cigarettes but no lighters or matches. Review of R27's electronic medical record (EMR) revealed diagnoses to include but not limited to schizophrenia, psychosis, and symbolic dysfunctions. Review of R27's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Summary for Mental Status (BIMS) score of 14, indicating intact cognition. Section E (Behaviors Symptoms) indicated that no behavioral symptoms were exhibited. Review of R27's smoking care plan dated 2/10/2018 included the following interventions: R27 must be supervised while smoking in authorized areas, wear a smoking apron, and keep cigarettes and lighters locked up except during scheduled smoking times. The goal was for R27 to remain free from injury and adhere to facility tobacco policies. Review of smoking assessments revealed there were only two completed, on 10/2/2024 and 4/29/2025. Interview on 4/30/2025 at 4:25 pm with MDS Coordinator (MDSC II), MDSC II revealed she was unsure of the frequency at which smoking assessments should be completed. After reviewing the medical record, she was unable to confirm whether quarterly assessments had been completed and stated she would follow up. Interview on 5/1/2025 at 10:10 am with Licensed Practical Nurse (LPN) LPN GG confirmed that smoking assessments should be completed quarterly. Interview with the Director of Nursing (DON) on 5/1/2025 at 3:55 pm confirmed that smoking assessments should be completed quarterly. 51215 2. Review of R39's admission records revealed he was admitted to the facility with diagnoses that include but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, tobacco use, dizziness and giddiness, and type 2 diabetes mellitus without complications. Review of R39 care plan dated 7/26/2024 revealed focus of smoking indicating R39 is a current smoker with a goal to remain safe from injury through the next review period. Interventions include a smoking history and safe smoking assessment will be completed upon admission/readmission, quarterly, annually, and/or with a change in smoking habits and care smoking care plan will be initiated. Resident must have cigarettes/lighters locked up at all times other than smoking time. Resident will smoke only in authorized areas. Smoking education has been provided to resident including: not smoking in facility; designated smoking areas; locking up cigarettes/lighters; cigarettes brought in by family/friends must be locked up; only facility ashtrays may be used. Violation of smoking rules or disregard for safety rules my [sic] result in revocation of smoking privileges. Smoking rules will be reviewed with the resident upon admission. The resident is a Supervised Smoker and must be supervised in authorized area when smoking individually or with a group. Review of physician orders for R39 include but not limited to: is resident abiding by smoking policy and procedures? Did the resident demonstrate any behaviors during your shift? If yes, document a progress note and describe behavior . During an observation on 5/1/2025 at 4:30 pm revealed R39 dropping a lighter out of his pocket as he walked in through the dining area. During an interview on 5/1/2025 5:45 pm with R39 revealed that he usually keeps his lighter until after the 7:00 pm smoke break because usually there is no one to take us out and different staff members punches the code in to let us out for the break and when we come back in I usually put the lighter back in the box. During a record review of R39's smoking assessment it was revealed that R39's last smoking assessment was completed on 10/2/2024. The only indicators were that R39 smokes tobacco and follows the facility's policy on location and time of smoking. During an interview on 5/1/2025 at 4:38 pm with the Social Work Director (SWD) revealed that R39 has had only two smoking evaluations since his admission to the facility. She stated that the dates of his smoking evaluations were on 10/26/2022 and 2/5/2023. She stated she was unaware of how often they were supposed to be done.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans and Comprehensive Assessments and the Care Delivery Process, the facility failed to develop and implement a comprehensive person-centered care plan for one of two residents (R) (R35) and failed to properly assess R35 in order to properly apply the data collected to the care provided. This failure had the potential to affect R35 by not assessing their psychosocial needs, goals, desired outcomes, and preferences. Findings include: Review of the facility's policy titled Comprehensive Care Plans implemented March 2025 revealed in section Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: .e. The resident and the resident's representative, to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: .iii. Social Service Director/ Social Worker. Review of the undated facility's policy titled, Comprehensive Assessments and the Care Delivery Process revealed under Policy Interpretation and Implementation: Assessment and information collection includes (WHAT, WHERE and WHEN?). The objective of the information collected (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. a. Assess the individual. (1) Gather relevant information from multiple sources, including: (a) Observation; (d) Resident and family interview; (2) Complete the Minimum Date Set (MDS) within 14 days after admission, within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive decline. Review of the care plan for R35 dated 1/30/2025 revealed a focus that R35 prefers to participate in self-directed activities as well as group activities and a goal that she will choose to participate in independent leisure pursuits such as in room movies, keeping up with the news, phone conversations, and family visits daily throughout the review period. Interventions include identify and discuss currently offered programs which coincide with R35 activity interests, invite and assist R35, as needed, to activities of interest if appropriate, such as socials, games, religious services, and movies and orient her to facility and program; provide calendar of activities. Care plan also states that R35 has an established advanced directive of a full code with a goal stating that R35 or healthcare decision maker shall participate in decisions regarding medical care and treatment by next review date. Interventions include to: allow opportunities for expression of feelings or concerns and promote opportunities for resident/healthcare decision maker to participate in decisions regarding care. Another focus area of concern is for R35 to remain in long term care (LTC) with a goal that R35 will remain LTC through review date as desired. Interventions include arrange care plan conference routinely and discuss R35's wishes and concerns about remaining in the facility. Interview/ Observation on 4/29/25 at 11:20 am revealed R35 lying in bed looking up at the ceiling. R35 denied attending any care plan meeting since admission and stated that she doesn't believe that there had been any or she would have attended and voiced her concerns. Review of R35s EMR revealed no documented care plan meetings since admission and no quarterly meeting notes were noted in her progress notes either by Nursing, the SSD, or any other discipline. A Social Service history & Initial Assessment was initiated on 1/30/2025 and completed on 2/25/2025 with no meetings scheduled for further evaluation or inclusion by other disciplines. Interview on 4/30/25 at 2:23 pm with the Social Services Director (SSD) revealed that it was her responsibility along with the MDS coordinator to invite residents and family to the care plan meetings. She stated that quarterly meetings were held for all residents. The SSD stated that all new admission meetings were held within 72 hours and were referred to as 72-hour meetings. She stated that all residents were invited to their meetings and choose whether they wanted to come or not and that all this is usually documented in the resident's progress notes section in the EMR. The SSD stated that additional care plan records are kept in the SSW section of the EMR along with the names of all attendees to the meetings. The SSD verified that there was no Comprehensive Care Plan (CCP) meeting, or 72-hour meeting documented in R35's EMR since she was admitted to facility and stated that I am unable to locate the sign-in sheet for the meeting that was held. The SSD was also unable to produce any documentation of the subsequent quarterly meeting that should have been held in the month of April 2025.

Based on observations, staff interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to provide necessary assistance with grooming and personal hygiene for one of 45 sampled residents (R) (R76) who required staff support due to cognitive impairment and physical limitations. The deficient practice had the potential to negatively affect R76's dignity, comfort, and psychosocial well-being. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) revealed under Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Under Policy Explanation and Compliance Guidelines: 1. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the electronic medical record (EMR) revealed R76 was admitted with diagnoses including but not limited to schizophrenia, cerebral infarction, type 2 diabetes, protein-calorie malnutrition, polyneuropathy, and chronic obstructive pulmonary disease (COPD). Review of R76's the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) documented that the resident required assistance with bathing and personal hygiene. Review of the care plan for R76 identified an ADL self-care performance deficit related to impaired balance, mobility, and cognition. Interventions included limited to extensive assistance with bathing, grooming, and personal hygiene, as well as monitoring for decline in ADLs. Observation and interview on 4/29/2025 at 11:45 am with R76 revealed visible facial hair and food debris in the beard. R76 stated he had not been offered a shave, and his nails were noted to be untrimmed. Observation on 4/30/2025 at 10:49 am revealed R76 seated in the dining area with facial hair. He stated he would like the hair on his face trimmed. Interview on 4/30/2025 at 11:45 am with Certified Nursing Assistants (CNA) HH and CNA DD revealed that both were new to the facility and had not offered grooming to R76. They stated that R76 never requested grooming. CNA DD mentioned concerns about a lesion on his face that might interfere with shaving. Interview on 5/1/2025 at 10:10 am with Licensed Practical Nurse (LPN) GG confirmed that R76's beard was occasionally groomed around a lesion. She acknowledged that grooming should be offered, and he had no current skin concerns that would prevent safe grooming. Interview on 5/1/2025 at 3:55 pm with the Director of Nursing (DON) confirmed that residents should be offered grooming as part of their ADLs and acknowledged confusion about the required frequency of grooming assessments.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Smoking, the facility failed to ensure smoking materials were maintained with the recreation staff and that smoking occurred only in the designated smoking area for one of ten residents (R) (R39) who smoke. This failure had the potential to create a fire hazard and unsafe environment for residents, staff and visitors in the facility. Findings include: Review of the facility's policy titled Resident Smoking revised December 2023 revealed in the Policy Explanation and Compliance Guidelines: . 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 6. Resident who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or of resident is safe to smoke at all. 13. Smoking materials of residents (such as matches and lighters) will be maintained by nursing staff. 14. Residents that have shown the ability to safely store and follow facility safe smoking rules can keep their own cigarettes but no lighters or matches. Review of R39's admission records in the electronic medical record (EMR) revealed he was admitted to the facility with diagnoses that include but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, tobacco use, dizziness and giddiness and type 2 diabetes mellitus without complications. Review of R39 care plan dated 7/26/2024 revealed focus of smoking indicating R39 is a current smoker with a goal to remain safe from injury through the next review period. Interventions include a smoking history and safe smoking assessment will be completed upon admission/readmission, quarterly, annually, and/or with a change in smoking habits and care smoking care plan will be initiated. Resident must have cigarettes/lighters locked up at all times other than smoking time. Resident will smoke only in authorized areas. Smoking education has been provided to resident including: not smoking in facility; designated smoking areas; locking up cigarettes/lighters; cigarettes brought in by family/friends must be locked up; only facility ashtrays may be used. Violating of smoking rules or disregard for safety rules my [sic] result in revocation of smoking privileges. Smoking rules will be reviewed with the resident upon admission. The resident is a Supervised Smoker and must be supervised in authorized area when smoking individually or with a group. Review of physician orders include but not limited to: is resident abiding by smoking policy and procedures? Did the resident demonstrate any behaviors during your shift? If yes, document a progress note and describe behavior. During an observation on 5/1/2025 at 4:30 pm revealed R39 dropping a lighter out of his pocket as he walked in through the dining area. During an interview on 5/1/2025 5:45 pm with R39 revealed that he usually keeps his lighter until after the 7:00 pm smoke break because usually there was no one to take us out and different staff members punched the code in to let us out for the break and when we came back in, I usually put the lighter back in the box. Review of R39's smoking assessment revealed that R39's last smoking assessment was completed on 10/2/2024. The only indicators were that R39 smokes tobacco and follows the facility's policy on location and time of smoking. During an interview on 5/1/2025 at 4:38 pm with the Social Services Director (SSD) revealed that R39 has had only two smoking evaluations since his admission to the facility. She stated that the dates of his smoking evaluations were on 10/26/2022 and 2/5/2023. She stated she was unaware of how often they are supposed to be done. During an interview on 5/1/2025 at 4:46 pm with the Director of Nursing (DON) revealed that R39 was not allowed to have lighter on him at any time. She stated that he is more than well aware of the rules that he was not allowed to have a lighter with him. The DON stated that she thought the smoking assessments were to be completed every six months but was told that now they are doing them quarterly. She revealed that a possible negative outcome could be that someone could get a hold of the lighter, someone who is not able to use it safely and could start a fire and burn themselves. During an interview on 5/1/2025 at 5:16 pm with the Administrator, she revealed that R39 was not supposed to have a lighter on him. She also stated that the potential negative outcome could be dropping it, and someone could get to it.

