Every finding on record at Heartwood Lodge Trinity Health

Based on interview and record review, the facility failed to initiate bowel protocol for one (Resident #4) of three residents reviewed for bowel and bladder. Findings:Resident #4 (R4)Review of an admission Record revealed R4 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of Parkinson's disease and chronic constipation. R4 depended on staff assistance for all of his activities of daily living. Review of the task monitoring-bowel elimination documentation for R4 reflected that a bowel movement had not been documented between the evening of 06/29/26 and the afternoon of 07/09/26. During an interview on 07/14/26 at 3:28 PM, R4 recalled recently not being able to have a bowel movement for quite a while and described it as uncomfortable and painful. Review of a care plan for R4 regarding constipation reflected that it had not been reviewed since April 2025. Review of nursing progress notes reflected no documentation that nursing had assessed R4 between 06/29/26 to 07/09/26. During an interview on 07/14/26 at 3:40 PM, the Director of Nursing indicated that nursing assessments of R4 and intervention for the constipation should have occurred sooner and that it was missed by nursing.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 07/13/2026 at 9:34AM, observed in dry storage room, a dented can of kidney beans on the can rack. During discussion of stocking procedures Dietary Dining Manager (DDM) O said the dented can should not have been stored on the can rack. On 07/13/2026 at 9:38AM, observed in walk in refrigerator, an open package of cooked ham that was wrapped in plastic film and sitting on the same tray as several raw pork loins. There was a pinkish liquid from the pork loins at bottom of the tray. DDM O confirmed that the ham was sitting on the tray with the raw pork loins and removed it from the walk-in cooler. According to the 2022 FDA Food Code Section 3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,P (b) Cooked READY-TO-EAT FOOD, P and (c) Fruits and vegetables before they are washed; P.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were performed for one (R32) of four residents observed during a medication administration observation. Findings include: A review of R32's admission Record, dated 7/13/26, revealed R32 was a [AGE] year-old resident that was admitted to the facility on [DATE] with multiple diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- a respiratory disease) and wheezing. A review of R32's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/9/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R32 was cognitively intact. During a medication administration observation on 7/14/26 at 7:45 AM, Licensed Practical Nurse (LPN) G administered multiple medications to R32, including one puff of Trelegy Ellipta Inhalation Aerosol Powder (a medication for COPD). Prior to administration of the Trelegy, LPN G instructed R32 that she needed to rinse and spit with water after she inhaled the Trelegy. R32 stated she knew. However, after R32 used the inhaler, she only swished the water in her mouth and swallowed it. R32 then took the rest of her pills with water. During this time, LPN G did not remind R32 that she needed to rinse her mouth out with the water and spit the water out instead of swallowing it. A review of R32's Medication Administration Record (MAR), dated 7/1/26 to 7/14/26 revealed the following instructions for the Trelegy Ellipta Inhalation Aerosol Powder: Rinse mouth with water after use to reduce aftertaste and incidence of candidiasis (a fungal infection). During an interview on 7/15/26 at 11:35 AM, Registered Nurse (RN) P stated she always has residents rinse their mouths out with water and spit it out after she administers inhaled medications. She stated she does it for all inhaled medications. That way I don't have to remember which ones that I specifically have to do them with. RN P further stated she has the residents rinse and spit because inhaled medications can cause thrush (a type of candida fungal infection). During an interview on 7/15/26 at 11:45 AM, LPN R stated she only has residents rinse their mouth out with water and spit the water out for certain types of inhaled medications. She stated she has them rinse and spit for inhaled medications that contain steroids, such as Trelegy and Advair. LPN R further stated if the resident does not rinse and spit with water the medication can cause thrush. A review of the Trelegy manufacturer's information, dated 2023, revealed that after inhaling the medication the resident needs to rinse their mouth out with water and spit the water out. Do not swallow the water. The manufacturer's information also revealed Trelegy can cause a fungal infection of the mouth or throat (thrush) and rinsing your mouth with water without swallowing after using Trelegy can help reduce the chance of getting thrush.

Based on observation, interview, and record review, the facility failed to treat one of three residents (Resident #8) with dignity. Findings: Resident #8 (R8) Review of an admission Record revealed R8 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of dementia. During an observation on 8/22/25 at 8:57 AM, R8 sat at the dining table in the common area of the yellow unit eating breakfast. R8 asked Certified Nurse Aide (CNA) G to warm up his eggs, they are ice cold. CNA G responded to him and told R8 that the microwave was broken. CNA G then turned and left the area. R8 did not finish his breakfast. During an interview on 8/22/25 at 9:15 AM, Dietary Manager (DM) O stated that there was a working microwave in the kitchen. During an interview on 8/26/25 at 9:10 AM, R8 recalled the incident on 8/22/25 (when his eggs were cold and he asked the aide to warm them up) and stated that CNA G sometimes did not help him. During an interview on 8/26/25 at 10:00 AM, the Administrator indicated that CNA G 's interaction with R8 on 8-22-25 was not acceptable and not how staff were expected to treat residents.

Based on interview and record review, the facility failed to prevent a fall for 1 of 2 residents reviewed (R1) for falls, resulting in R1 sustaining multiple rib fractures and a hip fracture. Findings include: A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/14/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed R1 was moderately cognitively intact. During an interview on 06/12/25 at 09:50 AM, R1 stated through short statements and yes/no answers that in February 2025 she rolled out of bed while staff were doing a bed bath. She stated staff rolled her to the side and she kept going until she was on the floor. R1 stated one staff member was present and giving her the bed bath. She stated usually only one staff member provides care to her, including bed baths. R1 denied the facility uses two staff members for her care. R1 stated after she fell out of bed onto the floor she had difficulty breathing and pain. She stated staff called an ambulance and staff stayed with her until the ambulance arrived. R1 stated she had several fractured ribs and a hip fracture. She stated she was in the hospital for several days, but did not have surgery. A review of R1's Fall Risk Assessment, dated 12/10/24, revealed R1 scored a 15 (Moderate Risk). A review of R1's Activities of Daily Living (ADL) Care Plan, dated 9/28/20 and revised on 12/27/23, revealed R1 required 2 staff participation for repositioning and turning in bed (date initiated: 4/6/23). However, R1 only needed total assistance of one person with brief changes and using the bed pan per the care plan. A review of R1's Nurse's Notes, dated 2/7/25, revealed, Resident observed laying on her left side on the floor next to the bed. Resident moaning with a snort like breathing. Resident complained of pain to back. Resident assessed, large forming bump noted on back of head. Hump in the middle of the bed observed Resident sent out to the emergency room for evaluation and treatment. Resident assessed . A review of the hospital's Internal Medicine Daily Inpatient Progress Note, dated 2/17/25, revealed on 2/7/25 R1 was admitted to the hospital due to rib fractures and a hip fracture after a fall. She presented to the ER (emergency room) after falling out of bed while receiving a bath at her facility. Workup revealed multiple rib fractures as well as a hip fracture. Additionally she was found to have a new LLL (left lower lobe) subsegmental PE (pulmonary embolism- a blood clot in the lung) and a very small left-sided pneumothorax (a condition that can be caused by a blunt or penetrating injury (e.g., from fractured ribs) where air leaks into the space between the lung and chest wall and causes the lung(s) to collapse) . A review of R1's hospital Discharge Summary, dated 2/17/25, revealed R1 had been seen in the emergency department after a fall from her bed at the facility while staff was giving her a bed bath. R1 fell approximately 3' (three feet) from the bed while staff where mobilizing her. R1 had pain in the chest wall. It was discovered at the hospital that she had sustained several rib fractures and a hip fracture. A review of Certified Nursing Assistant (CNA) D's typed statement, undated, revealed she was cleaning R1 up because R1 had a bowel movement. She rolled R1 onto her right side to clean her up. CNA D stated she needed more washcloths, so she turned around to grab some more washcloths. She stated when she turned back around, she heard R1 make a grunting/growling noise and R1 was rolling off the bed. CNA D stated she could not catch her in time before she rolled off the bed completely. CNA D stated she had checked R1's kardex (a summary of a resident's care needs) before providing care and she noticed R1 was one assist for toileting and two assist for transfers. CNA D stated she did not remember if she checked R1's bed mobility assistance on the kardex. She then expressed guilt/remorse that the incident occurred. A review of Licensed Practical Nurse (LPN) J's typed interview, undated, revealed she was told by CNA T that she needed to go to R1's room. LPN J stated when she arrived she saw R1 lying on her left side on floor on the right side of the bed. Staff had placed a pillow under her head. R1 was moaning with snort like breathing. LPN J stated she saw loose stools on the floor. LPN J stated she palpated R1's body and R1 stated she had pain on her back and left leg. LPN J stated she observed a goose egg on the back of R1's head. LPN J stated she only noticed a lump in the mattress when the former Director of Nursing (DON K told her there was a lump there. A review of CNA D's personnel file revealed she had a Final Written Warning Corrective Action Notice for an infraction on 2/7/25 (R1's fall during care?). She was written up for a Failure to follow policies, procedures, or regulations. However, there was not any additional information in the written warning that would elaborate of what those policies, procedures, or regulations were or what exactly CNA D failed to do. A review of CNA D's personnel file revealed she also had received a certificate of completion, dated 2/28/25, for Safe Resident Handling and Movement. During a second interview on 06/13/25 at 01:25 PM, the NHA stated CNA D had to complete training on safe resident handling because she rolled her (R1) away from her. The NHA stated if CNA D would have rolled her (R1) towards herself (CNA D), she would have caught her and R1 would not have rolled off the bed. The NHA further stated if there had been a hump/lump in the mattress staff should roll the resident over it and have another staff member on the other side of the mattress to make sure the resident did not roll off the bed. The NHA also stated she did not know what specifically CNA D received her final written warning for, but she can only assume it was because CNA D did not take proper precautions to prevent R1 from falling off the bed during care on 2/7/25.

Based on interview and record review, the facility failed to have the required attendance of a Medical Director, or a designated physician at the facility's Quality Assessment/Improvement (QAPI) meetings at least quarterly resulting in the potential for lack of oversight of the quality assurance process and coordination of medical care that could impact 74 of 74 residents residing within the facility. Findings include: Review of the QAPI monthly sign in sheets from 6/2024 to 6/2025 revealed the Medical Director or designated physician was in attendance on 6/12/24, 8/5/24, and 4/9/25. This leaves 8 months with no physician representation for the QAPI meetings. In an interview on 6/13/25 at 3:25 PM, the Nursing Home Administrator (NHA) reported the facility has monthly QAPI meetings and has not had their meeting for June 2025 yet. The NHA did not have an answer to why there was no Medical Director present at least quarterly to the meetings.

Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify and address issues and develop/implement appropriate plans of action in regard to 1) call light response time and care, 2) Grievances 3) MDS (minimum data set) late submissions and incorrect coding 4) antibiotic stewardship and infection control, 5) complete and accurate medical records, 6) available/updated policies and procedures annually reviewed, 7) and monitor nursing staff for compliance with nursing standards of practice. This deficient practice has the potential to affect all 74 residents who reside at the facility. Findings include: During an interview on 6/13/24 at 11:47 AM, The Nursing Home Administrator (NHA) was asked about her QAPI program and reported they have monthly QA meetings and are all learning together. The NHA reported she had access to the MDS (Minimum Data Set) Quality indicator report and will discuss them with the team. The NHA reported the report did not make sense when she first started a few months ago because it was not accurately reflecting the residents. The past Director of Nursing was not documenting things correctly and made the quality indicators look better than what they were. The NHA acknowledged the facility was just previously cited for infection control and complete and accurate medical records and aware we still had concerns about these issues and as follows: Call lights- When questioned about the concerns of call light response times and the needs of the residents being met per interviews of residents and review of call light timing data, and resident council minute concerns for 4/24/25 and 5/29/25 regarding call light timing and being turned off before the resident needs are met, the NHA reported this concern was identified and no ad hoc meeting was done yet. The NHA reported she gave this task to the Admissions person to have ownership, but they did not make it to the meeting and no follow up was done. Grievances- The NHA reported the Activities Director is supposed to bring resident grievances from the Resident Council Meetings to the IDT (interdisciplinary team) meetings. The NHA reported she reviewed the Resident Council Meeting minutes 6/12/25 (the day before this interview) and told the Activities Director she needed to add the resident grievances to the book and get them all onto forms. The NHA reported her Resident Council minutes were terrible, but she was a great activities person. The NHA reported once any grievance is addressed and completed by the designated department, she will get a copy of it to show it was completed. MDS (Minimum Data Set) late submissions- The NHA reported they were just starting a new admissions process and the MDS staff are involved but it is still in its planning stage. Did not address the late submissions. The NHA was informed of incorrect MDS coding at this time. Antibiotic Stewardship- The NHA reported the Infection Control Preventionist did not compare the Infection Control Pathway to the facility policy. The NHA reported she reached out to Corporate to help educate her more. Medical records- When queried about skin assessments not in an orderly manner, the NHA reported their current system is a definite improvement. They acknowledged a need for a Performance Improvement Plan (PIP) on 3/4/25 when the concern was identified and started the PIP in April. The NHA reported the Blue Unit is difficult to manage because of the rehab admissions and discharge turnover but they just got a new manager. The NHA reported they identified back in April about the Certified Nursing Assistants (CNA's) not having access to chart their tasks and corrected that by May. The NHA was informed that the CNA's were still not documenting appropriately in the EMR. Regarding the Pharmacy Medication Review, Consultation notes, Practitioner notes, laboratory/diagnostic records, and complete and accurate medical records to reflect the residents care lacking in the EMR, the NHA reported she talked to the staff and felt everyone was just focusing on the skin assessments. The NHA acknowledged some things would get uploaded to the EMR before the doctors and nurses could review them and nursing is now taking longer to get information into the medical records. There were several policies and procedures either not available, from the previous owners, not updated or annually reviewed by the facility as follows: Admissions, transfers and discharges. Infection Control Incontinence Care/Bowel and Bladder Care Skin/Wound Management Antibiotic Stewardship Water Management policy was from the previous owners and last reviewed 7/6/2020. Falls Management policy last reviewed/revised August 2021. Oxygen Administration policy last reviewed 1/2023. Care Plans- Form provided but does not indicate a policy and procedure. MDS policy dated 12/11/2015. The NHA did not have an answer to the lack of policies and procedures and reported they will sometimes use the same ones the hospital has. The QAPI Plan and Policy was requested during the entrance conference. The facility provided a blank plan and no additional details during the discussion of the concerns during the interview.

Based on interview and record review, the facility failed to formulate and implement an effective antibiotic stewardship program with written protocols for antibiotic use, documentation, and a monitoring system to provide feedback and ensure adherence to the antibiotic stewardship program. Findings: Review of the undated Infection Control policy provided by the facility contained a section titled Antibiotic Stewardship. This section included information on what components may be included as part of an antibiotic stewardship program. However, the description of the facility's program did not consist of written antibiotic use protocols, a protocol when a resident is admitted to the facility while on antibiotic therapy, necessary documentation surrounding antibiotic use, or include a description of a system to provide feedback to the prescribing medical practitioner. On 6/11/25 at 1:04 PM an interview and record review were conducted with Infection Preventionist (IP) L. IP L described a process identifying an infection through signs and symptoms, initial treatment measures and reporting to the medical provider. IP L reported obtaining labs, lab results and why and when antibiotic therapy would be initiated. IP L reported if antibiotic therapy was to be imitated prior to having laboratory results both nursing and the medical provider would document in the medical record. R26 Review of the Electronic Medical Record (EMR) reflected R26 admitted to the facility 5/19/25 with diagnoses that included a fracture and a history of repeated falls. The medical record reflected R26 had a urinary catheter that had been inserted during admission. Review of the EMR Progress Notes for R26 reflected a Nurses Note dated 6/2/25 at 5:42 PM of urine with increased cloudiness, sediment . and foul smelling. The entry reflected a lab specimen was obtained and transported to the lab for testing. Review of the laboratory urinalysis report dated 6/2/25 reflected an elevated white blood cell count (one of the signs of an infection). The EMR Progress Notes reflected a Nurses Note dated of 6/3/25 at 12:43 PM that the Lab had been called and the specimen was going to culture. The EMR Progress Note of 6/3/25 at 3:57 PM reflected The system has identified a possible drug allergy for the following order Cephalexin Capsule 500 mg (milligram) (an antibiotic) Give 1 capsule by mouth three times a day for UTI (urinary tract infection) for 7 days. This indicated an order to start an antibiotic had been received but the EMR did not reflect documentation the physician had been notified. The EMR did not reflect any documented justification for the initiation of antibiotic therapy pending culture results. Review of the EMR Progress Note entry on 6/3/25 at 4:50 PM reflected documentation that This order is outside of the recommended dose or frequency, Macrobid Oral Capsule 100 mg (an antibiotic) give 1 capsule by mouth every morning and at bedtime for UTI for 5 days . This drug's dose should be adjusted based on renal function. Manual screening is required. Review of the EMR did not reveal any documentation to explain the entries of two different antibiotics for UTI or that renal function was considered as part of the antibiotic therapy. Lab results for the urinalysis were identified but no culture results were found in the EMR as of 6/11/25. No documentation was found that indicated the medical provider had been contacted or that the medical provider had commented on the course of treatment. The: Miscellaneous (misc) section of the EMR reflected the last medical provider encounter occurred on 5/30/25 prior to the UTI. The EMR did not reflect a Care Plan for an active UTI or that antibiotic therapy had been initiated. Review of the EMR did not reflect another entry regarding antibiotic therapy from 6/3/25 until 6/6/25. However, on 6/6/25 at 4:45 PM there was a repeat entry that The system has identified a possible drug allergy . to the Cephalexin Oral tablet. Upon request the facility provided a timeline of R2's UTI identification and treatment to clarify information present and not identified in the EMR. IP L provided the following information: (R26) UTI Timeline 6/2/25 Resident voiced concern for UTI. Sediment noted in Foley Catheter with Urine foul odor 6/2/25 UA collected and sent to lab. 6/3/25 UA + (positive) Resident started on Macrobid 100 mg (twice daily) (times) 5 days pending culture results. 6/6/25 UA culture results sent to facility. Culture (positive) for . Physician notified and antibiotic changed to Keflex . End of timeline. On 6/12/25 at 11:35 AM the Nursing Home Administrator (NHA) and IP L were interviewed regarding the Antibiotic Stewardship Program and EMR documentation. The NHA reported the description of the facility Antibiotic Stewardship Program provided was the correct policy. The NHA reported that the physician does not document in the facility EMR. The NHA reported the physician uses a system that does not communicate with the facility EMR. IP L also acknowledged the physician does not document in the facility EMR and reported a request was submitted to the physician for the notes on R26. As of survey exit neither the NHA nor IP L provided any additional information that indicated the antibiotic therapy provided R26 was consistent with an antibiotic stewardship program.

This citation has two Deficient Practice Statements (DPS) DPS #1 Based on interview and record review, the facility failed to ensure an annual review was completed of the Infection Control policy and procedures to verify adherence to current national standards of care. Findings: Review of the Infection Control Policy and program provided by the facility did not reflect if or when a review had been conducted to ensure the policy and program met current standards of care. On 6/11/25 at 1:04 PM. during the Infection Control task, an interview was conducted with Infection Preventionist (IP) L. IP L was asked to provide documentation the facility Infection Prevention policy and program was reviewed annually. IP L indicated this information would be provided. On 6/13/25 at 9:54 AM an interview was conducted with the Director of Nursing (DON). The DON was informed that the Infection Control policy provided by the facility did not indicate when the policy had been implemented or reviewed. The DON was informed IP L had yet to provide verification of an annual review. The DON indicated this data is usually documented on the first page of the policy but if this review verification was available, it would be provided by survey exit. As of survey exit no documentation was provided by the facility that verified an annual review of the Infection Control policy had been conducted. DPS #2 Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During an interview with Environmental Services Director (ESD) [NAME], at 12:54 PM on 06/11/25, it was found that an annual review of the Water Management Plan had not taken place. Further interview found that ESD was unsure of the current members of the interdisciplinary water management team or when the last review of the water management plan had taken place. A record review of the facility policy entitled Water Management Policy Version 7.0 last reviewed [DATE], was found to be developed and maintained by the previous owners with no updated policy for the facility currently owned and operated under [NAME] Health Senior Communities.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled in 1 of 3 medication carts (Yellow Neighborhood Medication Cart) and 1 of 2 medication rooms (Yellow Neighborhood Medication Room) inspected, potentially affecting 25 of 74 facility residents. Findings Include: During an observation on 06/12/25 at 11:10 AM, the Yellow Neighborhood Medication Cart was inspected Licensed Practical Nurse (LPN) F. The following observation and interview were made: - A box of Ketotifen fumarate ophthalmic solution labeled [Resident # 52's last name] 2-10-25 [R52's room number] was observed in the medication cart. However, the solution bottle in the box was not labeled with any information that would identify the resident who the bottle belonged to should it become separated from the box. Other single user bottles/vials in other boxes in the medication cart were all labeled with resident names and/or room numbers. - LPN F stated she did not know if the vials and/or bottles in boxes that were for single resident user should be labeled with their names or other information to identify who the medications belonged to or if it was acceptable to just label the outside boxes. During an observation on 06/12/25 at 03:15 PM, the Yellow Neighborhood Medication Room was inspected with Clinical Care Coordinator (CCC) E. The following observation and interview were made: - A box of Tuberculin Purified Protein Derivative (TB PPD) solution 5 TU/0.1 ml (5 tuberculin units per 0.1 milliliters) was labeled 6-5-25 (open date). However, the vial inside the box was not labeled with an open date. - CCC E stated she was not sure if vials or bottles in boxes in the medication carts should be labeled with resident names if they are single user medications. She stated they are definitely labeled if they are inhalers in boxes because that goes into the resident's mouth. - CCC E also stated, I don't label the TB vials [with the open date]. That could cause confusion, especially if the date on the vial inside the box is different than the date on the box. I only label the TB vial box. The surveyor asked CCC E if there were two open TB vial boxes and the vials were not labeled, how would she know which box the vial goes to if they fall out of their individual boxes and the dates on the boxes are different. She stated, That's a good question. I'll have to find out and get back to you. During a second interview on 06/12/25 at 03:45 PM, CCC E stated, You learn something new every day. She stated she found out that the individual TB vials should be labeled with an open date in addition to the box being labeled. During an interview on 06/13/25 at 04:00 PM, Registered Nurse (RN) B stated the vials/bottles in boxes in the medication carts should be labeled with the residents' names in case they get separated from the boxes. She also stated that TB vials in the medication rooms should also be labeled with the open date in case they become separated from the boxes.

Based on interview and record review, the facility failed to ensure that monthly pharmacy review irregularities and pharmacist recommendations were received and addressed by the physician for 2 of 5 residents (R1 and R17) reviewed for monthly pharmacy medication regimen reviews. Findings include: A review of the facility's Medication Regimen Review policy, last revised 6/1/24, revealed, 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR (Monthly Regimen Review) and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained in the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected . 9.2 The attending physician should document in the residents' health (medical) record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1 If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. A review of the facility's Medication Regimen Review policy, last revised 6/1/24, revealed, 11. When the consultant pharmacist identifies a time-sensitive medication related concern during MRR that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician/prescriber to communicate the issue and obtain direction or new orders. 11.1 If the attending physician has not responded by the time the consultant pharmacist has completed his/her consultation for the day, the issue will be escalated to the medical director for immediate action by facility staff . 13. The attending physician/prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident . R1 A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. A review of R1's medical record, dated 6/27/24 to 6/12/25, revealed the pharmacist made recommendations on 8/27/24 (Labs), 1/31/25 (Vitamin D), and 4/30/25 (warfarin and feeds). However, the pharmacist's consultation reports for these dates that would detail what the actual recommendations were could not be located in R1's medical record. In addition, the pharmacist's review and/or consultation report for July 2024 was not in R1's medical record. During an interview on 06/12/25 at 12:55 PM, the Nursing Home Administrator (NHA) was notified R1's pharmacy review of July 2024 and consultation reports for 8/27/24, 1/31/25, and 4/30/25 could not be located in R1's medical record. The NHA stated she would try and locate them and would provide copies to the surveyor, if she can locate them. The NHA also stated that if she can locate the pharmacy consultation reports and the physician agreed with the recommendation, then she would provide supporting documentation that the recommendation was implemented. During a second interview on 06/13/25 at 8:50 AM, the NHA stated she could not locate R1's pharmacy recommendations that were signed by the physician (MD C). The NHA stated she contacted the pharmacy yesterday (6/12/25) and they sent copies of unsigned pharmacy consultation reports for 7/29/24, 8/27/24, 1/31/25, and 4/30/25. A review of R1's Consultation Report, dated 7/29/24 and unsigned, revealed the pharmacist recommended that the physician discontinue Vitamin D 3 2000 units daily and change it to Vitamin D 3 50,000 units twice monthly due to frequent dosing increased medication costs and it also placed R1 at increased risk for adverse events (negative side effects). However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A review of R1's Consultation Report, dated 8/27/24 and unsigned, revealed the pharmacist recommended lab monitoring (a CBC, BMP, and Phenobarbital trough concentration) starting on the next lab day and then every six months because R1 had Phenobarbital (a medication for seizures) prescribed. However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A review of R1's Consultation Report, dated 1/31/25 and unsigned, revealed the pharmacist recommended that the physician discontinue Vitamin D 3 2000 units daily and change it to Vitamin D 3 50,000 units twice monthly. This was the same recommendation that the pharmacist made on 7/29/24. However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A review of R1's Consultation Report, dated 4/30/25 and unsigned, revealed the pharmacist made a Clinical Priority Recommendation. Prompt Response Requested recommendation that warfarin (Coumadin- a blood thinner) not be administered with R1's tube feeding formula. The pharmacist recommended administering the warfarin one hour before or two hours after R1's received the formula because of a possible interaction between the formula and the medication (the formula can interfere with the effectiveness of the warfarin due to chemical incompatibilities). However, the NHA failed to provide documentation that the physician had reviewed and/or addressed this report. A second review of R1's medical record, dated 7/29/24 to 6/13/25, failed to reveal any evidence that the physician had reviewed and/or addressed R1's pharmacy recommendations for 7/29/24, 8/27/24, and 1/31/25. However, R1's medical record did reveal a Nurse's Note, dated 5/28/25 (29 days after the recommendation was made), that the nurse spoke to MD C about R1's Coumadin and he discontinued it and started R1 on a different blood thinner. During an interview on 6/13/25 at 9:30 AM, copies of any documentation that the physician had reviewed and/or addressed R1's pharmacy recommendations for 7/29/24, 8/27/24, and 1/31/25 were requested from the Director of Nursing (DON) (2nd request- 1st was to the NHA). In addition, any documentation that the physician had been notified prior to 5/28/25 of the pharmacist's 4/30/25 recommendation regarding R1's Coumadin was requested from the DON. During a second interview on 6/13/25 at 10:10 AM, the DON stated they could not locate any documentation that R1's pharmacy recommendations for 7/29/24, 8/27/24, and 1/31/25 were addressed by the physician. She also stated they could not find any documentation that the physician had been notified prior to 5/28/25 of the pharmacy recommendation on 4/30/25. During a third interview on 6/13/25 at 10:50 AM, the DON stated she found R1's physician signed pharmacy consultation report for 7/29/24. She stated she found it in a soft file binder (not in R1's medical record) in her office that the previous DON had left there. The DON also stated she would continue looking to see if she can locate R1's signed Consultation Reports for 8/27/24 and 1/31/25 and/or documentation that the pharmacist's recommendations were reviewed and/or address by the physician. However, at the time of the completion of the survey and the survey team's exit from the facility, the facility failed to provide documentation that the physician had reviewed and/or addressed R1's pharmacy recommendations for 8/27/24 and 1/31/25. A review of R1's Consultation Report, dated 7/29/24 and signed by the physician on 8/1/24, revealed the physician accepted the recommendation to change R1's Vitamin D 3 2000 units per day to Vitamin D 3 50000 units twice monthly. A review of R1's Medication Administration Records (MAR's), dated 8/1/24 to 6/13/25, revealed R1's Vitamin D 3 (cholecalciferol) was never changed per the pharmacy recommendation on 7/29/24 and provider approval on 8/1/24. Therefore, R1 had received Vitamin D 3 2000 units daily, instead of Vitamin D 3 50,000 units twice monthly, for over ten months after the physician agreed to change the dosing. R17 #1 of 2 Review of the admission Record reflected R17 originally admitted to the facility 1/18/17 with pertinent diagnoses that included Gastro-Esophageal Reflux Disease (GERD). Review of the EMR for R17 reflected a pharmacy Medication Regimen Review (MRR) was conducted 10/29/24 and a recommendation report had been submitted to the facility for physician review. The pharmacy recommendation reflected Please consider 1. Taper omeprazole to 20 milligrams (mg) (orally every other day) x (for) 7 days then Trial DC (discontinue). The EMR did not reveal the recommendation report had been reviewed and responded to by the physician. On 6/12/25 at 5:13 PM an email request was sent to the Nursing Home Administrator (NHA) requesting the Pharmacy recommendation response. On 6/13/25 at 2:56 PM the MRR recommendation of 10/29/24 reflected a response signed and dated 11/28/24 that I accept the recommendation above, please implement as written. Review of the EMR Doctor's Orders Summary for R17 reflected the accepted pharmacy recommendation had not been implemented and R17 had received the Omeprazole daily since the start date of 4/22/24. On 6/13/25 at 3:09 PM the NHA and the Director of Nursing (DON) were asked to review the MRR recommendation of 10/29/24. At 3:20 PM the DON reported that the facility did not implement as written as directed by the physician and acknowledged R17 continued to receive the medication. #2 of 2 Review of the EMR for R17 reflected a pharmacy Medication Regimen Review (MRR) was conducted 4/30/25 and a recommendation report had been submitted to the facility for physician review. The pharmacy recommendation reflected BMP (basic metabolic panel) on the next lab day . The EMR did not reveal the recommendation report had been reviewed and responded to by the physician. On 6/12/25 at 5:13 PM an email request was sent to the Nursing Home Administrator (NHA) which asked for the physician response to the pharmacy recommendation of 4/30/25. On 6/13/25 at 3:20 PM the facility provided the response to the pharmacy recommendation of 4/30/25 not found in the EMR. The response reflected it has been signed by a Unit Manager on 5/8/25 but six days later, on 5/14/25, the physician had signed as I accept the recommendation(s), please implement as written. At the bottom of the page was an unsigned and undated note that the lab had been completed on 2/5/25. No documentation was found in the EMR that indicated the physician had noted this lab result from 3 months prior or if it was acceptable to negate the instruction of 5/14/25 to implement as written. On 6/13/25 at 3:23 PM an interview was conducted with MDS RN U who reported she did not know if the Dr. was aware of the lab 2/5/25. As of survey exit no additional information was provided.