Based on observations, record review, staff interview, and review of facility policy titled, Medication Administration, the facility failed to provide two medications, as ordered by the prescriber, to meet the needs of one of three residents (R) R44 during medication review and administration. This failure had the potential to cause a disruption or delay in the medical progress of R44. Findings include: Review of the facility policy titled Medication Administration reviewed on January 2023, revealed under Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy Explanation and Compliance Guidelines: 1. Keep medication cart clean, organized and well stocked with adequate supplies.11. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Review of R44's admission records revealed R44 was admitted to the facility with diagnosis of chronic obstructive pulmonary disease (COPD), end stage renal disease, dependence on renal dialysis, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Observations on 4/30/2025 at 8:40 am revealed Licensed Practical Nurse (LPN) AA administering morning medication to R44 prior to her leaving the facility for dialysis. The medications included vitamin D 10 micrograms (mcg) one tablet, nephro vitamins one tablet, nifedipine extended release (ER) 90 milligrams (mg) one tablet, losartan potassium 100 mg one tablet, sertraline 25 mg one tablet, lactobacillus one capsule and doxazosin mesylate 4 mg one tablet were administered to R44 in the front lobby where four other residents were sitting. No hand hygiene was performed throughout the entire medication pass. During observation, LPN AA stated that sertraline 25 mg, megestrol acetate 600 mg/10 ml (milliliters) and labetalol 300 mg was not available in the medication cart. LPN AA retrieved sertraline 25 mg from the emergency medication box but megestrol acetate 600 mg/10ml and labetalol 300 mg was not available in-house. LPN AA contacted the Nurse Practitioner (NP) and received instructions to administer all available medications and monitor R44's blood pressure upon return from dialysis and inform NP of issues. Review of R44's medication administration records (MAR) revealed that R44 was to also receive megestrol acetate 600 mg/10 ml and labetalol 300 mg one tablet. R44's MAR also revealed that sertraline 25 mg one tablet was not available in the medication cart and was retrieved from the emergency medication supply. In an interview on 4/30/2025 at 9:37 am with LPN AA revealed that she would be contacting the pharmacy about the missing medications. LPN AA stated that normally if there were no issues with the reorder, medications usually take the pharmacy 24 hours to deliver the medications unless there was a back order or other issues. She stated that she would usually inform the provider after contacting the pharmacy to report what was said for the provider to give a directive. An interview on 4/30/2025 at 10:30 am with LPN AA revealed that she contacted the pharmacy and all medications would be delivered on the 6:00 pm run. She stated that the medication would be administered at its scheduled time of 9:00 am tomorrow morning and that the NP was made aware of the issue and that R44 was to be monitored for adverse effects. An interview on 5/1/2025 at 9:53 am with the Director of Nursing (DON) revealed if the nurse did not have access to the emergency medication system (Pyxis), they should get someone who had access to get the medication for the resident and to call the pharmacy and find out about the medication. The DON stated, If the medication is not in the pyxis, then the nurse should notify the provider for directions. She also stated, I expect the nurse to do what the provider directed and to notify the provider if there were changes. The DON revealed that the Nurse Practitioners (NP) were in the facility Mondays through Fridays from about 9:00 am to 5:00 pm and could be contacted if they were not in the facility. She also revealed that there were tele (via telephone) medicine services available after 5:00 pm.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Medication Administration, the facility failed to ensure the medication error rate was less than five percent for two of three residents (R) (R42 and R44) observed during medication administration. There were three errors with 26 opportunities for an error rate of 11.54 percent. This deficient practice had the potential for R42 and R44 to experience adverse reactions. Findings Include: Review of the facility's policy titled Medication Administration with review date of January 2023 revealed under Policy Explanation and Compliance Guidelines: 1. Keep medication cart clean, organized and stocked with adequate supplies.4. Wash hands prior to administering medication per facility protocol and product.7. Provide privacy. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. 19. Report and document any adverse side effects or refusal. Review of R44 admission records revealed R44 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD), end stage renal disease, dependence on renal dialysis, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease, acute respiratory distress and pleural effusion. Observations on 4/30/2025 at 8:40 am revealed Licensed Practical Nurse (LPN) AA administering morning medication to R44 prior to her leaving the facility for dialysis. The medications included vitamin D 10 micrograms (mcg) one tablet, nephro (kidney) vitamins one tablet, nifedipine extended release (ER) 90 milligrams (mg) one tablet, losartan potassium 100 mg one tablet, sertraline 25 mg one tablet, lactobacillus one capsule and doxazosin mesylate 4 mg one tablet were administered to R44 in the front lobby where four other residents were sitting. During observation LPN AA stated that sertraline 25 mg, megestrol acetate 600mg/10 ml (milliliter) and labetalol 300 mg were not available in the medication cart. LPN AA retrieved sertraline 25 mg from the emergency medication box but megestrol acetate 600 mg/10 ml and labetalol 30 mg were not available in-house. LPN AA contacted the Nurse Practitioner (NP) and received instructions to administer all available medications and monitor R44 blood pressure upon return from dialysis and inform NP of issues. Review of R44's medication administration records (MAR) revealed that R44 was to also receive megestrol acetate 600 mg/10 ml and labetalol 300 mg one tablet. R44's MAR also revealed that medication D3 400 units one tablet was prescribed and not vitamin D ten units. Sertraline 25 mg one tablet was not available in the medication cart and was retrieved from the emergency medication supply. R44 also refused her artificial tears and her breo- elipta inhaler 100-25 mcg. An interview on 4/30/2025 at 9:37 am with LPN AA revealed that she would be contacting the pharmacy about the missing medications. She also admitted not performing any form of hand hygiene during the medication pass and stated that it was not ok to give medication in a public area. LPN AA stated that she was aware that she did not wait or check to see if the resident swallowed the medication. LPN AA stated that I normally make sure that they swallow the medication. LPN AA stated that normally, if there was no issues with the order medications, it usually takes the pharmacy 24 hours to deliver the medications reordered unless there is a back order or other issues. She stated that she would usually inform the provider after contacting the pharmacy to report what was said for the provider to give directive. LPN AA also revealed if a resident refused any medication, the provider would also be notified. An interview on 4/30/2025 at 10:30 am with LPN AA revealed that she contacted the pharmacy and all medications would be delivered on the 6:00 pm run. She stated that the medication would be administered at its scheduled time of 9:00 am tomorrow morning. LPN AA stated that the NP was made aware and R44 was to be monitored for adverse effects. Record review on 5/1/2025 at 9:00 am of R44's MAR revealed that no monitoring was created nor completed R44 as instructed by the NP. Review of R44's Nurses Notes revealed no documentation was completed nor pass down log done relating to LPN AA's and the NP's conversation about the monitoring of R44. An interview on 5/1/2025 at 9:15 am with R44 revealed that she was not bothered by the nurse administering the medications to her in the front lobby. R44 stated that she doesn't really care about that. 2. Review of R42 admission records revealed R42 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side, and hypertensive heart disease without heart failure. Observations on 4/30/2025 at 10:00 am revealed LPN BB administering morning medications to R42. Medications included fluticasone propionate nasal spray 50 mcg, gabapentin 300 mg 1cap, diclofenac sodium 75 mg one tablet, lisinopril 20 mg one tablet, senna 8.6 mg two tablets, aspirin enteric coated (EC) 81 mg one tablet, docusate 100 mg one caplet, iron 325 mg one tablet, amlodipine 2.5 mg four tablets and MiraLAX 17 grams in 30 ml of water. LPN BB observed R42 swallowing pills administered and then left the room. MiraLAX (laxative) remained on the bedside table. An interview on 4/30/2025 at 10:15 am with LPN BB, she admitted to not staying with R42 to monitor her taking the MiraLAX instead of leaving it on the overbed table. LPN BB stated, she would normally make sure the resident takes the medication before leaving the room, but wanted to get to the next resident. An interview on 5/1/2025 at 9:53 am with the Director of Nursing (DON) revealed that it was her expectation for the staff to always get someone who has access to the emergency medication (Pyxis) to get the medication for the resident and to call the pharmacy and find out about the medication. The DON stated that if the medication was not in the pyxis then the nurse should notify the provider for directions. She also stated, I expect for the nurse to do what the provided directed and to notify the provider if there are changes. The DON revealed that the Nurse Practitioners (NP) were in the facility Mondays to Fridays from about 9:00 am to 5:00 pm and could be contacted if they were not in the facility. She also revealed that there was tele (telephone) medicine services available after 5:00 pm. She also stated, it is my expectation for there to be documentation in the form of a note or an order and for pass along report to be given to the incoming shift for them to be aware and continue to follow up. The DON confirmed that no documentation for the missing medications and conversation with the NP along with her directive was noted in R44s EMR. The DON confirmed that the charge nurse failed to document that the resident did not receive two of her medications and that a total of three medications were missing from the medication cart. She also confirmed that there was no documentation of the communication between LPN AA and the NP and the directive given for R44s monitoring. The DON went on to reveal that all medications with unrecognizable expiration should be immediately removed from the medication cart.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse. Specifically, the facility failed to ensure two residents (R) (R15 and R13) were free from abuse related to: (1) R15 exposed to sexual abusive behaviors presented by R16, and (2) R13 experiencing physical abuse from R20. On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: 1. A review of the facility policy titled Abuse, Neglect, and Exploitation revised 9/8/2022 revealed: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 with a Brief Interview of Mental (BIMS) score of zero, indicating severely impaired cognition. R15 had diagnoses including but not limited to Alzheimer's and depression. A review of the Quarterly MDS dated [DATE] revealed R16 with a BIMS score of 13, indicating resident was cognitively intact. R16 had diagnoses including but not limited to chronic kidney disease and hemiplegia and hemiparesis. Observations throughout the survey revealed that there were two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. A review of R16's progress note dated 8/31/2023, documented by the Nurse Practitioner (NP) revealed the following: [R16] was seen today for inappropriate sexual behavior. The nurse called that pt [patient] was trying to kiss other residents and touching them inappropriately, patient was also self-propelling himself around the facility. Unable to redirect the patient on many accounts. His room was also changed but did not help the pt to stop behaving inappropriately .Today was seen today to assess and redirect the patient. Patient unable to express his triggers. A review of R16's progress note dated 8/31/2023, documented by the DON revealed: assessed resident for sexually suggestive behaviors. Resident started on cimetidine. Resident self-propels throughout the facility and was noted to have socially sexually suggestive behaviors that may be offensive to others. A review of R16's progress note dated 9/5/2023, documented by the Physician revealed the following: [R16] seen today for inappropriate sexual behavior. The nurse called that pt was trying to kiss other residents and touching them inappropriately, patient was also self-propelling himself around the facility. Unable to redirect the patient on many accounts. His room was also changed but did not help the pt to stop behaving inappropriately. The patient recently started on cimetidine with no improvement in behavior per nursing staff was seen today to assess and redirect the patient. Patient unable to express his triggers. A review of R16's progress note dated 9/14/2023, documented by the Psychiatric NP (PNP) revealed the following: request by the nursing team for inappropriate sexual behaviors. Patient was noted on multiple occasions attempting to kiss and inappropriately touch other female patients per nursing team. Patient denies any depression or anxiety .He cannot explain his triggers. The patient does not recollect the incident. A review of R16's physician order dated 8/31/2023 revealed an order for Cimetidine 300 milligrams (mg) two times a day for hypersexuality. A review of R16's care plan dated 8/31/2023 revealed R16 had a behavior problem of sexually suggestive displays. During an interview on 10/26/2023 at 7:40 am, the DON stated that it was reported to her in clinicals that R16 masturbates in the common area. The DON stated that was the reason the resident was started on Cimetidine. The DON stated she did not receive a report of R16 attempting to kiss or attempting to touch other residents. The DON stated she was unaware of which female residents were involved. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator stated he was unaware of the allegations of sexual abuse. During an interview on 10/26/2023 at 9:47 am, the NP stated that she was notified by a nurse on 8/31/2023 that R16 attempted to kiss and touch another resident. The NP stated the progress note that she documented was incorrect and should have stated that R16 attempted to kiss and attempted to touch. The NP stated she was unaware the name of the nurse that reported the incident to her and stated she was also unaware of the female resident that R16 was alleged to kiss and/or touch. During an interview on 10/26/2023 at 10:18 am, the PNP stated a floor nurse reported the allegation of sexual abuse to her on 9/13/2023. The PNP stated that she was unaware the name of the nurse that reported the incident to her and stated she was also unaware of the female resident. During an interview on 10/26/2023 at 11:55 am, the Physician stated that it was reported to her by the NP on 9/5/2023 that R16 was having sexually inappropriate behavior towards others. During a follow-up interview on 10/26/2023 at 1:18 pm, the DON stated she had just spoken with CNA BB. The DON stated CNA BB confirmed R16 had kissed R15. The DON stated she did not consider that to be sexual abuse. During an interview on 10/26/2023 at 1:26 pm, the Staff Development Coordinator (SDC) stated that she was responsible for training the staff on abuse. The SDC stated she was unaware of the allegations of sexual abuse and that it had not been discussed in their daily clinical meetings. The SDC stated that kissing another resident is abuse if the resident is unable to consent. The SDC stated the resident should have a BIMS score of 12 or higher to give consent. During an interview on 10/26/2023 at 1:31 pm, the Social Services Director (SSD) stated she was unaware of the allegations of sexual abuse and that it had not been discussed in their daily clinical meetings. The SSD further stated R15 had a lows BIMS score and could not consent to being kissed. 2. A review of the clinical record revealed that R13 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, severe sepsis with septic shock, schizophrenia, and Wernicke's encephalopathy. A review of a quarterly MDS assessment revealed R13 presented with a BIMS score of 10 out of 15, indicating moderate cognitive deficits; R13 had a history of paranoid behaviors associated with his schizophrenia and was care planned for the same; R13 requires stand by assistance with Activities of Daily Living (ADL) care and can manage much of his care with supervision; and R13 can ambulate short distances but has an unsteady gait and uses a wheelchair when out of his room. An observation of R13 on 10/17/2023 at 1:15 pm revealed the resident in his room with four roommates. He is sitting on the side of the bed with his wheelchair next to him. He looks up and shakes/nods head when addressed but doesn't speak. An observation on 10/19/2023 at 10:30 am revealed R13 up in his wheelchair in the dining room during an activity. The game was balloon toss and R13 played from his wheelchair. He was observed standing at times and moving about freely in his wheelchair. He ambulates throughout the facility in his wheelchair with ease. He nods when spoken to but again but doesn't speak. A review of a Progress Note dated 8/17/2023 and found in the electronic medical record (EMR) revealed a nurses note regarding an incident in the dining room with another resident earlier that day and R13 sustained a laceration on the back of his scalp. During an interview with the Administrator on 8/16/2023, it was revealed that R13 was involved in a resident to resident altercation with R20. They were arguing over a pair of reading glasses in the dining room. When both men stood up from their wheelchairs, and R20 shoved R13, who was standing by the ice machine. R13 lost his balance and fell landing on his buttock and striking his head on the ice machine causing a laceration on the back of his head. He was assessed and treated in the facility that day. The NP and facility staff cleaned and dressed R13's head laceration. No other treatment was required. A review of the clinical record revealed that R20 was admitted to the facility on [DATE] from an acute care hospital with diagnoses including Traumatic Brain Injury with subdural hemorrhage. A review of R20's MDS revealed a BIMS score is six, indicating severe cognitive impairments. He required one staff assistant with all ADL care. He is mobile around the facility in a wheelchair. He did exhibit behavior problems and was frequently aggressive with staff by resisting care. In an interview with the DON on 10/19/2023 at 3:30 pm, she stated R20 was only in the facility for a couple of weeks primarily due to his aggressive behaviors and a need for a psychiatric or secure unit with increased supervision. She stated, .we tried to stay on him and watch him until we could get him taken care of .unfortunately this happened with [R13 name], wrong place/wrong time. The DON further stated that staff were in the dining room when it happened but couldn't get between them in time because it happened quickly, but the response time was nominal. In an interview with the Administrator on 10/23/23 at 11:30 am, he confirmed the events as described above. He stated he and the DON conducted the investigation and made all the notifications. There were no additional incidents between these two residents. The facility implemented the following actions to remove the IJ: 1. R16 was seen by NP on 8/31/2023 and recommendations for Cimetidine Tablet 300 mg one tablet two times daily were made and implemented. 2. R16 was referred to and seen by physician on 9/5/2023 and no new recommendations made. 3. R16 was referred to and seen by PNP on 9/14/2023 and a new medication (Zoloft 50mg once a day) recommendation was made and implemented. 4. R16 was placed on behavioral monitoring to assess and monitor for inappropriate touching or kissing behaviors toward others on 10/26/2023. 5. On 10/27/2023, R16 care plan was reviewed by the DON and was updated to assess, monitor, and address inappropriate sexual behaviors toward others. 6. On 10/27/2023, physician order obtained to send R16 out for evaluation and treatment as necessary. 7. On 10/27/2023, R16 was sent to input acute care hospital for behavioral assessment and treatment. On 10/28/2023, the resident returned to the facility with no new orders or recommendations. 8. On 10/29/2023 R15 was assessed by the SSD and NP. Resident presented at baseline and had no recollection of the events of 8/31/2023. 9. On 10/27/2023, the Regional Director of Operations (RDO), RDCO, and Medical Director (MD) reviewed the center policy Abuse and Neglect. No policy changes or recommendations were made as a result of this review. 10. The RDCO and Administrator reviewed the 24-hour reports for the past 30 days to identify residents with documented inappropriate sexual behaviors towards others. Identified documentation with possible allegations of Abuse and Neglect will be reported to the SSA and investigated per state guidelines and facility policy and procedure. Recommendations were reviewed in AD-HOC Performance Improvement meeting 10/26/2023 and 10/27/2023. 11. RDO re-educated the Administrator and DON on the Abuse and Neglect policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; investigation of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations on 10/26/2023. 12. On 10/26/2023, the SDC interviewed residents with a BIMS of 12 or higher to identify if any other resident has been inappropriately touched or kissed by R16 or any other resident of this facility. Findings of these interviews noted no resident reported any concerns with R16 or any other resident. Interviews were documented on the Resident Interview Tool. 13. On 10/30/2023, the SSD, NP, and Nurse Managers assessed residents with a less than 12 BIMs score for psycho-social well-being and change in mood and behavior. Findings of these assessments noted no resident changes in behavior. Assessments were documented on the Psycho-Social Well-Being Assessment Tool. 14. On 10/26/2023 through 10/27/2023, the DON, SDC, educated all staff on the importance of investigating alleged abuses and neglect. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurses (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100 %; MD one of one - 100% and NPs two of two - 100% OVERALL 92% on the Abuse and Neglect policy and procedure as of October 26, 2023. Employees on leave of absence/ leave - (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. All corrective actions were completed on 10/30/2023. The facility alleges that the IJ is removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the progress/encounter note dated 8/31/2023 revealed that R16 was seen by the NP and new orders were noted at that time. 2. A review of the progress/encounter note dated 9/5/2023 revealed that R16 was seen by the Physician and no new orders were written. 3. A review of the progress/encounter note dated 9/13/2023 revealed that R16 was seen by the PNP and new orders for Zoloft 50mg daily were noted on the Order Summary Report. 4. A review of the order summary report dated 10/26/2023 revealed that the medication and behavior monitoring were ordered and initiated. Nursing will continue monitoring and documenting behaviors per interview with the DON on 11/1/2023 at 12:30 pm. 5. A review was conducted of R16's Care Plan revised 10/27/2023 to include behavior monitoring for inappropriate sexual behaviors. The DON confirmed the updated care plan in an interview on 11/1/2023 at 12:30 pm. 6. A review was conducted of the order for transfer to a behavioral health facility for evaluation and treatment dated 10/27/2023. R16 returned to facility on10/28/2023 with no new orders. The Administrator confirmed these actions in an interview on 11/1/2023 at 12:30 pm and stated the facility will continue to monitor R16. 7. A review of a progress note dated 10/28/2023 revealed the resident returned to facility after psychiatric evaluation with no new orders. This was confirmed with DON on 11/1/2023 at 12:30 pm. 8. A review was conducted of the progress note dated 10/30/2023 for R15's psychosocial assessment. During an interview on 11/1/2023 at 2:00 pm, the DON confirmed R15 remained at baseline. 9. The Abuse Neglect and Exploitation Policy was reviewed, and no revisions were made. This was confirmed by an interview with the Administrator and RDCO on 11/1/2023 at 2:00 pm. 10. A review was conducted of the 24-hour reports and confirmation interviews with the RDCO and Administrator on 11/1/2023 at 12:30 pm. 11. A review was conducted of the Abuse and Neglect Inservice provided to all staff. A review was conducted of the sign in sheets and all staff interviewed from 1:20 pm through 2:30 pm sign in sheets. This included all staff present in the facility on 11/1/2023. The DON will be responsible for training any staff who are not present prior to their next shift. 12. A review was conducted of the list of male and female residents with BIMS score of 12 or higher and the interview questions asked regarding sexual (or other) abuse in the facility. None of the residents reported being abused in any way. 13. A review was conducted of the Psychosocial Well-being Evaluations for all residents with BIMS scores less than 12. No changes identified in the assessments. 14. A review was conducted of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 pm; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 pm; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant ADON at 2:30 pm. All corrective actions were completed on 10/30/2023. The IJ is removed on 10/31/2023. 49477