Based on observation, interview and record review, the facility failed to ensure that one resident (R224) of two residents reviewed for bowel and bladder, who admitted to the facility continent of bowel and bladder, received timely assistance to maintain continence. Findings include: Resident #224 (R224) Review of a Face Sheet revealed R224 admitted to the facility on [DATE] with pertinent diagnoses of fusion lumbar spine, urinary tract infection (UTI), and fractured lumbosacral spine and pelvis. Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. Review of the Care Plan for R224 revealed: Focus: I have indwelling catheter, initiated on 5/30/25 and revised on 6/2/25 by the MDS Coordinator. The MDS reflects R224 is continent. Focus: At risk for infection related to indwelling catheter, initiated on 6/2/25. Focus: . ADL (activities of daily living) . Interventions: . TOILET USE: I require 1 staff participation to use toilet, initiated 5/30/25. During an observation and an interview on 6/10/25 at 3:10 PM, R224 reported she was on antibiotics prior to admission for a urinary tract infection (UTI) and was on antibiotics that were not available upon admission to the facility. R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and soiled her pants because she could not wait that long. A couple staff at night will tell her to just go in her brief if she cannot hold it and not to worry about it. If you have to go, just go they told her. R224 reported it makes her feel bad when she urinates inside her brief even though the staff are very kind about it and will clean her up. R224 did not have an indwelling catheter. Review of the Call Light logs for R224 from 6/5/25 to 6/12/25 revealed the following call wait times: 6/5/25 at 6:28 AM, 27:14 minutes 6/5/25 at 7:48 AM, 40:31 minutes 6/5/25 at 12:23 PM, 24:22 minutes 6/5/25 at 8:01 PM, 20:40 minutes 6/6/25 at 7:58 AM, 40:37 minutes 6/6/25 at 9:30 AM, 22:33 minutes 6/6/25 at 1:48 PM, 30:01 minutes 6/8/25 at 9:10 PM, 36:17 minutes 6/9/25 at 7:31 PM, 23:06 minutes 6/10/25 at 11:14 AM, 41:46 minutes 6/11/25 at 5:16 AM, 35:17 minutes 6/11/25 at 6:06 AM, 2:19 minutes 6/11/25 at 7:55 AM, 45:49 minutes Review of the Nursing Progress notes dated 6/2/25 at 12:36 PM for R224 revealed: Urine culture results received . new orders received for . Bactrim DS (double strength) BID (twice a day) x 7 days. Review of the Urinary continence task list revealed R224 dated 6/1/25 to 6/10/25 revealed the resident had four incontinence episodes and on 5 days she was documented as toileted once a day. One example was on 6/7 when R224 was assisted toileting at 1:10 AM and again at 9:10 AM. There was no documentation to show R224 was toileted until 2:02 AM the next morning. In an interview on 6/11/25 at 4:35 PM, Certified Nursing Assistant (CNA) S reported staff are to document in the EMR each time a resident is toileted. CNA S reported she is aware of R224's concerns about long call light wait times. CNA S is aware of the 3rd shift staff not taking R224 to the bathroom and giving her a bed pan instead. CNA S reported she knows that is not how it is supposed to be. CNA S reported she told the DON of R224's concerns, and the DON did meet with the resident. A request for concern forms for R224 on 6/11/25 at 11:56 AM was made via email and the Nursing Home Administrator (NHA) responded that the resident did not have any concern forms. In an interview on 6/13/25 at 10:41 AM, the Director of Nursing (DON) reported she had been addressing call light times in daily meetings. The audits she had done so far were not problematic. The DON reported it is not the facility's practice to not assist a continent resident timely to the bathroom and advise residents to urinate in their brief. A reasonable time for call lights to be answered is about 5-10 minutes. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Urinary tract infections (UTIs) are the fifth most common type of health care-associated infection .Escherichia coli, a bacterium commonly found in the colon, is the most common causative pathogen ([NAME], 2020). The risk for a UTI increases in the presence of .urinary and fecal incontinence, and poor perineal hygiene practices. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1229). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to 1) assess, monitor, and act upon abnormal findings, 2) have medications available timely after admission, 3) timely follow up to labs and/or diagnostics, and 4) document accurate skin assessments for three residents (R70, R224, and R6) of 4 residents reviewed for quality of care. Findings include: Resident #70 (R70) Review of the Electronic Medical Records (EMR) for R70 revealed he admitted to the facility on [DATE] and had diagnoses of chronic diastolic (congestive) heart failure (CHF), sepsis, pressure ulcer, and Alzheimer's disease. Review of the Minimum Data Set (MDS) dated [DATE] for R70 revealed in section A2105, R70's discharge status was 13. deceased and indicated R70 died in the facility. Review of the Nursing Progress notes for R70 dated [DATE] at 3:38 PM revealed R70 had a change of condition, and the Emergency Medical Services (EMS) was called. Resident observed unable to hold himself up in the chair and could not help during 2-person transfer. Resident was able to answer questions very slurred. Resident then began to cough up coffee ground color emesis. VS (vital signs) taken 66/44 (blood pressure), 80 (pulse), 97.9 (temperature), 18 (respirations), 87% (oxygen saturation). LS (lung sounds) clear. Abdominal pain noted in RUQ and LUQ (right and left upper quadrant). There was no documentation to show the resident left the facility and went to the hospital and/or no documentation to show he died in the facility. In an interview on [DATE] at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q reported R70 did go to the hospital and died there, not at the facility. R70 should not have been documented in the MDS as a death in the facility. R70 acknowledged there were no transfer forms in the EMR indicating R70 left the facility accompanied by EMS. Review of the Physician Orders for R70 revealed no orders for the resident to be discharged or sent to the hospital. Review of the Physician Orders for R70 revealed: 1. 2 Grams (GM) Cefazolin Sodium Dextrose Intravenous solution every 8 hours was ordered [DATE] at 7:51 PM. (For sepsis) 2. Blood pressure, temperature, pulse, respirations, and oxygen on admission and readmission, every shift obtain vital signs. No parameters ordered. 3. Coccyx wounds: Cleanse with normal saline, cut aquacel to fit wounds and cover with optifoam dressing. Change daily. Start date was [DATE], no treatment documented on [DATE]. 4. No orders for oxygen. 5. Braden Assessment Completed the Braden Assessment (tool used to assess risk for developing pressure ulcers) in Assessment tab (sic) ordered [DATE]. 6. Review of the Physician Orders revealed: 7. On [DATE], Weekly Skin Audit, every day shift, every Sat . (Saturday) was ordered and discontinued on [DATE]. 8. On [DATE], Weekly Skin Audit, every day shift every Tue . (Tuesday) was ordered and discontinued on [DATE]. Medication not available Review of a Nursing Progress note dated [DATE] at 8:15 AM for R70 revealed: Nurse called pharmacy regarding IV medication and pharmacy confirmed it will be drop shipped to facility in the next 4 hours and pump will be drop shipped to (sic). Patient to receive IV antibiotic dose as soon as its received. (12-16 hours post admission.) No documentation to show the physician was notified the prescribed antibiotic had not been received at the facility and administered as ordered. Vital signs Review of the [DATE] Medication Administration Record (MAR) for R70 revealed vital signs were checked as done twice a day but the Vital signs report is documented as either done once a day or every other day. No documentation to show R70 was a CO2 (carbon dioxide retainer as seen in patients with chronic obstructive pulmonary disease (COPD). Review of the vital sign for R70 were as follows and not completed most days as ordered (Normal: SpO2 ?95%): [DATE] 12:05 90.0% Room Air [DATE] 08:32 90.0% Room Air [DATE] 14:10 90.0% Room Air [DATE] 11:55 96.0% Room Air [DATE] 02:46 89.0% Room Air [DATE] 00:47 91.0% Room Air [DATE] 09:45 91.0% Room Air [DATE] 12:31 91.0% Room Air [DATE] 08:36 90.0% Room Air [DATE] 09:07 90.0% Room Air [DATE] 13:39 90.0% Room Air [DATE] 23:27 92.0% Room Air [DATE] 12:03 90.0% Room Air [DATE] 09:00 90.0% Room Air [DATE] 23:46 92.0%Room Air 3/ 26/2025 12:10 91.0% Room Air [DATE] 02:25 92.0% Room Air Blood Pressures for R70 were as follows and no follow up to the start of the abnormally low blood pressure (since admission) documented on [DATE] at 8:31 AM. [DATE] 12:05 98 / 54 mmHg Sitting l/arm [DATE] 08:32 93 / 53 mmHg [DATE] 08:31 93 / 53 mmHg [DATE] 06:21 112 / 67 mmHg [DATE] 14:10 107 / 68 mmHg Lying l/arm [DATE] 11:55 107 / 71 mmHg Sitting l/arm [DATE] 02:46 118 / 73 mmHg Sitting l/arm Review of a Physician Progress note dated [DATE] and electronically signed on [DATE] for R70 revealed no indication the practitioner was aware of R70's trend of low oxygen levels. Exam: Respiratory: auscultation: no rales, rhonchi, or wheezes. Problems: Acute hypoxemic respiratory failure, Status: Active, onset, noted (assessed) Community acquired pneumonia of left lower lobe of lung, Status, onset [DATE], . Plan does not address low oxygen levels. Review of the Order Summary for R70 revealed no orders or standing orders for oxygen. Review of the Care Plan for R70 revealed no focus or interventions for oxygen. In an interview on [DATE] at approximately 4:15 PM, the Clinical Care Coordinator (CCC) R reported R70 had CHF and therefore having an oxygen level at 89-90% was okay for him. CCC R reported the facility had standing orders for oxygen levels of 89% and below. Residents are to receive 2 liters of oxygen via nasal cannula across the board but was unable to provide the orders before the end of this survey. CCC R reported normal oxygen levels are 89% and above and are to notify the physician if it is below 89%. In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported oxygen levels should be individualized per residents and if they have CHF, it could be normal to have an oxygen level below 90%, but there should be an order for it and an evaluation. Vital Signs-Acceptable Ranges for Adults . Pulse oximetry (SpO2) Normal: SpO2 ?95% Respirations 12 to 20 breaths/min, deep and regular . [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 500). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Completing a health assessment and physical examination is an important step toward providing safe and competent nursing care. The nurse is in a unique position to determine each patient's current health status, distinguish variations from the norm, and recognize improvements or deterioration in the patient's condition. Nurses must be able to recognize and interpret each patient's behavioral and physical presentation . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 516-517). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, An alteration in vital signs signals a change in physiological function. Assessment of vital signs provides data to identify nursing diagnoses, implement planned interventions, and evaluate outcomes of care .Verify and communicate significant changes in vital signs. Baseline measurements provide a starting point for identifying and accurately interpreting possible changes. When VS appear abnormal, have another nurse or health care provider repeat the measurement to verify readings. Inform the charge nurse or health care provider immediately, document findings in your patient's record, and report changes to nurses during hand-off communication (TJC, 2020). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E Book (p. 467-468). Elsevier Health Sciences. Kindle Edition. Coccyx Wounds Review of a Nursing Progress note dated [DATE] at 8:15 PM for R70 revealed the resident arrived at the facility and had a small open area to his coccyx with mediplex applied and to be changed every 3 days. Review of a Nursing Management progress note dated [DATE] for R70 revealed: Red area on sacrum is not open at this time as reported on admission assessment, [Physician] observed area with this writer. Protective barrier cream to area for prevention. Review of the Clinical Assessment tab for R70 revealed no Braden Assessment was completed. Review of the Clinical Assessment tab for R70 revealed the first Skin Assessment documented was on [DATE]. Review of a Nursing Progress note dated [DATE] for R70 revealed: [Physician] in today. New orders for wound care to coccyx . No wound assessment documented. Review of the Physician Orders for R70 revealed on [DATE] an order for : Coccyx wounds: Cleanse with normal saline, cut aquacel (wound treatment) to fit wounds and cover with optifoam dressing. Change daily. Review of the April Treatment Administration Record (TAR) for R70 revealed his first coccyx wound dressing was done [DATE] (one day after the nurse documented there was a new order on [DATE].) No dressing change was documented on [DATE]. No documentation in the EMR that a clinical assessment, physician progress note and/or skin/wound note, or treatment order was in place to address the sacral wound that worsened in 12 days between [DATE] and [DATE] after admission. Review of a Late Entry Nursing Management Skin/Wound Note dated [DATE] for R70 revealed he had a left coccyx wound that measured 3 cm (centimeters) x 2 m (sic) x <0.1 cm, wound bed pink without s/s (signs and symptoms) of infection. The right coccyx measured 3.5 cm x 1.5 cm x <0.1 cm, wound bed pink without s/s of infection. Review of the Care Plan for R70 revealed on [DATE] a care plan for a pressure injury to the left and right coccyx was initiated. (18 days after admission.) In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported there should be more information in the EMR for R70 and reported the care plans should reflect the residents needs timely. Skin assessments should be done upon admission and weekly. They do not have policies for skin assessments, and it should be the standards of practice for documentation. It is also the standard of practice to have an order to be discharged . R224 Resident #224 (R224) Review of a Face Sheet revealed R224 admitted to the facility on [DATE] with pertinent diagnoses of fusion lumbar spine, urinary tract infection (UTI), and fractured lumbosacral spine and pelvis. Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. Review of the Care Plan for R224 revealed: Focus: I have indwelling catheter, initiated on [DATE] and revised on [DATE] by the MDS Coordinator. The MDS reflects R224 is continent. Focus: At risk for infection related to indwelling catheter, initiated on [DATE]. Focus: . ADL (activities of daily living) . Interventions: . TOILET USE: I require 1 staff participation to use toilet, initiated [DATE]. During an observation and interview on [DATE] at 1:14 PM, R224 reported she went to the bathroom the day before and her hips popped and it hurt like the dickens. R224 reported staff did not use a gait belt to assist with her transfer but staff did hold on to her post-surgical support brace that was observed wrapped around her back and her abdomen. R224 was sitting in her wheelchair with ice packs to both sides of her hips. R224 reported her biggest concern was the communication between the hospital and the facility regarding her medications she needed. At this time the nurse came in to tell R224 that the Physician ordered x-rays on her hips. No urinary catheter was observed. During an observation and an interview on [DATE] at 3:10 PM, R224 reported she was on antibiotics prior to admission for a urinary tract infection (UTI) and they were not available upon admission to the facility. R224 denied having a urinary catheter. Urine Culture Review of a urine culture collected [DATE] (day of admission) that last resulted on [DATE] for R224 revealed Citrobacter freundii bacteria and reported This is an edited result. Previous organism was Gram negative bacilli on [DATE]. R224 was to start Bactrim (antibiotic) for 7 days per undated signature. Review of a Nursing Progress note dated [DATE] at 12:38 PM for R224 revealed: Has complaints of needing an antibiotic for a UTI and states that she was on an antibiotic prior to leaving the hospital. Attempting to obtain a clean catch urine, though resident states that she is incontinent more times than not. Doctor made aware of situation and to address this during visit today. Review of a Nursing Progress note dated [DATE] for R224 at 7:17 PM revealed: Resident continues with occasional complaints of needing to be on an antibiotic for a UTI. Husband brought this nurse a specimen cup of urine which was warm, and clear red in color. No particulates or any debris was seen. Urine was brought for chemstrip (sic) testing. Chemstrip (sic) was dipped into the cup and every testing field was stained into an orange color, except for glucose which remained blue. Paper towel used also turned an orange color. Note left for doctor to follow up with resident during his visit. Review of the Nursing Progress notes dated [DATE] at 12:36 PM for R224 revealed: Urine culture results received . new orders received for . Bactrim DS (double strength) BID (twice a day) x 7 days. Review of the June Medication Administration Record (MAR) for R224 revealed Bactrim was ordered on [DATE] and at 7:00 PM and she received her first dose. (3 days after admission.) Review of the Care Plan for R224 initiated [DATE] revealed: Focus: At risk for infection related to indwelling urinary catheter. Resident did not have an indwelling catheter. Focus: I have Urinary Tract Infection, initiated [DATE]. Review of the Order Summary for R224 revealed she had no orders for a urinary catheter and no orders to discontinue a urinary catheter X-ray Review of R224's EMR on [DATE] revealed no x-ray results were documented or scanned into the computer. In an interview on [DATE] at 3:45 PM, Licensed Practical Nurse (LPN) H was questioned about the results of R224's x-ray and did not know what the status was. LPN H then looked into the facilities EMR and could not find any x-ray results. LPN H then looked into the hospital medical records system and found the x-ray results for R224 and provided a copy. There was no documentation or indication the results were followed up on and/or informed the medical provider of the results. In an interview on [DATE] at 4:08 PM, Physical Therapist (PT) T reported she was aware that x-rays were ordered for R224 but did not know the results at this time. PT T reported R224 is to be transferred with a gait belt and is a standby assist with contact guard (it would be helpful to indicate if PT T reported R224 should not be transferred by staff grabbing her orthotic). In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported the nurses, and the managers are to follow up on labs and diagnostics results for the residents. Resident #6 (R6) Review of a Face Sheet revealed R6 admitted to the facility on [DATE]. Review of the MDS dated [DATE] for R6 revealed she had a stage II pressure ulcer upon admission. Review of the Order Summary Report for R6 revealed orders for Right buttocks- cleanse with NS (normal saline), Pat dry, apply zinc, and cover with optifoam every day shift for treatment. During an observation and an interview on [DATE] at 11:43 AM, R6 was lying in bed with a wound vac connected to a surgical wound in her groin. She reported she was admitted to the facility from the hospital after a procedure that required a wound vac in her groin. She had a wound vac at the hospital but could not come to the facility with it because it belonged to the hospital. R6 reported it took a few days after admission to the facility for her to get a wound vac and now has an infection in the wound which requires antibiotics. Review of an admission Skin Assessment for R6 dated [DATE] revealed R6 had a surgical incision in her groin that measured 5.5 cm (centimeters) x 5cm x 4.5cm and a stage II pressure ulcer on her left buttock that measured 1cm x 1 cm. Review of a Physician Progress note for R6 dated [DATE] revealed: . Patient did not arrive with wound vac dressing in place. The wound is being treated with wet to dry dressings until wound vac is available. There are no pain issues. Plan: Wound right Groin secondary to hematoma evacuation 9x5c3 cm (sic) Continue with current dressings until wound Vac is available. (Measurements differ than admission nursing progress note.) No mention of a stage II pressure ulcer. Review of the May Medication Administration Record/Treatment Administration Record (MAR/TAR) for R6 revealed the following: 1. Right groin wound-Cleanse with NS (normal saline), pat dry and apply dry gauze and cover with foam dressing until wound vac supplies are available PER [Physician] (NO ISLAND DRESSING) every day shift for treatment, start [DATE] and discontinued [DATE]. 2. APPLY WOUND VAC- To right groin When supplies arrive (Supplies expected to arrive [DATE]) Order can be discontinued and New wound vac orders created when wound vac is applied. May also d/c (discontinue) dry dressing order, every shift for treatment, start [DATE] and discontinue [DATE]. Review of a Nursing Progress note dated [DATE] at 9:58 AM for R6 revealed: . Right groin wound with foam border dressing in place until wound VAC supplies arrive, these have not yet. Complaining of increased pain and Tylenol is not adequate. Review of a Nursing Skin/Wound Note dated [DATE] at 11:35 AM for R6 revealed: Wound bed pink with yellowish areas, foul odor noted. 6 cm wide x 4 cm length x 3.9 cm deep. Surrounding skin/tissue ecchymotic (sic), fissures extending laterally and medially along abdominal fold line. Wound VAC applied to area with bridging foam to open fissures. [Physician] here and updated of VAC placement. No indication the physician was aware of or notified of the abnormal wound assessment described above other than he was notified the wound vac was in place. No indication of where or what wound this is described. Review of a Late Entry Nursing Skin/Wound Note for R6 dated [DATE] revealed: Left medial buttock wound 2.1 x 1.1 cm x 0.2 cm. Wound bed pink. Surrounding area reddened, intact. Blanchable. Island dressing applied (no foam border dressing available at this time.) Will replace when restocked. Review of an IDT (interdisciplinary) Note for R6 dated [DATE] revealed: . has a wound vac for incision to groin and a stage II buttocks to wound (sic). Review of a Nursing Skin Assessment dated [DATE] for R6 revealed her skin was not intact and no assessment of her surgical wound in the groin was documented: Treatment continues to right buttock, area appears to be slowly improving. No other new areas of concern identified. This document did not reference a skin assessment was documented anywhere else. Review of a Nursing Progress note dated [DATE] for R6 revealed: Called to resident's room d/t possible wound VAC leaking. She states, I can smell it, and I haven't been able to. Assessed dressing. Drainage noted at bottom of dressing at fold next to groin. Foul odor noted coming from dressing. You can hear an air leak at the same site. Dressing changed and treatment resumed. No indication the physician was notified of foul odor or wound assessment. (5 days after the first documented abnormal assessment.) Review of a Nursing Progress note Skin/Wound Note dated [DATE] at 1:17 PM for R6 revealed: 5cm x 5 cm x 4 cm right groin wound with foul smelling odor. Beefy red wound base. Bleeding noted to wound rim and inferior left aspect when old foam removed. Fissures extending laterally from each side of wound along abdominal fold line. Pain with dressing changes described as burning. Also, resident indicates pain to lateral aspect near hip where bruising is noted from hematoma. Wound VAC dressing reapplied. Physician aware of ongoing treatment. No indication the physician is aware of the condition of the wound. Review of a Nursing Progress Note for R6 dated [DATE] revealed: Wound vac placed on hold per physician at this time d/t (due to) bedside debridement, wound care provided per updated order. See skin note for updated measurement per physician. Review of a Skin Assessment dated [DATE] for R6 revealed her skin was not intact. Groin- Wound vac reinforced today. Coccyx- Continued treatment orders. No new skin issued noted. Review of a Nursing Progress note dated [DATE] revealed: Wound VAC replaced today at bedside by physician per new order. Physician ordered IV Ancef 2 G every 8 hours x 7 days d/t (due to) the foul odor and necrotic tissue he debrided at the bedside. Review of a Physician Note dated [DATE] for R6 revealed: Seen for examination of wound and reapplication of Wound Vac dressing. The foul smell has now subsided. Currently on IV antibiotics. Exam: Inspection Right Hi wound- There (sic) is no / minimal necrotic tissue. Wound floor has healthy tissue. No mention of a stage II pressure ulcer. Review of an IDT (interdisciplinary) Note for R6 dated [DATE] revealed: . She has a wound vac for stage II pressure ulcer on buttocks and is receiving IV (intravenous) therapy for wound infection. This did not address the surgical wound in in her groin. Review of an Order Summary for R6 revealed on [DATE] an order for 2 Grams (GM) of cefazolin (antibiotic) is to be given every 8 hours intravenously for wound healing. No cultures documented in the EMR. On [DATE] Doxycline Hyclate (antibiotic) ordered twice a day for bacterial infection in the groin wound for 2 weeks. On [DATE] fluconazole (antifungal), 200 mg (milligrams) ordered for 13 days. On [DATE] Amoxicillin-Pot clavulanate (antibiotic) 875-125 mg ordered for bacterial infection/Groin wound for 2 weeks. No orders for labs or wound cultures. Review of a Skin Assessment dated [DATE] for R6 revealed her skin was intact and No new issues. Right thigh dermatitis almost resolved. Review of the Care Plan for R6 revealed the following: Focus: Alteration in skin integrity related to Pressure injury to left buttock, initiated [DATE], Interventions: Assess/evaluate impaired area weekly and document per protocol. During an observation and an interview on [DATE] at 2:31 PM, R6 was in bed and reported her brief was soaked. R6 reported she is on Lasix (diuretic) and cannot always tell when she urinates and will be wet for long periods of time. CNA V entered the room and provided incontinence care at this time. R6's buttocks were observed to have a darker purple area the size of a tennis ball in the cleft of her buttocks with some maceration and blanchable skin throughout. No dressing in place per orders for Treatment and no signs of a pressure ulcer observed. R6 said it is better than it used to be. CNA V then applied a barrier cream with a new brief. Review of the June Medication Administration Record/Treatment Administration Record (MAR/TAR) for R6 revealed on [DATE] she did not receive a dressing change on her left buttocks as ordered and is documented as receiving dressing changes on [DATE] and [DATE], even though there was no dressing in place during the observation on [DATE]. A request for a policy for skin assessments was made and the facility provided a document dated 2019 with the name of another entity at the bottom of the form titled Wound Assessment and Monitoring from the Wound Prevention and Management Guidebook revealed: . Assess the wound initially and re-assess at least weekly to monitor progress toward healing. In an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) reported she was not working here when R6 admitted to the facility, but did help facilitate getting R6's wound vac after her admission to the facility. The DON reported it was an Admissions thing and did not have a back up of supplies at the facility. The DON confirmed there were no cultures in the EMR for R6's surgical wound and will look to see if any were done. No cultures were provided by the end of this survey. In an interview on [DATE] at 4:25 PM, Clinical Nurse Consultant (CNC) U reported they do not have formal policies for admissions, transfers and discharges and they just follow the standards of practice. The nurses perform weekly skin assessments here but do not have a policy for it. There are no policies for documenting or maintaining medical records. CNC U then reported the standards of practice should be followed for documentation and there should be an order for discharges.