Based on observations, interviews, record review, and facility policy review, the facility failed to report an incident of alleged abuse. Specifically, the facility failed to report an incident of sexual abuse for one of 27 residents (R) (R15). On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: A review of the facility policy titled Abuse, Neglect, and Exploitation revised 9/8/2022 revealed: The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 with a Brief Interview of Mental (BIMS) score of zero, indicating severely impaired cognition. A review of the Quarterly MDS dated [DATE] revealed R16 with a BIMS score of 13, indicating resident was cognitively intact. A review of R16's encounter note dated 8/31/2023 documented by the Nurse Practitioner (NP), an encounter noted dated 9/5/2023 documented by the Physician, and encounter note dated 9/14/2023 documented by the Psychiatric Nurse Practitioner (PNP) revealed R16 was on their caseload for attempting to kiss and inappropriately touching female residents. Observations throughout the survey revealed that there are two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. A review of facility reported incidents showed no evidence that the allegation of sexual abuse was reported as required. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator confirmed he was the Abuse Coordinator and stated he was unaware of the allegations of sexual abuse. The Administrator stated if he had known of the abuse, he would have reported it immediately. During an interview on 10/26/2023 at 9:47 am, the NP stated that she was notified by a nurse on 8/31/2023 that R16 attempted to kiss and touch another resident. The NP stated that she did not report the allegation to anyone and stated that she did not know if she was a mandatory reporter. The facility implemented the following actions to remove the IJ: 1. On 10/26/2023, the Administrator reported allegations of abuse and neglect related to the 8/31/2023 incident with R16 once alerted by the surveyor. 2. On 10/26/2023, the administrator was re-educated by the Director of Operations (DOO) on timely reporting, investigating and resolution of abuse and neglect allegations. 3. On 10/26/2023, the Regional Director of Operations (RDO) and the Administrator conducted an audit of all reported alleged violations and grievances in the last 30 days to validate that reporting occurred in a timely manner. All reported alleged violations and grievances in the last 30 days were made in a timely manner. 4. Between 10/26/2023 through 10/30/2023, the Social Services Director (SSD), NP, Staff Development Coordinator (SDC), and nurse managers interviewed and assessed residents using the Psycho-Social Well-Being Assessment. Any resident(s) with a noted change in baseline or who reported any change in psychosocial well-being was referred to Mental Health Provider for continuous treatment and support. 5. On 10/26/2023, the RDO and the VPCO reviewed the Abuse and Neglect Policy which includes timely reporting and follow up resolution. No revisions or amendments of the policy were recommended. 6. Beginning 10/26/2023, The DON, SDC, educated all staff on the importance of investigating alleged abuses and neglect to include proper notification of the reporting of alleged violations and grievances. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurses (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100 %; MD one of one - 100% and NPs two of two - 100% OVERALL 92% on the Abuse and Neglect policy and procedure as of October 26, 2023. Employees on leave of absence/ leave - (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. All corrective actions were completed on 10/30/2023. The facility alleges that the IJ is removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review was conducted of facility reported incident dated 10/26/2023 revealed the facility Administrator reported the 8/31/2023. This was confirmed by an interview with the Administrator on 11/1/2023 at 12:30 pm. 2. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator on 10/26/2023. Interview with Administrator and RDCO 11/1/2023 at 2:00 pm confirmed the Administrator had been re-educated. 3. A review was conducted of a statement dated 10/26/2023 by the Administrator related to the audit of allegations and grievances. The audits were confirmed in an interview with the RDCO and Administrator on 11/1/2023 at 4:30 pm. 4. A review was conducted of Psycho-Social Well-Being Assessment Tool for all residents completed on 10/30/2023 with no new concerns. The DON confirmed in an interview on 11/1/2023 at 12:30 pm that she would continue to audit for inappropriate behaviors and any necessary follow-up. 5. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator and RDCO on 10/26/2023. Interview with Administrator and RDCO 11/1/2023 at 2:00 pm confirmed their review and will update as needed. 6. A review was conducted of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 pm; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 pm; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant ADON at 2:30 pm. All corrective actions were completed on 10/30/2023. The IJ is removed on 10/31/2023.

Based on observations, interviews, record review, and review of the facility policy, the facility failed to investigate incidents of alleged abuse. Specifically, the facility failed to thoroughly investigate an incident of sexual abuse for one of 27 residents (R) (R15). On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: A review of the facility policy titled Abuse, Neglect, and Exploitation revised 9/8/2022 revealed: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 with a Brief Interview of Mental (BIMS) score of zero, indicating severely impaired cognition. A review of the Quarterly MDS dated [DATE] revealed R16 with a BIMS score of 13, indicating resident was cognitively intact. A review of R16's encounter note dated 8/31/2023 documented by the Nurse Practitioner (NP), an encounter noted dated 9/5/2023 documented by the Physician, and encounter note dated 9/14/2023 documented by the Psychiatric Nurse Practitioner (PNP) revealed R16 was on their caseload for attempting to kiss and inappropriately touching female residents. Observations throughout the survey revealed that there are two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. The facility was unable to provide any additional information on these allegations. The facility was unable to identify the female residents mentioned. There was no evidence (witness statements, interviews, assessments) to indicate that these allegations were investigated. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator confirmed he was the Abuse Coordinator and stated he was unaware of the allegations of sexual abuse. The facility implemented the following actions to remove the IJ: 1. R16 was seen by Nurse Practitioner on 8/31/2023 and recommendations for medication changes (Cimetidine Table 300 milligrams (mg) one tablet twice a day) were made and implemented. 2. R16 was referred to and seen by physician on 9/5/2023 and no new recommendations made. 3. R16 was referred to and seen by PNP on 9/14/2023 and a new medication (Zoloft 50 mg by mouth once a day) recommendation was made and implemented. 4. R16 was placed on behavioral monitoring to assess and monitor for inappropriate touching or kissing behaviors toward others on 10/26/2023. 5. On 10/27/2023, R16 was sent to input acute care hospital for behavioral assessment and treatment. No new orders or recommendations were made. 6. On 10/29/2023, R15 was assessed by the Social Services Director (SSD) and NP. Resident presented at baseline and had no recollection of the events of 8/31/2023. 7. On 10/27/2023, R16 care plan was reviewed by the DON and was updated to assess, monitor, and address inappropriate sexual behaviors toward others. 8. On 10/26/2023, the Administrator reported allegations of abuse and neglect related to R16 inappropriate sexual behavior once alerted by the surveyor. 9. On 10/27/2023, the Administrator interviewed the caregiver (s) and staff related to the allegations made regarding R16. Staff statements were collected and maintained in the investigation file. 10. On 10/26/2023, the administrator was re-educated by the Director of Operations (DOO) to conduct a thorough investigation and resolution of abuse and neglect allegations. 11. On 10/26/2023, the Regional Director of Operations (RDO) and the Administrator conducted an audit of all reported alleged violations and grievances in the last 30 days to validate that thorough investigations were completed. All reported alleged violations and grievances in the last 30 days were investigated appropriately. 12. On 10/302023, the SSD, NP and Nurse Managers assessed residents with a less than 12 BIMS score for psycho-social well-being and change in mood and behavior. Findings of these assessments noted no resident change in behavior. Assessments were documented on the Psycho-Social Well-Being Assessment Tool. 13. On 10/26/2023, the RDO and the Administrator reviewed the Abuse and Neglect Policy which includes timely reporting and follow up resolution. No revisions or amendments of the policy were recommended. 14. On 10/26/2023, the DON and the SDC educated all staff on the importance of reporting allegations of abuse and neglect to ensure proper investigating and correction action are implemented. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurses (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100 %; MD one of one - 100% and NPs two of two - 100% OVERALL 92% on the Abuse and Neglect policy and procedure as of October 26, 2023. Employees on leave of absence/ leave - (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. All corrective actions were completed on 10/30/2023. The facility alleges that the IJ is removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review was conducted of progress/encounter note dated 8/31/2023 revealed that R16 was seen by the NP and new orders were noted at that time. 2. A review was conducted of progress/encounter note dated 9/5/2023 revealed that R16 was seen by the Physician and no new orders were written. 3. A review was conducted of progress/encounter note dated 9/13/2023 revealed that R16 was seen by the PNP and new orders for Zoloft 50 mg daily were noted on the Order Summary Report. 4. A review was conducted of an order summary report dated 10/26/2023 revealed that the medication and behavior monitoring were ordered and initiated. Nursing will continue monitoring and documenting behaviors per interview with the DON on 11/1/2023 at 12:30 pm. 5. A review was conducted of the progress note dated 10/27/2023 detailing resident evaluation at [NAME] Behavioral Health. A review of emergency service patient care report was reviewed with the Director of Nursing on 11/1/2023 at 12:30 pm. 6. A review was conducted of progress notes dated 10/30/2023 and 10/31/2023 regarding assessment of R15 was reviewed with the Director of Nursing on 11/1/2023 at 12:30 pm. 7. Review of care plan updated on 10/26/2023 revealed R16 has a behavior problem of sexually suggestive displays and potential for sexually inappropriate behaviors toward others. This was reviewed with the DON on 11/1/2023 at 12:30 pm. 8. A review was conducted of facility reported incident dated 10/26/2023 reviewed with the Administrator on 11/1/2023 at 2:00 pm. 9. A review was conducted of witness statements by staff dated 10/27/2023. This was reviewed with the Administrator on 11/1/2023 at 2:00 pm. 10. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator on 10/26/2023. This was reviewed with the RDCO 11/1/2023 at 12:30 pm. 11. A review was conducted of statement dated 10/26/2023 by the administrator related to the audit of allegations and grievances. This was reviewed with the Administrator on 11/1/2023 at 2:00 pm. 12. A review was conducted of Psycho-Social Well-Being Assessment Tool for all residents completed on 10/30/2023. This was reviewed with the DON on 11/1/2023 at 12:30 pm. 13. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator and by the RDCO on 10/26/2023. This was reviewed with the Administrator on 11/1/2023 at 2:00 pm. 14. A review was conducted of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 pm; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 pm; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant ADON at 2:30 pm. All corrective actions were completed on 10/30/2023. The IJ is removed on 10/31/2023.