Based on interview and record review, the facility failed to transmit the Minimum Data Set (MDS) assessments timely for (R27, R35, R222 R224) of 4 residents reviewed for MDS transmissions. Findings include: Resident #27 (R27) Review of the MDS in the Electronic Medical Record (EMR) revealed R27 was due for her yearly annual assessment and had an ARD (assessment reference date)/Target date of 3/20/25. This assessment was completed on 6/5/25. Resident #35 (R35) Review of the MDS in the EMR revealed R35 was due to her yearly annual assessment and had an ARD (assessment reference date)/Target date of 5/4/25. This assessment was completed on 6/6/25. In an interview on 6/13/25 at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q confirmed R27 and R35's annual MDS assessments were over 120 days old. RN Q reported she was not sure what happened with R27's assessment but did find that R35's assessment was not flagged that it was due, or that it was late. RN Q reported R27 had an annual assessment that was missed and submitted an assessment based on the March data in the EMR. RN Q reported they need a new tracking system, so they do not miss any assessments. Resident #222 (R222) Review of the EMR for R222 on 6/11/25 revealed her ARD - 5-day assessment (5/29/25) was flagged as being 5 days overdue and her admission assessment dated [DATE] was flagged as 13 days overdue with a status of in progress. In an interview on 6/13/25 at 8:35 AM, RN Q reported R222's entry was not signed off until 6/6/25 and was one day late. The EMR showed it was 13 days overdue, and her entry was 5/29/25, which was submitted on 6/6/25. R222's Medicare started on 6/5/25 for a look back and was submitted on 6/11/25. Resident #224 (R224) Review of the EMR on 6/11/25 for R224 revealed she had a 5-day admission assessment due for a 5/30/25 entry to the facility and was flagged as being 5 days overdue. On 6/11/25 the status was showing it was in progress. In an interview on 6/13/25 at 8:35 AM, RN Q reported R224's MDS Entry submission was a day late but her Admission assessment was fine. When queried about the EMR flagging it was 5 days overdue, RN Q then clarified that it was in fact overdue. RN Q reported R224 entered the facility on 5/30/25 and the MDS was submitted on 6/6/25 and therefore it was submitted one day late. In an interview on 6/13/25 at 12:26 PM, the Nursing Home Administrator (NHA) reported she was told by RN Q that there were some late assessments, but they were working on it.

Based on interview and record review, the facility failed to answer call lights in a timely manner for one Resident (R224) and those who attended the Resident Council meeting. This deficient practice affects all residents who reside at the facility. Findings include: Review of the Resident Council Minutes dated 4/24/25 revealed call light concerns especially on the 2nd and 3rd shift. Number of Residents who share concern: *leave light on until need is met! No number or specific residents listed. There were 13 residents who were documented as attending the meeting. The meeting minutes were signed by the Nursing Home Administrator (NHA). Review of an email correspondence provided dated 4/25/25 revealed the Activities Director notified the previous Director of Nursing (DON) of the call light concerns. . However, the issue of Call Lights has come up again. They feel that they are not being answered in a timely manner. Typically, 2nd or 3rd shift but can be all over the place. Both residents from [NAME] and Yellow Units had the same complaint. They also said that staff will come in to answer the call light, say that they will let other staff know or that they will be right back, the need is never met. If staff could leave the call light on until the need is met, that would be best. Review of the Resident Council Minutes dated 5/29/25 revealed the Old business of call lights was not resolved to satisfaction. Seven residents were in attendance. The meeting minutes were signed by the NHA. Resident #224 (R224) Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. In an interview on 6/10/25 at 3:10 PM, R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and she soiled her pants because she could not wait that long. Review of the Call Light logs for R224 from 6/5/25 to 6/12/25 revealed the following call wait times: 6/5/25 at 6:28 AM, 27:14 minutes 6/5/25 at 7:48 AM, 40:31 minutes 6/5/25 at 12:23 PM, 24:22 minutes 6/5/25 at 8:01 PM, 20:40 minutes 6/6/25 at 7:58 AM, 40:37 minutes 6/6/25 at 9:30 AM, 22:33 minutes 6/6/25 at 1:48 PM, 30:01 minutes 6/8/25 at 9:10 PM, 36:17 minutes 6/9/25 at 7:31 PM, 23:06 minutes 6/10/25 at 11:14 AM, 41:46 minutes 6/11/25 at 5:16 AM, 35:17 minutes 6/11/25 at 7:55 AM, 45:49 minutes In an interview on 6/11/25 at 4:35 PM, Certified Nursing Assistant (CNA) S she is aware of R224's concerns about long call light wait times. CNA S reported she told the DON of R224's concerns, and the DON did meet with the resident. In an interview on 6/13/25 at 10:41 AM, the Director of Nursing (DON) reported she had been addressing call light times in daily meetings. The audits she had done so far were no problematic. A reasonable time for call lights to be answered is about 5-10 minutes. In an interview on 6/13/25 at 11:37 AM, the NHA reported she was aware of call light concerns in the facility and no ad hoc was done yet. The NHA gave the task to the Admissions Coordinator who did not make it to the Quality Assurance Meeting yet. The NHA reported she did not receive individual grievances resulting from the resident council meetings and only gets them once they are resolved to make sure they are complete.

Based on interview and record review, the facility failed to appropriately transfer and/or discharge two residents (R69, R70) of two residents reviewed for discharges. Findings include: Resident #69 (R69) Review of the MDS dated [DATE] for R69 revealed in section A2105, R69's discharge status was 04. Short-Term General Hospital (acute hospitals, IPPS), indicating R69 was discharged to the hospital. Review of a Nursing Progress note dated [DATE] for R69 revealed he was discharged with his son to an Assisted Living Facility. Review of a document titled Discharge Instructions dated [DATE] for R69 revealed: admission (sic) In Progress, with no locked date. The document was not complete with the reason for the discharge and where the resident was discharged to, and no document signed by the resident indicating he or his representative acknowledged or received discharge information/instructions. No Home Care Agency information was documented. No other discharge form was in the electronic medical record (EMR). Review of the Progress Notes for R69 dated [DATE] revealed: Reviewed medications and discharge instructions with son. All nonreturnables (sic) sent with son. Reviewed upcoming doctor appointment and home care agency follow up. No questions asked after opportunity offered. Resident discharged with son via private vehicle to [Assisted Living]. Review of the EMR for R69 revealed no discharge summary or recap of stay. In an interview on [DATE] at 8:35 AM, RN Q reported R69 did go home and was not sure why R69 would be flagged for hospitalization. RN Q then verified the Social Worker documented R69 went back to the hospital, but he actually went home. Resident #70 (R70) Review of the MDS dated [DATE] for R70 revealed in section A2105, R70's discharge status was 13. deceased and indicated as a death in the facility. Review of the electronic medical records (EMR) for R70 revealed the resident had a change of condition and the Emergency Medical Services (EMS) was called. There was no documentation to show the resident left the facility and went to the hospital and no documentation to show he died in the facility. Review of a Bed Hold & Leaves of Absence document dated [DATE] revealed a request to hold a bed. Review of the Physician Orders for R70 revealed no orders for the resident to be discharged or sent to the hospital. In an interview on [DATE] at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q reported R70 did go to the hospital and died there. R70 should not have been documented as a death in the facility. R70 acknowledged there were no transfer forms in the EMR indicating R70 left the facility accompanied by EMS. A request for an admission, transfer and discharge policy was requested via email on [DATE] at 2:47 PM and was provided with a copy of an alleged power point slide provided to staff during training when hired according to the Clinical Nurse Consultant U with a date of 2017 that revealed: Transfers to Hospital: Complete Resident Transfer Form. -What do you send with the resident? - Transfer Form, Face sheet, Med List, Advance Directives, Bed Hold Policy. -Review checklist. Notify: DON (Director of Nursing), Physician, Responsible Party. Nursing Note: - Change in Condition. Another power point slide dated 2017 revealed: discharge: Interdisciplinary Discharge Summary. Post- Discharge Plan of Care- Review Post-Discharge POC (plan of care), - review medications/treatments with resident/family, - Provide list of medications/treatments, - instruct resident to sign form and provide a copy of the form to the resident. Nursing Discharge Note Discharge Resident in Vision (an electronic medical record not used by the facility), - Discontinue orders, resolve care plans. In an interview on [DATE] at 4:25 PM, Clinical Nurse Consultant (CNC) U reported they do not have formal policies for admissions, transfers and discharges and just follow the standards of practice. CNC U then reported the standards of practice should be followed for documentation and there should be an order for discharges.