Based on observations, interviews, record review, and review of the Administrator position description, facility Administration failed to effectively oversee an abuse prevention program to promote, foster and maintain an abuse free environment. The facility census was 95. On 10/26/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and [NAME] President of Clinical Operations (VPCO) were informed of the Immediate Jeopardy (IJ) on 10/26/2023 at 5:36 pm. The noncompliance related to the IJ was identified to have existed on 8/31/2023. An Acceptable Removal Plan was received on 10/31/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/31/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing sexual abuse in the facility. Findings included: A review of the Administrator's position description revealed Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etc. are reported to the correct entity within the stated regulatory requirement . Treats all residents with dignity and respect. Promotes and protects all residents' rights . Report any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to appropriate regulatory entities. Protects residents from abuse, and cooperates with all investigations. The Administration failed to demonstrate competency consistently and effectively in the protection and promotion of residents' rights to be free from abuse that were included in the Administrator's job description. 1. The Administration failed to maintain an environment free from sexual abuse for one R15 perpetuated by R16. Cross reference to F600. 2. The Administration failed to ensure that incidents of sexual abuse for one R15 perpetuated by R16 was reported in a timely manner to required agencies. Cross reference to F609. 3. The Administration that incidents of sexual abuse for one R15 perpetuated by R16 was thoroughly investigated, and corrective actions implemented, including protection of the resident, in a timely manner. Cross reference to F610. Observations throughout the survey revealed that there are two units in the facility, the 100 Unit and the 200 Unit. On 10/25/2023 at 3:30 pm, R16 was observed in his wheelchair independently propelling himself on the 100 Unit towards the lobby area. On 10/26/2023 at 7:15 am, R16 was observed independently propelling himself on the 200 Unit near his bedroom area. On 10/30/2023 at 10:30 am, R16 was observed seated in his wheelchair in the dining room. On 10/31/2023 at 9:45 am, R16 was observed independently propelling himself down the main hallway towards the dining room. On 11/1/2023 at 11:15 am, R16 was observed seated in his wheelchair in the dining room in a group activity. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she intervened and reported to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. CNA AA further stated she had not witnessed R16 attempt to kiss any other residents. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she told R16 that behavior was inappropriate, separated the residents, and reported to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. During an interview on 10/26/2023 at 8:51 am, the Administrator confirmed he was the Abuse Coordinator and stated he was unaware of the allegations of sexual abuse. The Administrator stated if he had known of the abuse, he would have reported it immediately. The facility implemented the following actions to remove the IJ: 1. On 10/26/2023, a Root Cause Analysis (RCA) on the lack of recognition, reporting and investigation of abuse was completed by Regional Director of Operation (RDO), RDCO, VPCO, Administrator, and DON. Documentation of analysis was put on the RCA Tool and will be included in the next Quality Assurance Performance Improvement (QAPI) meeting. 2. On 10/26/2023, RDO re-educated the Administrator on adequately ensuring staff are properly trained to recognize and identify situations of inappropriate sexual behaviors that may lead to abuse and neglect; the importance of timely reporting and investigating all instances of abuse and neglect to prevent future recurrence that may affect the physical, mental, and psychosocial well-being for residents. 3. On 10/27/2023, the RDO issued a Performance Improvement Plan (PIP) to the Administrator. 4. Administrator hosted an AD HOC QAPI meeting on 10/26/2023 and 10/27/2023, with the MD, DON, RDCO, Administrator, VPCO, and RDO to review the center's residents at risk for being touched or kissed inappropriately. 5. On 10/26/2023, the RDO and the Administrator identified Improvement Activities based on the findings of the RCA. PIP plans and RCA documents will be maintained as part of the QAPI process. 6. Beginning 10/26/2023, the DON and Staff Development Coordinator (SDC) educated all staff on the importance of reporting, investigating, and implementing correction actions related to alleged abuse and neglect. Registered Nurses (RNs) 11 of 11 -100%; Licensed Practical Nurse (LPNs) 15 of 17 -88%; CNAs 26 of 31 - 84%; Administration 13 of 13 - 100%; Dietary nine of 11 - 82%; Housekeeping and Laundry nine of nine - 100%; Therapy 11 of 11 - 100%; Medical Director (MD) one of one - 100% and Nurse Practitioners (NPs) two of two - l 00% OVERALL 92% on the Abuse and Neglect policy and procedure as of 10/26/2023. on the Abuse and Neglect policy and procedure as of 10/26/2023. Employees on leave of absence Family Medical Leave (FMLA)- (0), vacation (0) agency staff or new hires will be re-educated by the Staff Development Coordinator prior to returning to duty and will not be given an assignment until they are given additional on-site education. The Administrator, DON, or the SDC will educate all new staff, agency staff or staff not already educated before they are given an assignment. 7. On 10/30/2023, the Administrator held additional AD HOC meeting with (Interdisciplinary Team (IDT), RDO, RDCO, and MD to discuss investigation and completion of IJ removal plan. All corrective actions were completed on 10/30/2023. The facility alleged that the IJ was removed on 10/31/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of RCA PIP dated 10/26/2023 with description of event, root cause and contributing factors, corrective action plans. This was confirmed in an interview with the RDCO, and Administrator on 11/1/2023 at 4:30 pm. 2. A review was conducted of the Abuse, Neglect, and Exploitation policy signed by the Administrator on 10/26/2023. This was reviewed with the RDCO on 11/1/2023 at 12:30 pm. 3. A review was conducted of the PIP dated 10/27/2023 for the Administrator placed on 30-day PIP with the following areas of concern - failure to identify, timely report, and investigate an allegation of abuse and/or neglect. This was confirmed in an interview with the Regional Director of Clinical Operations and Administrator on 11/1/2023 at 4:30 pm. 4. A review was conducted of the QAPI Meeting Minutes - QAPI AD HOC - investigation and completion of IJ Removal Plan. Also reviewed list of attendees: Administrator, Physician, DON, Assistant DON, RDCO, SSD, Activity Coordinator, Minimum Data Set (MDS) Coordinator, Unit Manager, SDC, Wound care nurse, Dietary Manager, and Business Office Manager. This was confirmed in an interview with the Administrator on 11/1/2023 at 4:30 pm. 5. A review was conducted of the RCA PIP dated 10/26/2023 with description of event, root cause and contributing factors, corrective action plans. This was confirmed in an interview with the RDCO and Administrator on 11/1/2023 at 4:30 pm. 6. Review of abuse training sign in sheets of all employees. Interviews of all staff present at facility on 11/1/2023 beginning at 1:20 pm and ending at 2:30 pm. The interviews verified that all staff were found to be knowledgeable and were able verbalize the information shared during the education. On 11/1/2023, the following staff were interviewed: LPN CC at 1:20 pm; Dietary Aide (DA) DD at 1:22 pm; DA EE at 1:22 pm; DA FF at 1:25 pm; DA GG at 1:27 pm; DA HH at 1:27 pm; Certified Dietary Manager (CDM) at 1:29 pm; Business Office Manager (BOM) at 1:32 pm; CNA II at 1:34 pm; CNA JJ at 1:35 pm; LPN KK at 1:35 pm; LPN LL at 1:36 pm; Housekeeper (HK) MM at 1:37 pm; HK NN at 1:39 pm; Maintenance OO at 1:40 pm; PT PP at 1:42 pm; CNA QQ at 1:43 pm; Certified Occupational Therapy Assistant (COTA) RR at 1:45 pm; HK SS at 1:47 pm; Laundry Aide (LA) TT at 1:48 pm; Registered Nurse (RN) UU at 1:49 pm; Maintenance VV at 1:51 pm; LPN WW at 1:53 pm; Activity Assistant XX at 1:55 pm; Account Manager for Housekeeping and Laundry at 1:57 pm; Physician YY at 1:58 pm; NP at 1:59 p.m.; Physical Therapy Assistant (PTA) ZZ at 2:02 pm; CNA AAA at 2:03 pm; Receptionist BBB at 2:04 pm; Activity Director (AD) at 2:07 pm; Admissions Coordinator (AC) at 2:08 pm; Director of Therapy (DOT) at 2:09 p.m.; LPN CCC at 2:11 pm; CNA AA at 2:14 pm; CNA DDD at 2:14 pm; Staffing Coordinator at 2:16 pm; SDC at 2:17 pm; MDS Coordinator at 2:18 pm; CNA EEE at 2:24 pm; and Assistant DON at 2:30 pm. 7. A review of QAPI Meeting Minutes - QAPI AD HOC - investigation and completion of IJ Removal Plan. Also reviewed list of attendees: Administrator, Physician, DON, ADON, RDCO, SSD, Activity Coordinator, MDS Coordinator, Unit Manager, SDC, Wound care nurse, Dietary Manager, and Business Office Manager. This was confirmed in an interview with the Administrator on 11/1/2023 at 4:30 pm. All corrective actions were completed on 10/30/2023. The IJ was removed on 10/31/2023.

Based on observations, interviews, and record review, the facility failed to provide daily wound care treatments, as ordered, for one of five residents (R) (R9) reviewed for pressure sores. Actual harm was identified to have occurred on 1/12/2023 when the facility failed to identify and provide for R9 related to a Stage 3 facility acquired pressure ulcer to her sacrum. Findings included: A review of the clinical record revealed that R9 was admitted to the facility on [DATE] with diagnoses including cerebral infarction with encephalopathy, acute chronic respiratory failure, and anoxic brain injury. A review of R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was completely dependent on two staff for all Activities for Daily Living (ADL) care, R9 had a gastric tube for nutrition, and had a tracheostomy to maintain her airway. A review of the care plan dated 4/5/2023 for R9 revealed she was care-planned for multiple wounds in different stages of healing. Interventions included turning and repositioning every two to three hours, low air loss mattress, and positioning devices to offload pressure in a bedbound resident. A review of a Wound Care Specialist progress note dated 1/12/2023 found in the Progress Notes tab of the Electronic Medical Record (EMR) revealed R9 had a history of wounds and with the wound care clinic. On that date, R9 presented with a new facility acquired Stage 3 wound on her sacrum. The wound was measured 7cm (centimeter) length X 7.5cm width X0.2cm depth. The wound had a small amount of drainage and no odor. The wound care orders were for devices to offload pressure such as pressure redistribution mattresses, and off load heels. The dressing changes were to be completed daily with Dakins, apply Santyl, cover with foam dressing, change daily and as needed for soiling or accidental removal. A review of the Treatment Administration Records (TAR) for January 2023 revealed the wounds were not treated as ordered on 1/14/2023, 1/16/2023, 1/20/2023, 1/28/2023, and 1/29/2023. A review of the TAR for February 2023 revealed no treatment was documented on 2/4/2023, 2/4/2023, and 2/25/2023. A review of the TAR for March 2023 revealed no dressing changes were documented as completed on 3/5/2023, 3/12/2023, and 3/20/2023. A review of the TAR for April 2023 revealed no dressing changes or wound care on 4/5/2023, 4/9/2023, and 4/11/2023. A review of a Wound Center progress note dated 5/25/2023 revealed on 5/11/2023 .the wound continues to deteriorate .family removes offloading devices at times . A review of the TAR for May 2023 revealed there was no documented wound care on 5/6/2023 and 5/7/2023. A review of a Wound Center progress note dated 5/25/2023 revealed Wound with marked deterioration since last visit. Depth increased with significant necrotic tissue present and a strong odor. The note stated that the resident's son had been considering hospice, but R9 was still a full code/full treatment. During an interview with the facility wound care nurse on 10/29/2023 at 11:40 am, he stated he works Monday through Friday most weeks. A review of his wound care progress notes revealed the Licensed Practical Nurse (LPN) provided treatments and documented on the wound care weekly for January 2023 on 1/17/2023 as initial exam, and again 1/27/2023. In February 2023 he noted wound care on 2/6/2023, 2/14/2023, and 2/21/2023. For March 2023 the wound nurse documented the wound care on 3/10/2023 and 3/14/2023, and there was no improvement/no change. For April 2023 the wound care was documented on 4/10/2023, 4/16/2023, and 4/25/2023 each of these treatments had a status of no change in the wound status. In May 2023 there was only one documented treatment on 5/31/2023 and the wound had deteriorated and was downgraded to unstageable with measurements now at 11cm X 11cm X 5cm depth. During an interview with the Director of Nursing (DON) on 10/27/2023 at 12:00 pm, the DON stated that she remembered R9 well. When the TARs were reviewed with the DON, she confirmed the TARs for R9 were incomplete and there was no documentation that wound care was provided on the dates listed on the above TARs. The DON stated the facility wound nurse cares for the wounds between wound clinic visits, and in his absence, it's up to the floor nurse to complete. The DON confirmed there were lapses in the documentation and she would see if there was anything else she could find. On 10/29/2023 at 8:40 am, the DON was asked if any additional documentation was found and she stated, No.