Based on observation, interview, and record review, the facility failed to assess one resident (R66) for self-administration of medication and failed to track and record medication use. Findings: Review of the Electronic Medical Record (EMR) reflected R66 was admitted to the facility 5/1/25 with pertinent diagnoses that included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), and Emphysema. On 6/11/25 at 9:43 AM, R66 was observed in a recliner chair receiving supplemental oxygen through a nasal cannula. Also observed were a nebulizer machine, a device like a Continuous Positive Airway Pressure (CPAP) machine and an Albuterol multidose inhaler on the over-the-bed table next to the Resident. On 6/12/25 at 2:34 PM an observation and interview were conducted with R66 in his room. The Albuterol multi-use inhaler was again observed on the over the bed table next to R66. R66 reported he used the inhaler sometimes a couple of times a day. R66 reported staff had not asked him if he had used it or how often. R66 indicated staff never asked him anything about the inhaler. Review of the EMR Doctor's Orders for R66 reflected an order for Ventolin HFA Inhalation Aerosol Solution 90 micrograms (mcg) (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for COPD/wheezing. May leave at bedside with a start date of 5/5/25. The policy provided by the facility titled 2.1 Self Administration of Medications last revised 6/1/24 was reviewed. The policy reflected, Procedure: 1. Facility should comply with the facility policy applicable law and the State Operations Manual with respect to resident self-administration of medications. The facility policy reflected in conjunction with the interdisciplinary care team, should assess and determine . whether self-administration is safe and clinically appropriate, based on the resident's functionality and health condition, The policy further reflected the facility must educate residents on possible side effects of the medication, ensure that the resident can correctly administer and address the storage of the medication. The facility policy also reflected 4. Facility should regularly observe the resident self-administering medications. And 8.the interdisciplinary care team should routinely assess the resident's cognitive, physical and visual ability to carry out this responsibility per facility policy. 10. Facility staff should document the self-administering of medications on the Medication Administration Record (MAR) . And 11. Facility should document the self-administration and self-storage of medications in the resident's care plan. Review of Progress Notes and the Assessment section of the EMR did not reveal any documentation the Resident had been assessed, educated, or monitored for proper and safe use of the inhaler. Review of MARs for R66 from 5/5/25 through 6/13/25 reflected documentation of one self-administration on 5/22/25 even though R66 reported using the inhaler sometimes a couple of times a day. On 6/13/25 at 9:54 AM the self-administration of medication by R66 was discussed with the Director of Nursing (DON). The DON was informed the EMR did not reveal the assessments and monitoring indicated by the facility policy had been conducted. The DON reported that if the information was not evident it likely was not there. As of survey exit no additional information had been provided.

Based on interview and record review, the facility failed to respect the dignity of one (R224) of two residents reviewed for dignity. Findings include: Resident #224 (R224) Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. In an interview on 6/10/25 at 3:10 PM, R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and soiled her pants because she could not wait that long. A couple staff at night will tell her to just go in her brief if she cannot hold it and not to worry about it. If you have to go, just go they told her. R224 reported it makes her feel bad when she wets inside her brief even though the staff are very kind about it and will clean her up. In an interview on 6/13/25 at 10:41 AM, the Director of Nursing (DON) reported she had been addressing call light times in meetings and daily. The audits she had done so far were not problematic. A reasonable time for call lights to be answered is about 5-10 minutes. In an interview on 6/13/25 at 11:37 AM, the NHA reported she was aware of call light concerns in the facility and no ad hoc was done yet.

Based on interview and record review, the facility failed to accurately notify the physician/provider in a timely manner of a fall with injury for 1 of 2 residents (R15) reviewed for falls. Findings include: A review of R15's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R15 had multiple diagnoses that included a traumatic subdural hemorrhage (brain bleed) with a loss of consciousness. A review of R15's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/21/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R15 was cognitively intact. During an interview on 06/10/25 at 12:30 PM, R15's spouse stated R15 had been in the hospital on and off five times since November 2024. Even though R15's MDS indicated he was cognitively intact, his spouse was interviewed because he had just returned to the facility after an 11-day hospital stay and was not alert and/or oriented at the time. A review of R15's progress notes, dated 11/13/24 to 6/11/25, revealed the following: - Incident Note, dated 11/18/24, revealed, CNA (certified nursing assistant) observed resident on the floor of bathroom at 0725 am. Resident was lying on his back with legs out in front of him and his head against the bathroom door . skin tear to L (left) elbow and swelling to back of head noted . change of condition place in dr. (doctor) book . - Nurse's Notes, dated 11/21/24, revealed, wife called from hospital to give update . resident is being admitted to hospital- elevated white count (high white blood cell count- potentially a reaction to an infection, tissue damage, or swelling)), small intercranial bleed (brain bleed) . A review of R15's Nursing/Physician Communication form, dated 11/18/24, revealed that on 11/18/24 at 7:25 AM, R15 had an unwitnessed fall and was found laying on the bathroom floor next to the door. It also revealed R15 had a skin tear to the left elbow and R15 was complaining of a headache. However, the form did not reveal that R15 also had swelling to the back of the head at the time they were found. In addition, R15's Nursing/Physician Communication form revealed Nurse Practitioner (NP) R was made aware of the incident on 11/20/24 (two days after the incident). A further review of R15's medical record failed to reveal that the physician/provider had been notified prior to 11/20/24 when NP R had noted the fall on the Nursing/Physician Communication form. During an interview on 06/13/25 at 4:57 PM, the Nursing Home Administrator stated she did not know if the physician was notified of R15's fall prior to 11/20/24. She stated the physician should have been notified at the time of the fall. In addition, the NHA stated if the surveyor could not find the documentation in R15's medical record that the physician/provider had been notified of R15's fall prior to 11/20/24, then they probably had not been notified. During an interview on 06/13/25 at 05:02 PM, Clinical Care Coordinator (CCC) E stated the nurse should have called the physician on 11/18/24 after R15 fell. She stated if it was after hours, the on-call physician/provider should have been notified. CCC E stated if that was the case (the fall occurred after hours, and the on-call physician/provider was notified) then the nurse would have also placed the notification in the Doctor's Book so the attending physician would know about the fall when he next came in for physician rounds. She stated the nurse should have documented the phone notification in the progress notes. CCC E stated she did not know personally if the physician/provider had been notified of R15's 11/18/24 fall prior to 11/20/24 because she was not an employee of the facility at that time. However, she did state that if the notification was not documented in R15's medical record, then it probably did not occur.

Based on interview and record review, the facility failed to report an allegation of neglect to the state survey agency for 1 of 19 sampled residents (R1). Findings include: A review of the facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy and procedure, revised February 2025, revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Serious Bodily Injury means an injury involving extreme physical pain . requiring medical intervention such as surgery, hospitalization, or physical rehabilitation . A review of the facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy and procedure, revised February 2025, further revealed, The Administrator or his/her designee will notify the State Agency and any other agencies (i.e., law enforcement, adult protective services) as appropriate of alleged violations involving abuse. neglect, misappropriation of resident property and injuries of unknown source. Serious bodily injury is reported immediately but not later than 2 hours after forming the suspicion if the allegation involves abuse or results in serious bodily injury . Resident #1 A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/14/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed R1 was moderately cognitively intact. During an interview on 06/12/25 at 09:50 AM, R1 stated through short statements and yes/no answers that in February 2025 she rolled out of bed while staff were doing a bed bath. She stated staff rolled her to the side and she kept going until she was on the floor. R1 stated one staff member was present and giving her the bed bath. She stated usually only one staff member provides care to her, including bed baths. R1 denied the facility uses two staff members for her care. R1 stated after she fell out of bed onto the floor she had difficulty breathing and pain. She stated staff called an ambulance and staff stayed with her until the ambulance arrived. R1 stated she had several fractured ribs and a hip fracture. She stated she was in the hospital for several days, but did not have surgery. A review of R1's Fall Risk Assessment, dated 12/10/24, revealed R1 scored a 15 (Moderate Risk). A review of R1's Activities of Daily Living (ADL) Care Plan, dated 9/28/20 and revised on 12/27/23, revealed R1 required 2 staff participation for repositioning and turning in bed (date initiated: 4/6/23). However, R1 only needed total assistance of one person with brief changes and using the bed pan per the care plan. A review of R1's Nurse's Notes, dated 2/7/25, revealed, Resident observed laying on her left side on the floor next to the bed. Resident moaning with a snort like breathing. Resident complained of pain to back. Resident assessed, large forming bump noted on back of head. Hump in the middle of the bed observed Resident sent out to the emergency room for evaluation and treatment. Resident assessed . A review of the hospital's Internal Medicine Daily Inpatient Progress Note, dated 2/17/25, revealed on 2/7/25 R1 was admitted to the hospital due to rib fractures and a hip fracture after a fall. She presented to the ER (emergency room) after falling out of bed while receiving a bath at her facility. Workup revealed multiple rib fractures as well as a hip fracture. Additionally she was found to have a new LLL (left lower lobe) subsegmental PE (pulmonary embolism- a blood clot in the lung) and a very small left-sided pneumothorax (a condition that can be caused by a blunt or penetrating injury (e.g., from fractured ribs) where air leaks into the space between the lung and chest wall and causes the lung(s) to collapse) . A review of Certified Nursing Assistant (CNA) D's typed statement, undated, revealed she was cleaning R1 up because R1 had a bowel movement. She rolled R1 onto her right side to clean her up. CNA D stated she needed more washcloths, so she turned around to grab some more washcloths. She stated when she turned back around, she heard R1 make a grunting/growling noise and R1 was rolling off the bed. CNA D stated she could not catch her in time before she rolled off the bed completely. CNA D stated she had checked R1's kardex (a summary of a resident's care needs) before providing care and she noticed R1 was one assist for toileting and two assist for transfers. CNA D stated she did not remember if she checked R1's bed mobility assistance on the kardex. She then expressed guilt/remorse that the incident occurred. During an interview on 06/12/25 at 2:00 PM, the Nursing Home Administrator (NHA) stated she definitely had an investigation for this incident. She stated she did not report the incident to the state survey agency (SSA) because Regional Nurse Consultant (RNC) Q told her not to because the facility determined that the reason that R1 fell off the bed and onto the floor was a mattress issue from a hump in the mattress and not the result of anything that was reportable. During a second interview on 06/13/25 at 01:25 PM, the NHA stated CNA D had to complete training on safe resident handling because she rolled her (R1) away from her. The NHA stated if CNA D would have rolled her (R1) towards herself (CNA D), she would have caught her and R1 would not have rolled off the bed. The NHA further stated if there had been a hump/lump in the mattress staff should roll the resident over it and have another staff member on the other side of the mattress to make sure the resident did not roll off the bed.

This citation pertains to intake # MI00- 1 Based on interview and record review, the facility neglected to follow the plan of care and use 2 staff persons to transfer one resident (Resident #5) from the bed to a wheelchair, resulting in a fractured right arm. Findings: Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year old female, originally admitted to the facility on [DATE], from a local emergency room , following a fall and subsequent displaced fracture of the left femur. Other pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Brief Interview for Mental Status assessment, dated 4/26/21, revealed R5 was cognitively intact. The discharge plan for R5 was to transfer to an assisted living facility following short term rehabilitation. Review of a Care Plan Conference Summary, dated 3-23-21, reflected the following: Resident requires 2 person assist with transfers; slide board used due to toe-touch weight bearing only. Bed mobility requires 2 people due to pain in shoulders and hip. Therapy recommends an assisted living moving forward. Review of a Kardex Report, dated 4/18/21, revealed the following needs for R5 related to Mobility/Transferring: BED MOBILITY: I require 2 staff participation to reposition and turn in bed. Small towel roll outside of the left thigh/knee area for comfort. TOILET USE: I require limited 2 staff participation to use drop arm commode and a slide board. I need assist to lift up while another staff member completes peri care and clothing. Help me maintain left TTWB (toe touch weight bearing) by placing a foot under mine. TRANSFER: I require limited 2 staff participation to use a slide board for transfers to/from wheelchair and bed. Help me keep left foot touching the floor. TTWB. Review of a Care Plan for R5, initiated on 03/15/21, revealed the Focus: I have a ADL (activity of daily living) self care performance deficit related to a fall sustaining left femur fracture, weakness . frozen right shoulder . and impaired vision. Intervention: I require extensive 2 staff participation to use a slide board for transfers to/from wheelchair to bed. Review of an Incident-Accident report, dated 4-18-21 at 1:00 P.M., revealed the following witness statement given by Certified Nurse Aide (CNA) F, During transfer with (R5), I was standing in front of resident to transfer (R5) from bed to WC (wheelchair). During transfer I heard 3 pop noises in the right arm. I was holding onto gait belt as (R5) sat in the (wheelchair) she screamed in pain right at the same time I heard the pops. During an interview with complainant G on 05/20/21 at 12:04 P.M., complainant G voiced the following: (R5) already had a broken leg, and was supposed to have two people helping with transfers. I don't understand why only one person transferred (R5) and now (R5) has a broken arm too. It makes no sense. Complainant G also shared frustration with the now prolonged healing process; (R5) now had a leg and arm fracture to heal. (R5) had a frozen right shoulder, and couldn't move that arm, they knew that. During an interview on 05/20/21 at 2:05 P.M., CNA F reported getting R5 ready to go to get a shower, had a gait belt around the waist of R5, and in the process of sliding R5 from the bed to the wheelchair, heard and felt the right arm break. CNA F confirmed being the only staff person in the room at the time of the transfer. CNA F indicated the following regarding R5's transfers status, all I knew was that she was a slide board. During another interview on 05/21/21/ at 10:15 A.M., CNA F reiterated being the only staff person in the room with R5 at the time of the transfer on 04/18/21, that resulted in a right spiral fracture of the humerus. CNA F indicated seeing other staff transfer R5 with only one staff person and a slide board and I was just doing what they were doing. During an interview on 05/21/21 at 8:15 A.M., R5 stated that on 4-11-21 (1) a worker helped with a transfer from the bed to a wheelchair, (2) my right arm didn't move well, and (3) we heard it break, it hurt so bad. R5 indicated being very frustrated because R5 is right handed and is now dependent on staff for almost everything. When asked to give the facility a letter grade (A+ to F) representing the care received during the stay at the facility from 03/15/21 to 04/27/21, R5 answered E. Review of an Emergency Department Patient Summary, dated 04/18/21 at 10:49 P.M., reflected: Reason for visit: right arm fracture, Pain Intensity Scale: 9-severe/excruciating, Cause of Injury: transferring on slide board at nursing home and arm was twisted.