Based on record review and staff interview, the facility failed to notify the resident's representative timely of an allegation of sexual abuse for one of 27 samples residents (R) (R15). Findings included: A review of the clinical record revealed that R15 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's and depression. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R15 presented with a Brief Interview of Mental (BIMS) score of zero, indicating severely impaired cognition. During an interview on 10/26/2023 at 8:22 am, Certified Nursing Assistant (CNA) AA stated she observed R16 to grab R15 by the face, pull her face towards his and attempted to kiss R15. CNA AA stated she reported the incident to the Administrator. CNA AA stated this incident occurred on the 200 hall a couple of months ago. During an interview on 10/26/2023 at 8:27 am, CNA BB stated she observed R16 kiss R15 on the lips. CNA BB stated she reported this incident to the nurse on shift. CNA BB stated this incident occurred in the dining room in June 2023 or July 2023. A review of R15's complete clinical record revealed no evidence R15's family was notified of these incidents. During an interview on 10/31/2023 at 12:53 pm, the Director of Nursing (DON) stated she would check to see if the family of R15 had been notified of the allegation of sexual abuse. During a follow up interview on 10/31/2023 at 2:25 pm, the DON provided a progress note and stated the family of R15 was notified on 10/31/2023 of the allegation of sexual abuse that was reported on 8/31/2023.

Based on observations, resident and staff interviews, and review of the facility policy titled, Preventative Maintenance Program, the facility failed to ensure that the facility was maintained in a safe, clean, home-like environment in nine of 43 Resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) and the therapy room, related to being in disrepair. Findings include: 1. Review of the facility's policy titled Preventative Maintenance Program dated September 2023, revealed: A Preventative Maintenance Program shall be developed and implements to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years. Observation on 10/17/2023 at 9:38 am revealed Resident (R) (R32) was in bed and the head of the bed was tilting downwards and the foot of the bed was upwards. The bed looked bent in the middle of the outside frame. The bed did not have a headboard or a footboard. Observation 10/17/2023 at 9:55 am of room [ROOM NUMBER] revealed the bathroom sink had a plastic bag wrapped around the handles and the spigot. Observation on 10/17/2023 at 10:06 am of room [ROOM NUMBER] revealed the bathroom ceiling was patched around the sprinkler and had a hole around it. Observation on 10/17/2023 at 10:06 am of room [ROOM NUMBER] revealed the ceiling was patched with brown color and did not match; and the overhead light was not flush with the ceiling. Observation on 10/17/2023 at 11:05 am of room [ROOM NUMBER] revealed the sink counter was broken and the vent over the toilet was hanging loosely. Observations on 10/17/2023 at 11:10 am of the therapy room revealed the ceiling needed repair around the large light and several other areas. There were holes in the ceiling and the light was not flush with the ceiling. Interview and observations on 10/18/2023 at 1:13 pm in the therapy room with the Administrator and the Regional Property Manager (AA) revealed that this was where one of the pipes burst at Christmas Eve this past year (2022), referencing the patched ceiling that needed repair in several places. The Administrator also stated the pipe was broken in five places in the building, but it doesn't leak now. The Administrator also stated that the materials were there, but they had no maintenance person. Interview and observations on 10/18/2023 at 1:16 pm in room [ROOM NUMBER] with the Administrator and AA revealed the sink was leaking, the plastic bag was gone, and the water was turned on and water was coming out from the bottom of the sink onto the floor. The Administrator stated he would get it fixed. Interview and observations on 10/19/2023 at 1:16 pm in room [ROOM NUMBER] with the Administrator and AA revealed the sink appeared loose on wall, the wall around the light above the sink had holes and torn sheetrock, and the wall behind the bed was scuffed up badly. Sheetrock was missing in the scuffed-up areas. AA stated the sink will need to be caulked. Interviews and observations on 10/18/2023 at 1:22 pm with the Administrator and AA revealed the exit sign by the emergency exit in front of Central Supply was hanging loose. Interview on 10/18/2023 at 1:42 pm with the Administrator stated regarding the repairs that are needed per his acknowledgement, we have to get the manpower. We have done some repairs. It's a work in progress. Interview and observations on 10/18/2023 at 2:45 pm with R32 in room [ROOM NUMBER], R32 revealed someone came and worked on my bed. After looking under and on the side of the bed, there was no evidence it had been fixed. Interview and observations on 10/18/2023 in room [ROOM NUMBER] with AA verified the bed was in disrepair. AA got under the bed and revealed the foot motor was not working. 2. Observation on 10/17/2023 at 10:01 am during tour and screening of residents, revealed in room [ROOM NUMBER] next to bed A, a nightstand missing a door with another door resting against the wall, peeling paint on the wall, baseboard needing repair, and the closet door missing the wooden shutters to cover the resident's personal items. Observation on 10/17/2023 at 10:20 am during tour and screening of residents, revealed in room [ROOM NUMBER] next to bed B, a patio door missing blinds and damaged blinds laying on the floor. Observation on 10/17/2023 at 10:30 am during tour and screening of residents, revealed in room [ROOM NUMBER] behind bed A, the wall paint peeled, and scraped, scuffed sheetrock. Observation on 10/17/2023 at 10:30 am during tour and screening of residents, revealed in room [ROOM NUMBER] four residents sharing a walk-in closet space with missing cabinet doors and damaged doors hanging off the hinges, shared a bathroom missing the toilet tissue paper holder, and two rolls of toilet tissue paper resting on back of commode tank. Interview during walking rounds on 10/18/2023 at 1:20 pm with the Administrator, AA, and another state surveyor revealed the Administrator and AA confirmed damaged and missing material on closet doors, nightstand cabinet missing doors, damaged walls of peeled paint and chipped, scuffed sheetrock, and one baseboard needing repair. The Administrator revealed the facility had been without a Maintenance Director for several months and it is his responsibility to ensure the resident's rooms did not have damaged furniture. He further stated they ordered new furniture but have not had an opportunity to complete the repairs and replacement improvement duties due to the high occupancy of newly admitted residents. AA stated the conditions of the rooms were unacceptable and needed attention of repairs and removal of damaged, unrepairable items.

Based on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to provide hand hygiene practices during tracheostomy (trach) care for one of one Resident (R) (R 243) reviewed for trach care. This deficient practice increased R243's risk for infection. Findings include: Review of the facility policy titled, Tracheostomy Care, updated December 2022, revealed: Preparation and Assessment. 8. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. 9. Wash hands. Clean the Removable Inner Cannula. 14. Remove and discard gloves into appropriate receptacle. 15. Wash hands and put on fresh gloves. 16. Replace the cannula carefully and lock in place. Review of the undated Admission Record for R243 located in the Electronic Medical Record (EMR), revealed R243 was admitted to the facility with multiple diagnoses including but not limited to tracheostomy status, chronic respiratory failure with hypoxia, respiratory disorder, unspecified intellectual disabilities, unspecified injury of head, and diabetes mellitus. Review of the most recent admission Minimum Data Set (MDS) for R243 dated 9/23/2023 revealed a Brief Interview for Mental Status (BIMS) score of 0, which indicated R243 was unable to complete the interview due to cognitive deficits. Review of R243's care plan revealed R243 had a trach related to diagnosis of chronic respiratory failure, respiratory disorder, intellectual disabilities, and impaired breathing mechanics dependence on supplemental O2 [oxygen]. Observations on 10/17/2023 at 10:46 am revealed R243 lying in bed with head of the bed elevated. R243 was non-verbal. Trach was in place and secured with ties. Oxygen (O2) via trach collar at 3 liters (L)/minute (min). Observation of trach care on 10/18/2023 at 11:51 am performed by Licensed Practical Nurse (LPN) GG revealed R243 was positioned on their back in the bed. LPN GG explained she was going to do trach care on R243. The bedside table of R243 was covered with a pillowcase. Supplies included trach care kit, inner cannula, 4 x 4-inch gauze, sterile water, and suction kit. LPN GG washed her hands with soap and water and donned non-sterile gloves. LPN GG opened all containers. LPN GG removed gloves and washed hands. With ungloved hands, LPN GG dumped the contents of the trach care kit onto the non-sterile pillowcase. LPN GG indicated she did this wrong and wanted to start over. LPN GG threw away all opened containers and removed the pillowcase. LPN GG put a towel on the bedside table. LPN GG did not sanitize the table. LPN GG put the supplies on the towel on the bedside table and opened the containers. LPN GG removed her gloves and donned (put on) sterile gloves. LPN GG did not sanitize hands between removing and donning gloves. LPN GG removed the box out of the sterile trach kit and put it on the towel, touching the towel with her sterile gloves. LPN GG then removed the sterile drape and put it on top of the towel, picked up the box and put it on top of the sterile drape and filled the box with sterile water. LPN GG removed the rest of the contents of the trach kit and put it on top of the sterile drape. LPN GG placed the gauze in the sterile water. LPN GG removed her sterile gloves and put on non-sterile gloves. LPN GG did not sanitize hands. LPN GG removed her non-sterile gloves, washed her hands, and donned non-sterile gloves. LPN GG removed gauze around trach site and removed the inner cannula. LPN GG removed her non-sterile gloves, washed her hands, and put on sterile gloves. LPN GG inserted a new inner cannula. LPN GG did not clean inside the trach area or suction R243. LPN GG took the sterile gauze in the sterile water and cleaned around the outside of the trach. LPN GG applied divided gauze around the trach site.

Based on observations, resident and staff interviews, and review of the facility policy titled, Answering the Call Light, the facility failed to provide a working system that allows residents to call for staff assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area for three of 28 sampled Residents (R) (R13, R49, and R193). The deficient practice had the potential for residents needs not being met timely. Findings include: Review of the facility policy titled, Answering the Call Light revealed: The purpose of this procedure is to respond to the resident's requests and needs. 7. Report all defective call lights to the nurse supervisor promptly. Observation and test of the call light system on 10/17/2023 at 9:00 am revealed the call light in room [ROOM NUMBER] for R13, R49, and R193 did not work. Interview and initial screening on 10/17/2023 at 9:00 am in room [ROOM NUMBER] with R13, R49, and R193 revealed that their call lights had not worked for a while, now close to three weeks or more. R193 stated that they told them that they came but they did not fix it. R#193 also stated they said they needed to get some part, but they never came back. This Surveyor asked R193 to press their call light. The Surveyor went outside the room to check but the call light did not come on. Observation and test of the call light system on 10/17/2023 at 2:30 pm with the Director of Nursing (DON) and the Regional Supervisor (EE) revealed R13's, R49's, and R193's call light was not functioning properly. The DON and EE confirmed that the call light in room [ROOM NUMBER] did not function properly. Interview on 10/17/2023 at 2:35 pm with the DON revealed the call light will show at the nurse's station even though it is not showing outside the door of the resident's room. This Surveyor went with the DON to the nurse's station and the light was not showing at the nurse's station. The DON stated that she will put a cow bell in the resident's room. Observation on 10/17/2023 at 3:30 pm in room [ROOM NUMBER] revealed no cow bell on R13's, R49's, or R149's bedside tables. Observation and interview on 10/18/2023 at 8:50 am revealed a male standing on a ladder outside of the room [ROOM NUMBER] door removing the call light. An employee from a communications company (FF) stated that he was at the facility to replace the call light system in room [ROOM NUMBER]. FF stated that he received a call from his supervisor yesterday (10/17/2023) afternoon that the call bell was not working in this room. He stated that it had been a long time since he has been at the facility. He stated that he does not come that often but comes when he gets a call.

Based on observation and interviews the facility failed to maintain a safe, clean, homelike environment on two of two halls (100 Hall and 200 Hall). Findings include: During observation on 8/23/22 at 9:25 a.m. revealed 100 Hall sitting area behind couch has an area of dry wall missing on either side. During observation on 8/23/22 at 9:33 a.m. revealed on the 100 Hall on the right side, ceiling tiles had a brown substance and are noted to be sagging. Maintenance Director revealed these are the result of the air conditioning unit leaking. States the air conditioner has been fixed but confirms the tiles need to be replaced. During interview on 8/23/22 at 10:28 a.m. with the Maintenance Director confirmed the above findings. States he has been doing maintenance intermittently on the building. States he is currently painting rooms and once painting is complete will start on work in the common areas and floors. During interview on 8/23/22 10:29 a.m. with the Vice President of Property revealed his expectation is for the facility to be kept in a safe, clean, and homelike environment. States the above-mentioned items should have been addressed immediately, especially if residents are residing in these rooms. During observation on 8/23/22 at 10:54 a.m. revealed room 116 had an area on an exterior wall, adjacent to the air conditioner unit and the floor measuring approximately 24 inches tall by 12 inches wide of wall material peeling away with flaking areas exposing concrete material. Black discoloration was seen on wall material and on concrete block material. Also observed on an interior wall next to the restroom door, an area measuring approximately 6 inches wide by 12 inches tall of protruding wall material was peeling with brown discoloration. During observation on 8/23/22 at 10:58 a.m. revealed the shared restroom between rooms 116 and 114 revealed both door frames to have scattered dried brownish orange flaking areas on the lower areas of all door frames. Also observed in the same restroom a section of floor tiles measuring approximately 1 inch wide by 14 inches long adjacent to the commode to be missing and black colored substance on the floor. During observation on 8/23/22 at 11:10 a.m. revealed room 103 had blinds torn down and floor tile tore up below window. Residents living area visible from outside. During observation on 8/23/22 at 11:16 a.m. revealed room 102 baseboards are peeling away from the wall in the resident's bathroom area near sink. During observation on 8/23/22 at 11:28 a.m. revealed room 120 had an area on the exterior wall adjacent to the air conditioner unit and the floor measuring approximately 8 inches tall by 12 inches wide of flaking material with black discoloration. During observation on 8/25/22 at 11:41 a.m. revealed rooms 204, 206, 208, and 210 had several blinds observed with pieces missing and in disrepair. During interview and observational tour on 8/23/22 at 1:16 p.m. with Vice President of Property revealed he had been made aware of repairs needed in rooms 103 and 102. He stated he would add this to his on-going list of things he has to repair. During interview and tour of the facility on 8/25/22 at 11:00 a.m. with the Administrator to several rooms and areas with damages, Administrator revealed that he was aware of all damages and stated that they are in the process of repairing damages. He also revealed that rooms with damages are in QA. He stated that they will begin with painting rooms first, then repair of baseboards with plans to put up wall backboards to prevent damages from headboards. He stated a lot of the walls were damaged due to moving of beds during COVID pandemic. He stated most of the material has already been ordered including the paint that's needed to paint the dayroom walls which is ready for pick up. Administrator stated that the cooling system runs along the areas of the ceiling where repair is needed because of condensation. He has ordered materials to repair the ceiling and prevent further damage from condensation.

Based on interviews, record review, and facility policy 'Notification of Changes', the facility failed to promptly notify the family/representative of a change in condition for two of 40 sampled residents (R) #337 and #386. Findings include: Review of facility policy 'Notification of Changes' last revised 1/3/22 revealed 'The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.' 1. R#337 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 13 out of 15, indicating cognitively intact. Record review revealed on 8/16/21 at 2:00 a.m. R#337 was found to be in respiratory distress and sent to the hospital. Further review of R#337's record does not reveal resident's responsible party was not notified of transfer to the hospital. 2. R#386 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE] Section C-Cognitive Status revealed R#386 was never/rarely understood. Record review revealed on 6/29/21 R#386 had a fall from bed. Further review of R#386's record revealed resident's responsible party was not notified of the fall. During interview on 8/25/22 at 9:10 a.m. with Director of Nursing revealed it is her expectation for staff to notify the responsible party immediately when a change of condition occurs with a resident. Confirmed there was no documentation that either resident's responsible party was notified of the change of condition.

Based on interview, record review, observations, and review of facility policy, the facility failed to ensure one of 21 sampled residents (Resident #7) was free of physical abuse. Licensed Practical Nurse (LPN) DD was observed hitting Resident (R)#7 with a coat hanger; R#7 sustained multiple bruises. Additionally, there was evidence of previous potential incidents of abuse from LPN DD towards R#7 that were not reported by staff, investigated or addressed; resulting in a failure to protect R#7 from LPN DD. Findings include: Review of the facility policy titled GA Abuse Prohibition - State of GA (Georgia) dated August 2019 revealed the following. Policy (Corporation) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: -Screening of potential hires; -Training of employees (both new employees and ongoing training for all employees); -Prevention of occurrences; -Investigation of incidents and allegations; -Protection of patients during investigations; and -Reporting of incidents, investigations, and Center response to the results of their investigations. Definitions: Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment . 3. Training will be provided to all employees through orientation and a minimum of annually and will include: . 3.3 how staff should report their knowledge related to allegations without fear of reprisal; . 3.5 what constitutes abuse, neglect, and misappropriation of patient property . 5. Staff will identify event - such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately, move the patient to a safe environment, and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Review of the clinical record revealed R#7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#7 did not speak and was rarely able to make herself understood. The resident sometimes responded to simple, direct communication. R#7 was unable to complete the Brief Interview for Mental Status (BIMS) interview. Staff assessment indicated R#7 was severely cognitively impaired. Review of R#7's Mood Assessment revealed the resident had been assessed by staff and the resident had no indicators of depression. An assessment of the resident's behaviors revealed no behaviors were exhibited during the review period. Assessment of the resident's Functional Status revealed R#7 required limited assistance with bed mobility, transfer, walking in the room and hallway. R#7 required extensive assistance with dressing, hygiene, and was totally dependent for toileting, feeding and bathing. R#7 was incontinent of bowel and bladder and had a gastrostomy (G) feeding tube. Review of R#7's Medication Administration Record [REDACTED]. Additional medication included [MEDICATION NAME] (anticonvulsant) one mg, one tablet by G tube three times a day for agitation /anxiety. A review of R#7's Comprehensive Care Plan initiated 5/13/19 revealed the resident had the potential to exhibit physical behaviors related to Dow[DIAGNOSES REDACTED] and autism, including but not limited to self-injurious behaviors such as pinching self, resulting in bruises, using the right heel to hit the left leg, aggressive behaviors towards others and self, hitting staff, agitation, resisting care, labs, treatments, redirection, and destroying property. Interventions dated 9/26/19 included monitoring for non-verbal signs/symptoms of pain and medicate as ordered, and psych consult for medication. An intervention dated 7/20/2020 revealed R#7 was to be redirected if she was observed hitting herself. Review of the Nurse Practitioner Encounter Note dated 5/7/2020 revealed nursing staff reported worsening agitation and behaviors. The note revealed the resident received Klonopin ([MEDICATION NAME]) one mg three times a day. [MEDICATION NAME] ([MEDICATION NAME]) was increased to 50 mg twice a day. Review of a Change of Condition Progress Note dated 6/3/2020 revealed R#7 was noted to have healing bruises to the left side of her face, right lateral forearm, right trochanter (bony protuberance by which muscles are attached to the upper part of the thigh bone), right and left upper thigh, and left lower forearm. The resident was unable to state how bruising occurred due to cognitive deficits. Review of a Nurse Practitioner Encounter Note dated 6/4/2020 revealed the resident was seen after diffuse ecchymosis (discoloration of the skin from bleeding underneath, typically caused by bruising) was noted to the resident yesterday. Bruises were noted to the left chest, right upper arm, left posterior (further back position) arm, right hip, right posterior thigh, right and left thigh, and left lower leg. Ecchymosis was of varying colors ranging from bright purple to yellow. An investigation was currently pending. Review of the form titled, CNA Shower Sheet dated 6/4/2020 and signed by Nurse Practitioner (NP) NN revealed a diagram with the following bruises and notations: -The posterior right arm had a large purple bruise in the area extending from the elbow to the wrist. There was a smaller bruise noted without the color described. -The left posterior thigh had three smaller yellowish bruises. -The left anterior (front) of the left thigh had five bruises described as yellowish. -A bruise to the right anterior (front) thigh just above the knee was described as yellowish to bluish. -A bruise to the right trochanter (hip) area was described as purplish yellow. -A bruise to the right anterior upper arm was described as purple. -A bruise to the left anterior chest was described as a yellow bruise. There were no measurements of any of the bruised areas. Review of the Facility Incident Report Form to the State Survey Agency, dated 6/3/2020 revealed R#7 was noted with injuries of unknown origin. The Director of Nursing (DON) assessed the resident on 6/3/2020 and found many bruises. The investigation revealed Certified Nursing Assistant (CNA) EE stated she observed R#7 come out of her room (the resident was ambulatory) repeatedly. Licensed Practical Nurse (LPN) DD took the resident back to her room and shut the door. R#7 exited the room again and LPN DD became upset with the resident's actions. After the fourth time the resident came out of the room, LPN DD went into the room. CNA EE stated the door was cracked and she heard R#7 whimper. She stated she went to the room and witnessed LPN DD hitting R#7 with a coat hanger. CNA EE stated she got (R#7) out of the situation and kept her with me. When I came in on Monday, I noticed bruises all over her body. They were not present on Sunday or over the weekend that I could see. I have had a bad feeling over the last two days and decided that I need to report this incident. CNA EE told the Administrator that she had not reported the incident initially because she was afraid of retribution by LPN DD. The investigation revealed, during an interview with LPN FF, he stated a while back he recalled LPN DD speaking to R#7 in a loud, aggressive manner. LPN FF was no longer employed at the facility. The investigation revealed LPN DD was interviewed and was asked if she was aware of any incident involving R#7. LPN DD denied knowing how R#7 obtained the bruises, but confirmed the DON found bruising on the resident. She denied the allegation that she had hit the resident. When asked if she knew why she had been suspended, she revealed that some of the CNAs went to the DON and complained about her. Her affect was flat and she did not react to the fact that the police had been called and she was a prime suspect. LPN DD remained very calm during her questioning and denied any involvement with creating bruising to R#7. She was suspended and later terminated due to the incident/investigation. LPN DD was not available for interview. According to the investigation, the Atlanta Police Department was contacted and a report was made. An officer came to the facility to investigate and was shown the bruises. A police photographer was called to take pictures of the bruises. The officer interviewed CNA GG who revealed he had not witnessed this incident (with the coat hanger) but that approximately two weeks earlier he observed LPN DD grab R#7 by her arms forcefully after the resident urinated on herself. He did not know if R#7 had bruising (resulting from the incident). CNA GG stated he heard LPN DD talk very sternly and use curse words towards R#7. CNA GG stated that R#7 got on LPN DD's nerves and R#7 was a very busy resident. CNA GG no longer worked at the facility and was unavailable for interview. Six residents were interviewed as part of the investigation and stated the nurses and CNAs were not rude to them and they had not witnessed LPN DD harming another resident. The Summary and Conclusion of the final report dated 6/9/2020 revealed the following: 1. The resident was discovered to have bruising on her body in various locations. Origin unknown. Reported as such. 2. Interview with the CNA revealed that there was a suspect and the suspect was identified. 