This pertains to intake MI 1661, and MI 1800 Based on interview and record review, the facility failed to prohibit abuse, neglect and the liklihood for ongoing abuse and neglect for 2 residents (Resident #103 and Resident #104) of 5 residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) that began on 11/17/18, as a result of the facility's failure to establish a protocol to follow when allegations of sexual abuse are made; and failed to follow established procedures to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement, an allegation of sexual abuse for two residents (Resident #103 and #104). This deficient practice has the potential to affect all vulnerable residents in this facility. Findings include: Review of a facility policy Freedom from Abuse and Neglect last reviewed (MONTH) 16, (YEAR), reflected (Name of Facility) prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. (Facility) is committed to meeting the requirements of all applicable Local, State, and Federal laws and regulations pertaining to any potential resident mistreatment, including all provisions of the Elder Justice Act (EJA). The Purpose of the policy is To describe the facility programs, policies and procedures in place to ensure appropriate resident protection from abuse, neglect, misappropriation of personal property, or exploitation. The facility Freedom from Abuse and Neglect policy and procedure included the following definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Physical Abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Neglect is the failure of the facility, its employees or service providers to provide the goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Covered Individual under the Elder Justice Act means each individual who is an owner, operator, employee, manager, agent, or contractor of a long-term care facility. Law Enforcement Entity under the Elder Justice Act means a police department or sheriff department of a political subdivision, i.e. a city, county, township or village. The policy specifies that The Administrator is the Abuse Prevention Coordinator for (Facility Name). Allegations of abuse, neglect, or exploitation will be reported to the Administrator/Abuse Prevention Coordinator immediately, but not later than 2 hours after forming the suspicion, if the events that caused the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not involve abuse and do not result in serious bodily injury. It is the additional responsibility of all employees to immediately report any incident of suspected abuse, neglect, mistreatment, misappropriation, or exploitation of any Center resident to the licensed staff member in charge. In turn, the Administrator or Director of Nursing will report allegations of abuse, neglect, misappropriation of resident property, or exploitation to the (State Agency) as required under State and Federal Regulations. All covered individuals in the facility must also comply with the following Elder Justice Act provision by reporting reasonable suspicions of a crime to both the (State Agency) and the (County Sheriff Department). The policy specifies steps to take to protect residents and indicates The Administrator, Director of Nursing, or their designee will take steps necessary to protect the resident(s) from the potential for abuse while the investigation is in progress and prior to the investigation final conclusions. If an employee is suspected of perpetrating potential abuse, that employee will be asked to leave the facility and will be removed from the schedule until such time that they can be cleared of any wrong-doing. If there is ever a threat of immediate danger to any resident being posed by a visitor, any employee may immediately call (County Sheriff Department) by dialing 911. Further review of the facility policy Freedom from Abuse and Neglect last reviewed (MONTH) 16, (YEAR) did not reflect any procedures to specifically address allegations of sexual assault. Resident #104 Review of a facility Admission Record dated 2/18/19 reflected Resident #104 was an [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #104 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7/15 and needed extensive assistance from two people for bed mobility, transfers, dressing, and toilet use. Review of a Facility Investigation Summary reported to the State Agency (SA) on 2/17/19 reflected [AGE] year-old female admitted to the center for rehabilitation and return to the community alleged she felt as if a man had put himself inside of her while patting on her backside . Review of Nursing/Physician Comments (a physician progress notes [REDACTED]. Last evening, patient stated to nurse that a male came into her room and sexually assaulted her. When questioned about this today patient tells me I was half awake. I don't know what I said. When asked specifically about the event she states, I don't remember that happening; I don't know. Denies any pain or discomfort specifically in the GU ([MEDICAL CONDITION]) region. BM (bowel movements) this AM were normal, without blood per staff. Urinating without difficulty. There were concerns re: loose stools x3 with foul odor however no BM yet today. No abdominal pain/discomfort. Patient is oriented to person only at baseline. The Assessment and Plan (A/P) noted: 1. Abuse allegation-no current signs-continue to monitor for new symptoms. During an interview on 3/7/19 at 8:45 a.m., Nurse Practitioner (NP) Q reported she had been on-call over-night 2/17/19 and was contacted by Licensed Practical Nurse (LPN) R who reported that Resident #104 had made a sexual allegation. NP Q said LPN R did not tell her that Resident #104 said, a man put himself inside her. NP Q said she asked a few more questions about who Resident #104 was and if there were any other complaints. NP Q said she told the nurse she would be in later that morning and examine Resident #104. NP Q said when she arrived at the facility on 2/17/19 there was no information in the progress notes about what had been alleged, the day shift nurse didn't know much about it and suggested she could find more details in an incident report. NP Q said she didn't have access to incident reports. NP Q said if she had been told Resident #104 alleged sexual assault, she would have contacted her supervising physician for guidance regarding a physical exam or what steps needed to be taken. Review of a written statement provided by Certified Nurse Aide (CNA) S reflected During my nightly rounds at approximately 12:30 in the morning, I heard resident in room (Resident #104's room) yelling out for help. When I entered the room, I could hear and smell that she was having problems with gas so I assumed she would ask to be changed. The resident stated, A man hurt me. I asked her to repeat what she said, and she replied a man hurt her. I then asked where and how a man hurt her and she said, I can't see it, but it's right here .as she moved her hand to touch her backside right below her wound vac. I then asked, How did he hurt you? She replied, He put himself in there. As she tapped on her bottom. I asked her to say it again to make sure I had heard her and understood her correctly. She stated, I can't say it; you know .when a man puts himself inside you. I then asked her to hold on one moment so I could get the nurse. I told her I would be right back. I ran to get the nurse and we returned to her room and clarified her statement of the incident she had reported to me. Attempts were made to contact CNA S on 3/7/19 via telephone and were unsuccessful due to the number provided did not allow messages to be left. Review of a written statement dated 2/17/19 timed 0045 (12:45 a.m.) documented by Licensed Practical Nurse (LPN) R reflected CNA called nurse to room. Nurse in and (Resident #104) stated to nurse that A man was here, and he put it in there, resident pointed to rectal area. Director of Nursing (DON) notified by (CNA S). Nurse completed skin, pain assessments and interviewed resident. Resident stated, His parts when asked what was put in there. Resident denied pain at this time stating, It doesn't hurt anymore, he took it out. Resident stated that she did not look and the man and did not recognize his voice. Resident stated she was lying on the left side facing the wall. During interview, resident stated, I don't think it was a dream (nurse had not asked about this). Nurse then asked resident if resident had had dreams like this in the past and resident stated that she had, but not as bad as this. Resident stated that incident was about an hour and a half ago. Nurse asked resident what was happening just before incident to better establish a timeline (lunch, dinner, sleeping .). Resident stated that she had been in bed sleeping. Resident stated that the room was dark with only a faint light. The statement provided also included the following assessment: Skin check: Several small red areas on resident mid/lower back. Left shin with dry dark area. VAC dressing in place to right buttock. Hemorrhoids, but no rectal tearing or bleeding noted. Right foot by 5th toe, calloused area. Resident had small stool in brief, noted with orange tint and mucous (sample saved). Nurse asked resident if resident felt safe at this time, resident stated that she felt better and wanted a light on in her room, staff left resident lamp on. Resident requested to lay on her back so she could see the door, this was completed and resident resting quietly with eyes closed at this time. On-call physician, DON, and administrator aware of above. Resident started on UTI (urinary tract infection monitoring, no new orders at this time. During a telephone interview on 3/7/19 at 10:40 a.m., LPN R reported she was notified by CNA S of the alleged sexual assault on 2/17/19 at approximately 12:30 p.m. LPN R confirmed the written statement noted above was accurate. LPN R said the DON did not instruct her to call the police or preserve the scene for collection of evidence by law enforcement. LPN S reported a male CNA (CNA X) had been working on the other side of the unit until 11:00 p.m. Review of an Incident Report dated 2/17/19 reflected (Resident #104) stated a man came into her room and put himself into her rectum. Notes included in the incident report documented by the DON, dated 2/17/19 reflected Resident stated a man came into her room and put himself into her rectum. Resident was noted to have a large BM (Bowel Movement) after the incident was stated. Resident was assessed by the Nurse Practitioner. DON and Administrator was notified. Investigation in progress. The incident report indicated that the DON had been notified on 2/17/19 at 00:32 (12:32 a.m.), Nurse Practitioner (NP) Q on 2/17/19 at 1:27 a.m., and Resident #104's daughter on 2/17/19 at 12:30 p.m. During an interview on 3/7/19 at 11:10 a.m., the Nursing Home Administrator (NHA) said there was not a separate provision in the facility Freedom from Abuse and Neglect policy to address how to manage an allegation of sexual abuse. The NHA said she did not call the police as soon as the allegation was reported because the resident said she thought she was dreaming. The NHA confirmed she contacted Resident #104's daughter on the afternoon of 2/17/19 and told the daughter that she and the Director of Nursing had decided not to do a rape kit because the resident thought she was dreaming, and they didn't want to traumatize her any further. The NHA also reported that a statement was not obtained from the male CNA (CNA X) who worked on the unit Resident #104 lived on until 11:00 p.m. on 2/16/19 (the time Resident #104 alleged the sexual assault occurred), nor was CNA X removed from duty while an investigation was completed. The Administrator also said no other males were working at the time the allegation was made. Review of the Staffing Sheet for 2/16-2/17/19 reflected a male nurse aide, CNA X was on duty on part of the unit where Resident #104 lived until 11:00 p.m. on 2/16/19 (the time Resident #104 alleged the sexual assault happened). Another male aide was also on duty 2/16/19-2/17/19, working on a different unit. During a telephone interview on 3/7/19 at 12:28 p.m., Family Member (FM) Z reported she had not been notified of the allegation of sexual assault until 14 hours after the incident. FM Z said the NHA told her that her mom (Resident #104) screamed and yelled out at 12:45 a.m. on 2/17/19 and that they (the facility) didn't want to do a rape kit because they didn't want to traumatize her. FM Z said she figured that by the time she found out about what had been reported, Resident #104 would have been cleaned up (peri-care provided) a few times and figured it would be too late to find anything (evidence). FM Z said she was contacted by the Sergeant investigating the allegation the week after Resident #104 was discharged from the facility, who told her that at that point it was too late to do a rape kit, but that they had up to three days to collect evidence if they had been called sooner. FM Z said that she would not have refused such an exam and without it, no one will ever really know what happened. Review of a Statement obtained from Resident #104 on 2/25/19 (eight days after the alleged sexual assault, 6 days after Resident #104 was discharged from the facility) via a telephone call from the DON reflected (Resident #104) was interviewed via phone. Resident stated she didn't know the person that came into her room. She stated she had her back towards the door of her room. She stated she was lying on her right side. She stated, a man put himself into my butt. She denied pain. She stated she felt safe at the facility. She denied seeing the man enter or exit the room. She does not know what he looked like or his skin color. She stated that she may have been dreaming but was not sure. During a follow-up interview on 3/7/19 at 1:21 p.m., the NHA reported that she was the facility Abuse Prevention Coordinator. When asked, the NHA said she did not call the police as soon as the allegation of sexual assault was reported because she did not think there was a reasonable suspicion of a crime. The NHA said she reached out to the non-emergency (County Sheriff) to establish a working relationship with local law enforcement. During a telephone interview on 3/12/19 at 1:16 p.m., Sergeant Y reported that his first contact with the Administrator of the facility was via a telephone call on 2/19/19. Sgt. Y said the initial conversation involved general questions about what, when and to whom reports should be made with the sheriff department. Sgt. Y said that after several questions, the Administrator said she had something that may need to be reported, but that the Administrator didn't have pertinent details about Resident #104, such as date of birth. Sgt. Y then said that the report wasn't made to him until after Resident #104 had discharged from the facility to another living situation in another county. Sgt. Y said that the investigation was very difficult because the Administrator had waited so long to report the alleged sexual assault. Sgt. Y said the Administrator should have called 911 dispatch and a deputy would have been sent out and a kit (an exam completed when there is an alleged sexual assault) completed. Sgt. Y also confirmed he had been told no males had been working at the time the allegation was made. The Nursing Home Administrator and the Director of Nursing were informed on 3/7/18 at 4:09 p.m of an Immediate Jeopardy (IJ) that began on 2/17/19 at 12:30 a.m., as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for one resident (Resident #104) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. During an interview on 3/7/19 at 11:10 a.m., the Director of Nursing and the Administrator said they did talk about having the resident sent out for a rape kit but ultimately decided not to so the resident would not be traumatized any further. In a follow up interview with the Nursing Home Administrator on 3/7/19 at 1:21 PM, she stated that she did not believe the allegation constituted the reasonable suspicion of a crime and that if she felt it was sexual assault she would have called the state survey manager to figure out what to do, resulting in immediate jeopardy for Resident #104, who was her own responsible party and alleged that a man had put himself inside of her the night of 2/17/19, causing the resident to become fearful and asking to be turned so that she could see the door and sleep with the light on. This deficient practice has the potential to affect all vulnerable residents in this facility. On 3/7/19, the surveyor verified the facility implemented the following to remove the high likelihood the identified deficient practice would occur again: 1. 3/7/19. Investigation process continued with interviews of staff on unit providing care on 2/17/19 and CNA X assigned to the neighborhood. 2. 3/7/19. CNA X suspended pending results of the investigation 3. 3/7/19. All currently residing residents with BIMS 7 or less will be audited for behaviors. Those exhibiting behaviors within the last 30 days will have a nursing assessment completed to rule out signs or symptoms of abuse. 4. 3/7/19. All currently residing residents that can be interviewed (BIMS 8 or higher) have been interviewed to identify suspicions of abuse. 5. 3/7/19. An audit of investigative reports in the last 30 days has been reviewed to ensure that witness interviews were conducted per facility policy. No investigative reports in the last 30 days. 6. 3/7/19. Regional Clinical Quality and Risk Director provided Facility Protocol for Managing Sexual Abuse Allegation. 7. 3/7/19. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 8. 3/7/19. All Actively scheduled clinical staff members (this would include licensed nurses and CENA staff) received education on the facility practice in an event of an allegation of sexual abuse. 9. 3/7/19 All actively scheduled clinical leadership positions have been trained on the facility practice related to an allegation of sexual abuse and completion of a full investigation. 10. 3/7/19 Remaining staff will receive education prior to working on next scheduled shift. 11. 3/7/19. Developed a plan to have the Interdisciplinary team review alleged incidents requiring a thorough investigation, including witness interviews, during the Monday - Friday Morning Stand-Up Meeting to ensure a thorough investigation per established policy. 12. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided on Facility Protocol for Managing Sexual Abuse Allegation. 13. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 14. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided Facility Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy. Reviewed and approved by Medical Director. Reviewed and approved by Administrator, per protocol. 15. 3/7/19. 6:44p. Training with clinical managers on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 16. 3/7/19 6:44p. Verified 100% resident interviews completed for residents with a BIMs 8 or higher. No concerns relating to abuse identified. 17. 3/7/19, 6:44p. Verified 100% of resident nursing assessments completed for those individuals that have a BIMs less than 8 and have exhibited any behaviors within the last 30 days. No concerns relating to abuse identified. 18. 3/7/19, 7p. Training completed using abuse policy and protocol for managing sexual abuse allegation with second shift nurses (nurses work 12 hour shifts). 19. 3/7/19, 11p. Training completed using abuse policy and protocol for managing sexual abuse allegation with third shift nursing assistants. 20. 3/8/19, 7 am. Training completed using abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 21. 3/8/19, 10a. Retraining completed with first shift nurses and nursing assistants on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 22. 3/8/19, 10a. Meeting with Medical Director on education plan for physician and physician extenders on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. Physician and physician extenders will receive education prior to working on next scheduled shift. 23. 3/8/19, 11a. Training completed with Physician Assistant on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 24. 3/8/19, 11a. Training completed with nursing educator on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 25. 3/8/19. Training initiated with clinical staff on recognizing behaviors, documenting on behaviors, and documenting behavioral interventions with response. 26. 3/8/19. Training initiated with licensed nursing staff on completion of unusual occurrence reports and notifications. 27. 3/8/19. IDT progress note and skin assessment reviews completed for residents within the last 30 days, both current and discharged , to identify any changes in behavior or condition that may indicate an allegation of abuse, misappropriation, or neglect. Additional findings were discovered on 3/8/19 pertaining to the start of the Immediate Jeopardy and are as follows: Resident #103 According to a facility Admission Record dated 3/12/2019, Resident #103 was an [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) quarterly assessment indicated Resident #103 was cognitively impaired and needed extensive assistance from two people for bed mobility, transfers, dressing, toilet use, and personal hygiene. During a telephone interview on 3/8/19 at 1:12 p.m., LPN D reported she was aware CNA X was not allowed to care for Resident #103. When asked why, LPN D said that Resident #103 had alleged that CNA X played with his butthole while cleaning him up. LPN D said she reported the allegation to the NHA immediately but didn't think that CNA X had been suspended, just reassigned to care for other residents. When asked, LPN D said she thought the incident had happened three months prior but couldn't be sure. During an interview with the facility Recruiter AA on 3/8/19 at 2:00 p.m., the Employee File of CNA X was reviewed. The file did not reveal any indication CNA X had ever been suspended pending investigation of alleged abuse. Recruiter AA explained that the facility does not track situations where a staff member is involved in an allegation of abuse or neglect and only contains written proof of disciplines or verbal warnings. During an interview on 3/8/19 at 2:20 p.m., the NHA reported that she did have a soft file investigation into an allegation of sexual abuse by CNA X made by Resident #103. Review of the Soft File investigation into the alleged sexual assault revealed the following: A statement dated 11/17/19, documented by LPN D reflected Was approached by (POA CC), (Resident #103's wife), where she reported an allegation about a possible sexual assault. I spoke with her and she expressed that she did not want to get anyone in trouble and also stated that she did not think it was true. I had her write out a statement of what her husband told her. See attached statement. I immediately reported it to our administrator. Skin and pain assessment done .I spoke to (Resident #103) about the allegation. He stated that an aide for nurses is obsessed with his fanny. When I asked what he meant by that he stated He fingers my rear end for about an hour and goes on to say he just see what he sees. He's in my business. When I asked where his hand was, (Resident #103) states Inside my butt. He is fingering my rear end and I think it excites the high school football and college players (there was a football game playing on the TV at the time of the conversation.) I asked what the person looked like (Resident #103) replied Kind of husky, shaved head, muscular with a weird look in his eyes. It's a weird way to spend a Saturday night. When I asked if this had happened on Saturday night, he stated that Saturday is the only day the game plays. I asked him when was the last time this had happened he stated last night. A handwritten statement made by Resident #103's wife and Power of Attorney (POA) CC dated 11/17/18 reflected (Resident #103, Room number) reported to me that a male aide, who is a big man and bald, when tending (Resident #103) uncovers him, grabs his testicles, rolls him over and sticks a finger in his anus. (Resident #103) tells me this happens several times. Review of a Conclusion of Investigation (undated and unsigned, no author identified) included in the Soft File for the allegation of sexual abuse made by Resident #103 about a male CNA reported on 11/17/19 reflected Resident has a history of being delusional, making inappropriate sexual comments to staff, agitation, yelling out and confusion. Resident has a [DIAGNOSES REDACTED]. (Resident #103's) wife reported on 11/17/19 that the resident told her that a male had put his finger in his anus and grabbed his testicles. She stated, I don't believe (it) because he did this in the past at (name of another facility) and nothing happened. She continued to say that he is more confused since his last stroke. (Resident had a stroke on 10/18/18). Resident was interviewed and stated that he was talking about the boys on the field and pointed to the TV. It was noted that there was a football game on television at the time. When asked if he was afraid or fearful, he stated no. He said that he felt safe. He denied anyone hurting him or doing anything to him. Interview of staff, (CNA X) stated that the resident was incontinent of stool and he provided peri-care. When asked if the resident made any statements to him during peri-care, CNA replied No. Spoke with (POA CC) via phone on 11/19/19. She stated that she thought her husband was done with that stuff. She went on to say that he did not like make caregivers in the past. (POA CC) stated that he will continue to make allegations because he prefers female caregivers. (POA CC) agreed to have limited male caregivers for peri-care when possible. Investigation concludes no allegation made. (Resident #103's) spouse reports history of this type of behavior and supports female caregivers. Male caregiver reassigned a different assignment. Resident verbalizes feeling safe and no change in condition of care or behaviors. Resident continues on documentation for on-going behaviors. Further review of the Soft File pertaining to the alleged sexual assault reported on 11/17/18 did not reflect any documentation other than what was written in the document labeled Conclusion of Investigation that the resident felt safe. Review of Progress Notes for the date range 11/13/18-11/19/18 did not reflect any mention of the allegation of sexual assault reported on 11/17/18 by Resident #103's POA. No documentation to support Resident #103 verbalized he was talking about a television program or report of verbalizing safety was found. Review of a Care Plan initiated on 8/23/18 indicated Resident #103 has Behavior disturbances related to living in nursing facility, loneliness, and feelings of abandonment by my wife and children, [MEDICAL CONDITION], impulsive, anxious, may relive previous fracture of arm, packs belongings, tearful, may threaten to throw myself on floor, will also put self on floor after threat, speaking inappropriately, be verbally aggressive with staff (call them names, swear at them) and make frequent false allegations for attention. He removes splint at times. Interventions in the care plan included: I will have no evidence of behavior problems and I will be easily redirected. The intervention of No male caregivers was not added to the care plan until 3/11/19. During an interview on 3/8/19 at 2:25 p.m., the NHA said she did not have CNA X suspended, did not call the police to report an allegation of sexual assault and did not report the allegation of sexual assault to the State Agency. During a telephone interview on 3/8/19 at 4:12 p.m., POA CC said she reported the allegation of sexual abuse because she felt it was important to tell the nurse. POA CC said the facility never suggested the police be called and simply reassigned CNA X. When asked, POA CC denied Resident #103 had ever made sexual abuse allegations before. The NHA and DON in the presence of the Regional Nurse Consultant were informed on 3/8/19 at 2:30 p.m. the Immediate Jeopardy began on 11/17/18 as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for a second resident (Resident #103) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. On 3/12/19 the surveyor confirmed the

This pertains to intake MI 679, MI 1661, and MI 1800 Based on interview and record review, the facility failed to prevent abuse, neglect and the liklihood for ongoing abuse and neglect for 3 residents (Resident #102, #103 and Resident #104) of 5 residents reviewed for abuse, resulting (A) pain and emotional distress when rough care was provided by a Certified Nurse Aide (CNA) who neglected to follow a care plan for one resident (Resident #102), and (B) an Immediate Jeopardy (IJ) that began on 11/17/18, as a result of the facility's failure to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement, an allegation of sexual abuse for two residents (Resident #103 and #104) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. This deficient practice has the potential to affect all vulnerable residents in this facility. Findings include: Review of a facility policy Freedom from Abuse and Neglect last reviewed (MONTH) 16, (YEAR), reflected (Name of Facility) prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. (Facility) is committed to meeting the requirements of all applicable Local, State, and Federal laws and regulations pertaining to any potential resident mistreatment, including all provisions of the Elder Justice Act (EJA). The Purpose of the policy is To describe the facility programs, policies and procedures in place to ensure appropriate resident protection from abuse, neglect, misappropriation of personal property, or exploitation. The facility Freedom from Abuse and Neglect policy and procedure included the following definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Physical Abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Neglect is the failure of the facility, its employees or service providers to provide the goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Covered Individual under the Elder Justice Act means each individual who is an owner, operator, employee, manager, agent, or contractor of a long-term care facility. Law Enforcement Entity under the Elder Justice Act means a police department or sheriff department of a political subdivision, i.e. a city, county, township or village. The policy specifies that The Administrator is the Abuse Prevention Coordinator for (Facility Name). Allegations of abuse, neglect, or exploitation will be reported to the Administrator/Abuse Prevention Coordinator immediately, but not later than 2 hours after forming the suspicion, if the events that caused the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not involve abuse and do not result in serious bodily injury. It is the additional responsibility of all employees to immediately report any incident of suspected abuse, neglect, mistreatment, misappropriation, or exploitation of any Center resident to the licensed staff member in charge. In turn, the Administrator or Director of Nursing will report allegations of abuse, neglect, misappropriation of resident property, or exploitation to the (State Agency) as required under State and Federal Regulations. All covered individuals in the facility must also comply with the following Elder Justice Act provision by reporting reasonable suspicions of a crime to both the (State Agency) and the (County Sheriff Department). The policy specifies steps to take to protect residents and indicates The Administrator, Director of Nursing, or their designee will take steps necessary to protect the resident(s) from the potential for abuse while the investigation is in progress and prior to the investigation final conclusions. If an employee is suspected of perpetrating potential abuse, that employee will be asked to leave the facility and will be removed from the schedule until such time that they can be cleared of any wrong-doing. If there is ever a threat of immediate danger to any resident being posed by a visitor, any employee may immediately call (County Sheriff Department) by dialing 911. Resident #104 Review of a facility Admission Record dated 2/18/19 reflected Resident #104 was an [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #104 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7/15 and needed extensive assistance from two people for bed mobility, transfers, dressing, and toilet use. Review of a Facility Investigation Summary reported to the State Agency (SA) on 2/17/19 reflected [AGE] year-old female admitted to the center for rehabilitation and return to the community alleged she felt as if a man had put himself inside of her while patting on her backside . Review of Nursing/Physician Comments (a physician progress notes [REDACTED]. Last evening, patient stated to nurse that a male came into her room and sexually assaulted her. When questioned about this today patient tells me I was half awake. I don't know what I said. When asked specifically about the event she states, I don't remember that happening; I don't know. Denies any pain or discomfort specifically in the GU ([MEDICAL CONDITION]) region. BM (bowel movements) this AM were normal, without blood per staff. Urinating without difficulty. There were concerns re: loose stools x3 with foul odor however no BM yet today. No abdominal pain/discomfort. Patient is oriented to person only at baseline. The Assessment and Plan (A/P) noted: 1. Abuse allegation-no current signs-continue to monitor for new symptoms. During an interview on 3/7/19 at 8:45 a.m., Nurse Practitioner (NP) Q reported she had been on-call over-night 2/17/19 and was contacted by Licensed Practical Nurse (LPN) R who reported that Resident #104 had made a sexual allegation. NP Q said LPN R did not tell her that Resident #104 said, a man put himself inside her. NP Q said she asked a few more questions about who Resident #104 was and if there were any other complaints. NP Q said she told the nurse she would be in later that morning and examine Resident #104. NP Q said when she arrived at the facility on 2/17/19 there was no information in the progress notes about what had been alleged, the day shift nurse didn't know much about it and suggested she could find more details in an incident report. NP Q said she didn't have access to incident reports. NP Q said if she had been told Resident #104 alleged sexual assault, she would have contacted her supervising physician for guidance regarding a physical exam or what steps needed to be taken. Review of a written statement provided by Certified Nurse Aide (CNA) S reflected During my nightly rounds at approximately 12:30 in the morning, I heard resident in room (Resident #104's room) yelling out for help. When I entered the room, I could hear and smell that she was having problems with gas so I assumed she would ask to be changed. The resident stated, A man hurt me. I asked her to repeat what she said, and she replied a man hurt her. I then asked where and how a man hurt her and she said, I can't see it, but it's right here .as she moved her hand to touch her backside right below her wound vac. I then asked, How did he hurt you? She replied, He put himself in there. As she tapped on her bottom. I asked her to say it again to make sure I had heard her and understood her correctly. She stated, I can't say it; you know .when a man puts himself inside you. I then asked her to hold on one moment so I could get the nurse. I told her I would be right back. I ran to get the nurse and we returned to her room and clarified her statement of the incident she had reported to me. Attempts were made to contact CNA S on 3/7/19 via telephone and were unsuccessful due to the number provided did not allow messages to be left. Review of a written statement dated 2/17/19 timed 0045 (12:45 a.m.) documented by Licensed Practical Nurse (LPN) R reflected CNA called nurse to room. Nurse in and (Resident #104) stated to nurse that A man was here, and he put it in there, resident pointed to rectal area. Director of Nursing (DON) notified by (CNA S). Nurse completed skin, pain assessments and interviewed resident. Resident stated, His parts when asked what was put in there. Resident denied pain at this time stating, It doesn't hurt anymore, he took it out. Resident stated that she did not look and the man and did not recognize his voice. Resident stated she was lying on the left side facing the wall. During interview, resident stated, I don't think it was a dream (nurse had not asked about this). Nurse then asked resident if resident had had dreams like this in the past and resident stated that she had, but not as bad as this. Resident stated that incident was about an hour and a half ago. Nurse asked resident what was happening just before incident to better establish a timeline (lunch, dinner, sleeping .). Resident stated that she had been in bed sleeping. Resident stated that the room was dark with only a faint light. The statement provided also included the following assessment: Skin check: Several small red areas on resident mid/lower back. Left shin with dry dark area. VAC dressing in place to right buttock. Hemorrhoids, but no rectal tearing or bleeding noted. Right foot by 5th toe, calloused area. Resident had small stool in brief, noted with orange tint and mucous (sample saved). Nurse asked resident if resident felt safe at this time, resident stated that she felt better and wanted a light on in her room, staff left resident lamp on. Resident requested to lay on her back so she could see the door, this was completed and resident resting quietly with eyes closed at this time. On-call physician, DON, and administrator aware of above. Resident started on UTI (urinary tract infection monitoring, no new orders at this time. During a telephone interview on 3/7/19 at 10:40 a.m., LPN R reported she was notified by CNA S of the alleged sexual assault on 2/17/19 at approximately 12:30 p.m. LPN R confirmed the written statement noted above was accurate. LPN R said the DON did not instruct her to call the police or preserve the scene for collection of evidence by law enforcement. LPN S reported a male CNA (CNA X) had been working on the other side of the unit until 11:00 p.m. Review of an Incident Report dated 2/17/19 reflected (Resident #104) stated a man came into her room and put himself into her rectum. Notes included in the incident report documented by the DON, dated 2/17/19 reflected Resident stated a man came into her room and put himself into her rectum. Resident was noted to have a large BM (Bowel Movement) after the incident was stated. Resident was assessed by the Nurse Practitioner. DON and Administrator was notified. Investigation in progress. The incident report indicated that the DON had been notified on 2/17/19 at 00:32 (12:32 a.m.), Nurse Practitioner (NP) Q on 2/17/19 at 1:27 a.m., and Resident #104's daughter on 2/17/19 at 12:30 p.m. During an interview on 3/7/19 at 11:10 a.m., the Nursing Home Administrator (NHA) said there was not a separate provision in the facility Freedom from Abuse and Neglect policy to address how to manage an allegation of sexual abuse. The NHA said she did not call the police as soon as the allegation was reported because the resident said she thought she was dreaming. The NHA confirmed she contacted Resident #104's daughter on the afternoon of 2/17/19 and told the daughter that she and the Director of Nursing had decided not to do a rape kit because the resident thought she was dreaming, and they didn't want to traumatize her any further. The NHA also reported that a statement was not obtained from the male CNA (CNA X) who worked on the unit Resident #104 lived on until 11:00 p.m. on 2/16/19 (the same time that Resident #104 alleged the sexual assault occurred), nor was CNA X removed from duty while an investigation was completed. The Administrator also said no other males were working at the time the allegation was made. Review of the Staffing Sheet for 2/16-2/17/19 reflected a male nurse aide, CNA X was on duty until 11:00 p.m. on 2/16/19 (the time Resident #104 alleged the sexual assault occurred). Another male aide was also on duty 2/16/19-2/17/19 working on a different unit. During a telephone interview on 3/7/19 at 12:28 p.m., Family Member (FM) Z reported she had not been notified of the allegation of sexual assault until 14 hours after the incident. FM Z said the NHA told her that her mom (Resident #104) screamed and yelled out at 12:45 a.m. on 2/17/19 and that they (the facility) didn't want to do a rape kit because they didn't want to traumatize her. FM Z said she figured that by the time she found out about what had been reported, Resident #104 would have been cleaned up (peri-care provided) a few times and figured it would be too late to find anything (evidence). FM Z said she was contacted by the Sergeant investigating the allegation the week after Resident #104 was discharged from the facility, who told her that at that point it was too late to do a rape kit, but that they had up to three days to collect evidence if they had been called sooner. FM Z said that she would not have refused such an exam and without it, no one will ever really know what happened. Review of a Statement obtained from Resident #104 on 2/25/19 (eight days after the alleged sexual assault, 6 days after Resident #104 was discharged from the facility) via a telephone call from the DON reflected (Resident #104) was interviewed via phone. Resident stated she didn't know the person that came into her room. She stated she had her back towards the door of her room. She stated she was lying on her right side. She stated, a man put himself into my butt. She denied pain. She stated she felt safe at the facility. She denied seeing the man enter or exit the room. She does not know what he looked like or his skin color. She stated that she may have been dreaming but was not sure. During a follow-up interview on 3/7/19 at 1:21 p.m., the NHA reported that she was the facility Abuse Prevention Coordinator. When asked, the NHA said she did not call the police as soon as the allegation of sexual assault was reported because she did not think there was a reasonable suspicion of a crime. The NHA said she reached out to the non-emergency (County Sheriff) to establish a working relationship with local law enforcement. During a telephone interview on 3/12/19 at 1:16 p.m., Sergeant Y reported that his first contact with the Administrator of the facility was via a telephone call on 2/19/19. Sgt. Y said the initial conversation involved general questions about what, when and to whom reports should be made with the sheriff department. Sgt. Y said that after several questions, the Administrator said she had something that may need to be reported, but that the Administrator didn't have pertinent details about Resident #104, such as date of birth. Sgt. Y then said that the report wasn't made to him until after Resident #104 had discharged from the facility to another living situation in another county. Sgt. Y said that the investigation was very difficult because the Administrator had waited so long to report the alleged sexual assault. Sgt. Y said the Administrator should have called 911 dispatch and a deputy would have been sent out and a kit (an exam completed when there is an alleged sexual assault) completed. Sgt. Y also confirmed he had been told no males had been working at the time the allegation was made. The Nursing Home Administrator and the Director of Nursing were informed on 3/7/18 at 4:09 p.m of an Immediate Jeopardy (IJ) that began on 2/17/19 at 12:30 a.m., as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for one resident (Resident #104) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. During an interview on 3/7/19 at 11:10 a.m., the Director of Nursing and the Administrator said they did talk about having the resident sent out for a rape kit but ultimately decided not to so the resident would not be traumatized any further. In a follow up interview with the Nursing Home Administrator on 3/7/19 at 1:21 PM, she stated that she did not believe the allegation constituted the reasonable suspicion of a crime and that if she felt it was sexual assault she would have called the state survey manager to figure out what to do, resulting in immediate jeopardy for Resident #104, who was her own responsible party and alleged that a man had put himself inside of her the night of 2/17/19, causing the resident to become fearful and asking to be turned so that she could see the door and sleep with the light on. This deficient practice has the potential to affect all vulnerable residents in this facility. The facility implemented the following to remove the high likelihood the identified deficient practice would occur again: 1. 3/7/19. Investigation process continued with interviews of staff on unit providing care on 2/17/19 and CNA X assigned to the neighborhood. 2. 3/7/19. CNA X suspended pending results of the investigation 3. 3/7/19. All currently residing residents with BIMS 7 or less will be audited for behaviors. Those exhibiting behaviors within the last 30 days will have a nursing assessment completed to rule out signs or symptoms of abuse. 4. 3/7/19. All currently residing residents that can be interviewed (BIMS 8 or higher) have been interviewed to identify suspicions of abuse. 5. 3/7/19. An audit of investigative reports in the last 30 days has been reviewed to ensure that witness interviews were conducted per facility policy. No investigative reports in the last 30 days. 6. 3/7/19. Regional Clinical Quality and Risk Director provided Facility Protocol for Managing Sexual Abuse Allegation. 7. 3/7/19. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 8. 3/7/19. All Actively scheduled clinical staff members (this would include licensed nurses and CENA staff) received education on the facility practice in an event of an allegation of sexual abuse. 9. 3/7/19 All actively scheduled clinical leadership positions have been trained on the facility practice related to an allegation of sexual abuse and completion of a full investigation. 10. 3/7/19 Remaining staff will receive education prior to working on next scheduled shift. 11. 3/7/19. Developed a plan to have the Interdisciplinary team review alleged incidents requiring a thorough investigation, including witness interviews, during the Monday - Friday Morning Stand-Up Meeting to ensure a thorough investigation per established policy. 12. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided on Facility Protocol for Managing Sexual Abuse Allegation. 13. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 14. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided Facility Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy. Reviewed and approved by Medical Director. Reviewed and approved by Administrator, per protocol. 15. 3/7/19. 6:44p. Training with clinical managers on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 16. 3/7/19 6:44p. Verified 100% resident interviews completed for residents with a BIMs 8 or higher. No concerns relating to abuse identified. 17. 3/7/19, 6:44p. Verified 100% of resident nursing assessments completed for those individuals that have a BIMs less than 8 and have exhibited any behaviors within the last 30 days. No concerns relating to abuse identified. 18. 3/7/19, 7p. Training completed using abuse policy and protocol for managing sexual abuse allegation with second shift nurses (nurses work 12 hour shifts). 19. 3/7/19, 11p. Training completed using abuse policy and protocol for managing sexual abuse allegation with third shift nursing assistants. 20. 3/8/19, 7 am. Training completed using abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 21. 3/8/19, 10a. Retraining completed with first shift nurses and nursing assistants on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 22. 3/8/19, 10a. Meeting with Medical Director on education plan for physician and physician extenders on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. Physician and physician extenders will receive education prior to working on next scheduled shift. 23. 3/8/19, 11a. Training completed with Physician Assistant on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 24. 3/8/19, 11a. Training completed with nursing educator on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 25. 3/8/19. Training initiated with clinical staff on recognizing behaviors, documenting on behaviors, and documenting behavioral interventions with response. 26. 3/8/19. Training initiated with licensed nursing staff on completion of unusual occurrence reports and notifications. 27. 3/8/19. IDT progress note and skin assessment reviews completed for residents within the last 30 days, both current and discharged , to identify any changes in behavior or condition that may indicate an allegation of abuse, misappropriation, or neglect. Additional findings were discovered on 3/8/19 pertaining to the start of the Immediate Jeopardy and are as follows: Resident #103 According to a facility Admission Record dated 3/12/2019, Resident #103 was an [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) quarterly assessment indicated Resident #103 was cognitively impaired and needed extensive assistance from two people for bed mobility, transfers, dressing, toilet use, and personal hygiene. During a telephone interview on 3/8/19 at 1:12 p.m., LPN D reported she was aware CNA X was not allowed to care for Resident #103. When asked why, LPN D said that Resident #103 had alleged that CNA X played with his butthole while cleaning him up. LPN D said she reported the allegation to the NHA immediately but didn't think that CNA X had been suspended, just reassigned to care for other residents. When asked, LPN D said she thought the incident had happened three months prior but couldn't be sure. During an interview with the facility Recruiter AA on 3/8/19 at 2:00 p.m., the Employee File of CNA X was reviewed. The file did not reveal any indication CNA X had ever been suspended pending investigation of alleged abuse. Recruiter AA explained that the facility does not track situations where a staff member is involved in an allegation of abuse or neglect and only contains written proof of disciplines or verbal warnings. During an interview on 3/8/19 at 2:20 p.m., the NHA reported that she was aware of an incident between CNA X and Resident #103 and had a soft file investigation into an allegation of sexual abuse by CNA X made by Resident #103's wife on 11/17/18. Review of the Soft File investigation into the alleged sexual assault revealed the following: A statement dated 11/17/19, documented by LPN D reflected Was approached by (POA CC), (Resident #103's wife), where she reported an allegation about a possible sexual assault. I spoke with her and she expressed that she did not want to get anyone in trouble and also stated that she did not think it was true. I had her write out a statement of what her husband told her. See attached statement. I immediately reported it to our administrator. Skin and pain assessment done .I spoke to (Resident #103) about the allegation. He stated that an aide for nurses is obsessed with his fanny. When I asked what he meant by that he stated He fingers my rear end for about an hour and goes on to say he just see what he sees. He's in my business. When I asked where his hand was, (Resident #103) states Inside my butt. He is fingering my rear end and I think it excites the high school football and college players (there was a football game playing on the TV at the time of the conversation.) I asked what the person looked like (Resident #103) replied Kind of husky, shaved head, muscular with a weird look in his eyes. It's a weird way to spend a Saturday night. When I asked if this had happened on Saturday night, he stated that Saturday is the only day the game plays. I asked him when was the last time this had happened he stated last night. A handwritten statement made by Resident #103's wife and Power of Attorney (POA) CC dated 11/17/18 reflected (Resident #103, Room number) reported to me that a male aide, who is a big man and bald, when tending (Resident #103) uncovers him, grabs his testicles, rolls him over and sticks a finger in his anus. (Resident #103) tells me this happens several times. Review of a Conclusion of Investigation (undated and unsigned, no author identified) included in the Soft File for the allegation of sexual abuse made by Resident #103 about a male CNA reported on 11/17/19 reflected Resident has a history of being delusional, making inappropriate sexual comments to staff, agitation, yelling out and confusion. Resident has a [DIAGNOSES REDACTED]. (Resident #103's) wife reported on 11/17/19 that the resident told her that a male had put his finger in his anus and grabbed his testicles. She stated, I don't believe (it) because he did this in the past at (name of another facility) and nothing happened. She continued to say that he is more confused since his last stroke. (Resident had a stroke on 10/18/18). Resident was interviewed and stated that he was talking about the boys on the field and pointed to the TV. It was noted that there was a football game on television at the time. When asked if he was afraid or fearful, he stated no. He said that he felt safe. He denied anyone hurting him or doing anything to him. Interview of staff, (CNA X) stated that the resident was incontinent of stool and he provided peri-care. When asked if the resident made any statements to him during peri-care, CNA replied No. Spoke with (POA CC) via phone on 11/19/19. She stated that she thought her husband was done with that stuff. She went on to say that he did not like make caregivers in the past. (POA CC) stated that he will continue to make allegations because he prefers female caregivers. (POA CC) agreed to have limited male caregivers for peri-care when possible. Investigation concludes no allegation made. (Resident #103's) spouse reports history of this type of behavior and supports female caregivers. Male caregiver reassigned a different assignment. Resident verbalizes feeling safe and no change in condition of care or behaviors. Resident continues on documentation for on-going behaviors. Further review of the Soft File pertaining to the alleged sexual assault reported on 11/17/18 did not reflect any documentation other than what was written in the document labeled Conclusion of Investigation that the resident felt safe. Review of Progress Notes for the date range 11/13/18-11/19/18 did not reflect any mention of the allegation of sexual assault reported on 11/17/18 by Resident #103's POA. No documentation to support Resident #103 verbalized he was talking about a television program or report of verbalizing safety was found. Review of a Care Plan initiated on 8/23/18 indicated Resident #103 has Behavior disturbances related to living in nursing facility, loneliness, and feelings of abandonment by my wife and children, [MEDICAL CONDITION], impulsive, anxious, may relive previous fracture of arm, packs belongings, tearful, may threaten to throw myself on floor, will also put self on floor after threat, speaking inappropriately, be verbally aggressive with staff (call them names, swear at them) and make frequent false allegations for attention. He removes splint at times. Interventions in the care plan included: I will have no evidence of behavior problems and I will be easily redirected. The intervention of No male caregivers was not added to the care plan until 3/11/19. During an interview on 3/8/19 at 2:25 p.m., the NHA said she did not have CNA X suspended, did not call the police to report an allegation of sexual assault and did not report the allegation of sexual assault to the State Agency. During a telephone interview on 3/8/19 at 4:12 p.m., POA CC said she reported the allegation of sexual abuse because she felt it was important to tell the nurse. POA CC said the facility never suggested the police be called and simply reassigned CNA X. When asked, POA CC denied Resident #103 had ever made sexual abuse allegations before. The NHA and DON in the presence of the Regional Nurse Consultant were informed on 3/8/19 at 2:30 p.m. the Immediate Jeopardy began on 11/17/18 as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for a second resident (Resident #103) and record review reflected they did not have appropriate facility policies and procedures to address