3. Interview with the CNA who reported it revealed that the resident was hit with a hanger on a Sunday evening and that she did not report it until Wednesday. 4. Interview with the same CNA revealed that she did intervene and remove the resident from the situation and protected her throughout the shift . 7. Facility completed a head to toe assessment of the resident. Bruises were noted in various stages of healing. They were present on forearms, back, legs, and buttocks . 9. Facility has assessed all residents on the unit for injuries and/or bruises and none were found. 10. Facility interviewed all other staff assigned to the care of the resident. Some staff members did substantiate inappropriate conduct of the nurse suspect. 11. Facility suspended all other employees who had knowledge of the nurse's inappropriate conduct and failed to report it. 12. Facility has conducted 100 % education regarding abuse and abuse reporting. Staff affirming information that they are mandated reporters and have the obligation to do so. 13. Facility interview with the nurse suspect did not get a confession to the incident. Suspect was not present when the police arrived due to suspension. 14. All alert and oriented residents on the unit and assigned to the nurse suspect's care were interviewed by the Director of Social Services and questioned about the care and services they received. Residents reported that they have not seen mistreatment of [REDACTED]. 15. Facility has terminated the employee (LPN DD) due to the severity of the allegation and presence of bruises on a resident in her care and that she failed to report them. 17. The facility has held an Ad Hoc (as needed) QAPI (Quality Assurance Performance Improvement) meeting to discuss the failure of reporting and the plan of correction to prevent recurrence has been put in place. This will be monitored by the Administrator on a weekly basis. 18. The facility does substantiate that an incident did occur and that the resident has bruises of unknown origin. The facility is unable to determine if the suspect contributed to the bruises. 19. The facility will hold ongoing education regarding zero tolerance of abuse and the need to report immediately. LPN DD's employee file was reviewed. The file revealed a criminal background check had been completed on 12/26/18. There were no disciplinary actions or criminal activities noted. LPN DD had no record of abuse. There was no evidence in the employee file of LPN DD being reported to the Board of Nursing. An observation was conducted of R#7 on 12/1/2020 at 12:30 p.m. revealed the resident was calm and sitting in a chair. The resident had no visible bruising noted and was clean and dry and did not respond to the surveyor's greeting. An observation conducted of R#7 on 12/2/2020 at 3:30 p.m. revealed the resident was in a low bed sleeping. There were no visible bruises or other signs or injury. An observation observed of R#7 on 12/3/2020 at 11:30 a.m. revealed R#7 was awake and getting up out of a low bed. There was no bruising or other signs of injury. An interview was conducted with Nurse Practitioner (NP) NN on 12/3/2020 at 10:45 a.m. revealed that on 6/4/2020, R#7 had small diffuse bruising to many areas of her body. The bruises were in different stages of healing. She confirmed R#7 hit herself at times but she did not feel that the resident could not have caused all of the bruises due to their locations. She stated that some of the bruises were deep purple but she did not consider the bruises to be a severe or major injury. NP NN stated the bruises were monitored following the incident but did not require medical treatment. An interview was conducted with CNA OO on 12/3/2020 at 10:55 a.m. revealed that R#7 got upset at times and hit at herself, but she redirected her and the resident usually complied. An interview was conducted with R#7's Power of Attorney on 12/4/2020 at 11:30 a.m. She revealed that staff had notified her of R#7 having bruises on her body. She stated the resident was non-verbal and could not understand commands. The resident exhibited behaviors leading to bruising before she came to the facility. She stated that the resident's behavior had changed during the time she was at home. She stated R#7 was docile but she became unmanageable, hitting at her parents and even banging her head against the door in her bedroom. She stated R#7 would self-harm by kicking herself in the shins with her heels to the point that her shins and heels would be swollen and blue. She stated the family had to resort to placing swimming noodles on the resident's extremities to prevent her from harming herself. She was admitted to the facility after a hospitalization because of her behaviors at home and the family's inability to care for her. She stated she had an outdoor visit with R#7 three weeks ago and had seen no indication that R#7's behavior was different after the incident that occurred in June 2020. A telephone interview was conducted on 12/4/2020 at 11:15 a.m. with CNA EE, who continued to be employed by the facility, revealed that on the date of the incident in June 2020, R#7 continued to come out of her room and LPN DD took her back to her room. She felt that LPN DD was irritated as the resident continued to come out of her room and shred paper. She stated about the fourth time the resident came out of the room, she followed her back to her room and witnessed LPN DD hitting R#7 with a plastic hanger. She stated she observed the resident being hit on her thighs and other parts of her body but she could not recall exactly where because so much time had gone by. CNA EE stated LPN DD also grabbed R#7's arms when she took her back to the room and she later saw bruises that resembled fingerprints. She revealed she had never seen LPN DD hit R#7 before, but it seemed the resident aggravated her. She stated she did not report the incident to the supervisor at the time it happened because she worked with LPN DD every day and was afraid. She stated she returned to work a couple of days later and saw dark purple bruises on the resident, stating, I knew I had to do something. CNA EE went to the Director of Nursing (DON) and told her R#7 needed an immediate skin assessment. She stated she had received abuse training in the past and knew about the reporting requirements. CNA EE confirmed she should have reported the incident immediately.

Based on interview, record review, and review of facility policy, the facility failed to ensure abuse allegations were reported promptly to the Administrator and to the State Survey Agency for one of 21 sampled residents (Resident #7). Incidents of staff to resident abuse towards Resident (R)#7 were either not reported or not reported timely. R#7 sustained multiple bruises after she was observed being hit with a coat hanger by Licensed Practical Nurse (LPN) DD. The incident was witnessed by staff; however, it was not reported for several days. Previous incidents by LPN DD towards R#7 were not reported. The failure to report abuse created an environment in which abuse could occur undetected and without consequence. Findings include: Review of the facility policy titled, GA Abuse Prohibition - State of GA (Georgia) dated August 2019 revealed the following. Definitions: Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment . 3. Training will be provided to all employees through orientation and a minimum of annually and will include: . 3.3 how staff should report their knowledge related to allegations without fear of reprisal; . 3.5 what constitutes abuse, neglect, and misappropriation of patient property . 5. Staff will identify event - such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately, move the patient to a safe environment, and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law . Review of the clinical record revealed Resident (R)#7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#7 was unable to complete the Brief Interview for Mental Status (BIMS) interview. Staff assessment indicated R#7 was severely cognitively impaired. Review of a Change of Condition Progress Note dated 6/3/2020 revealed R#7 was noted to have healing bruises to the left side of her face, right lateral forearm, right trochanter (bony protuberance by which muscles are attached to the upper part of the thigh bone), right and left upper thigh, and left lower forearm. The resident was unable to state how bruising occurred due to cognitive deficits. Review of a Nurse Practitioner Encounter Note dated 6/4/2020 revealed the resident was seen after diffuse ecchymosis (discoloration of the skin from bleeding underneath, typically caused by bruising) was noted to the resident yesterday. Bruises were noted to the left chest, right upper arm, left posterior (further back position) arm, right hip, right posterior thigh, right and left thigh, and left lower leg. Ecchymosis was of varying colors ranging from bright purple to yellow. An investigation was currently pending. Review of the initial facility report to State Survey Agency dated 6/3/2020 revealed R#7 was noted with injuries of unknown origin. The Director of Nursing (DON) assessed the resident and found many bruises. The investigation revealed Certified Nursing Assistant (CNA) EE stated she observed R#7 come out of her room repeatedly. Licensed Practical Nurse (LPN) DD took the resident back to her room and shut the door. R#7 exited the room again and LPN DD became upset with the resident's actions. After the fourth time the resident came out of the room, LPN DD went into the room. CNA EE stated the door was cracked and she heard R#7 whimper. She stated she went to the room and witnessed LPN DD hitting R#7 with a coat hanger. CNA EE stated she, got (R#7) out of the situation and kept her with me. When I came in on Monday, I noticed bruises all over her body. They were not present on Sunday or over the weekend that I could see. I have had a bad feeling over the last two days and decided that I need to report this incident. CNA EE told the Administrator that she had not reported the incident initially because she was afraid of retribution from LPN DD. The investigation revealed there had been prior incidents between LPN DD and R#7. LPN FF stated during the investigation, a while back he recalled LPN DD speaking to R#7 in a loud, aggressive manner. There was no evidence that LPN FF reported his observations to the Administrator prior to the investigation. The investigation revealed the Atlanta Police Department was contacted and an officer came to the facility to investigate the incident. The officer interviewed CNA GG who revealed he had not witnessed the incident with the coat hanger; however, approximately two weeks earlier, he observed LPN DD forcefully grab R#7 by her arms after the resident urinated on herself. He did not know if R#7 had bruises. CNA GG stated he heard LPN DD talk very sternly and use curse words towards R#7. CNA GG stated that R#7 got on LPN DD's nerves and stated, She (R#7) is a very busy resident. There was no evidence that CNA GG had reported the incident to the Administrator. The Summary and Conclusion of the final report revealed the following: Interview with the CNA who reported it (CNA EE) revealed the resident was hit with a hanger on a Sunday evening (5/31/2020) and she did not report it until Wednesday (6/3/2020). An interview was conducted with the Administrator on 12/1/2020 at 3:15 p.m. The Administrator revealed that CNA GG and LPN FF had been suspended at the time of the investigation and were not currently employed at the facility. CNA EE was suspended at the time of the investigation but remained employed by the facility. LPN DD was suspended during the investigation and was terminated as a result of the investigation. A telephone interview was conducted on 12/4/2020 at 11:15 a.m. with CNA EE. She revealed that on 6/1/2020, R#7 continued to come out of her room and LPN DD took her back to her room. She felt that LPN DD was irritated as the resident continued to come out of her room and shred paper. She stated about the fourth time the resident came out of the room, she followed her into the room and witnessed LPN DD hitting R#7 with a plastic hanger. She stated the resident was hit on her thighs and other parts of her body. She could not recall exactly where she was hit because of the amount of time that had gone by. CNA EE stated LPN DD also grabbed R#7's arms when she took her back to the room and she saw bruises that resembled fingerprints when she later returned to work and noticed the bruising on R#7. She revealed she had never seen LPN DD hit R#7 before, but it seemed that the resident aggravated her. She stated she did not go to the supervisor at the time because she worked with LPN DD every day and was afraid of LPN DD. She stated she returned to work and saw dark purple bruises on the resident and stated, I knew I had to do something. CNA EE went to the Director of Nursing (DON) and told her R#7 needed an immediate skin assessment. She stated she had received abuse training in the past and knew about the reporting requirements. CNA EE confirmed she should have reported the incident immediately.