This pertains to intake MI 1661 and MI 1800 Based on interview and record review, the facility failed to develop and implement policies and procedures to prevent abuse and neglect and report the reasonable suspicion of a crime according the the Elder Justice Act (EJA) for 2 residents (Resident #103 and Resident #104) of 5 residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) that began on 11/17/18, as a result of the facility's failure to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement, an allegation of sexual abuse for two residents (Resident #103 and #104). This deficient practice has the potential to affect all vulnerable residents in this facility. Findings include: Review of a facility policy Freedom from Abuse and Neglect last reviewed (MONTH) 16, (YEAR) reflected (Name of Facility) prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. (Facility) are committed to meeting the requirements of all applicable Local, State, and Federal laws and regulations pertaining to any potential resident mistreatment, including all provisions of the Elder Justice Act (EJA). Further review of the policy reflected the facility correctly defined abuse, sexual abuse, physical abuse, and neglect. The policy also described a Covered Individual under the Elder Justice Act means each individual who is an owner, operator, employee, manager, agent, or contractor of a long-term care facility. The policy clearly explained that a Law Enforcement Entity under the Elder Justice Act means a police department or sheriff department of a political subdivision, i.e. a city, county, township or village. The policy specifies that The Administrator is the Abuse Prevention Coordinator for (Facility Name). Allegations of abuse, neglect, or exploitation will be reported to the Administrator/Abuse Prevention Coordinator immediately, but not later than 2 hours after forming the suspicion, if the events that caused the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not involve abuse and do not result in serious bodily injury. It is the additional responsibility of all employees to immediately report any incident of suspected abuse, neglect, mistreatment, misappropriation, or exploitation of any Center resident to the licensed staff member in charge. In turn, the Administrator or Director of Nursing will report allegations of abuse, neglect, misappropriation of resident property, or exploitation to the (State Agency) as required under State and Federal Regulations. All covered individuals in the facility must also comply with the following Elder Justice Act provision by reporting reasonable suspicions of a crime to both the (State Agency) and the (County Sheriff Department). Resident #104 Review of a facility Admission Record dated 2/18/19 reflected Resident #104 was an [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #104 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7/15 and needed extensive assistance from two people for bed mobility, transfers, dressing and toilet use. Review of a Facility Investigation Summary reported to the State Agency (SA) on 2/17/19 reflected [AGE] year-old female admitted to the center for rehabilitation and return to the community alleged she felt as if a man had put himself inside of her while patting on her backside . During an interview on 3/7/19 at 8:45 a.m., Nurse Practitioner (NP) Q reported she had been on-call over-night 2/17/19 and was contacted by Licensed Practical Nurse (LPN) R who reported that Resident #104 had made a sexual allegation. NP Q said LPN R did not tell her that Resident #104 said a man put himself inside her. NP Q said she asked a few more questions about who Resident #104 was and if there were any other complaints. NP Q said she told the nurse she would be in later that morning and examine Resident #104. NP Q said when she arrived at the facility on 2/17/19 there was no information in the progress notes about what had been alleged, the day shift nurse didn't know much about it and suggested she could find more details in an incident report. NP Q said she didn't have access to incident reports. NP Q said if she had been told Resident #104 alleged sexual assault, she would have contacted her supervising physician for guidance regarding a physical exam or what steps needed to be taken. Review of a written statement provided by Certified Nurse Aide (CNA) S reflected During my nightly rounds at approximately 12:30 in the morning, I heard resident in room (Resident #104's room) yelling out for help. When I entered the room, I could hear and smell that she was having problems with gas so I assumed she would ask to be changed. The resident stated, A man hurt me. I asked her to repeat what she said, and she replied a man hurt her. I then asked where and how a man hurt her and she said, I can't see it, but its right here .as she moved her hand to touch her backside right below her wound vac. I then asked, How did he hurt you? She replied, He put himself in there. As she tapped on her bottom. I asked her to say it again to make sure I had heard her and understood her correctly. She stated, I can't say it; you know .when a man puts himself inside you. I then asked her to hold on one moment so I could get the nurse. I told her I would be right back. I ran to get the nurse and we returned to her room and clarified her statement of the incident she had reported to me. Attempts were made to contact CNA S on 3/7/19 via telephone and were unsuccessful due to the number provided did not allow messages to be left. Review of a written statement dated 2/17/19, timed 0045 (12:45 a.m.) documented by Licensed Practical Nurse (LPN) R reflected CNA called nurse to room. Nurse in and (Resident #104) stated to nurse that A man was here, and he put it in there, resident pointed to rectal area. Director of Nursing (DON) notified by (CNA S). Nurse completed skin, pain assessments and interviewed resident. Resident stated, His parts when asked what was put in there. Resident denied pain at this time stating, It doesn't hurt anymore, he took it out. Resident stated that she did not look and the man and did not recognize his voice. Resident stated she was lying on left side facing the wall. During interview resident stated, I don't think it was a dream (nurse had not asked about this). Nurse then asked resident if resident had had dreams like this in the past and resident stated that she had, but not as bad as this. Resident stated that incident was about an hour and a half ago. Nurse asked resident what was happening just before incident to better establish a timeline (lunch, dinner, sleeping .). Resident stated that she had been in bed sleeping. Resident stated that the room was dark with only a faint light. The statement provided also included the following assessment: Skin check: Several small red areas on resident mid/lower back. Left shin with dry dark area. VAC dressing in place to right buttock. Hemorrhoids, but no rectal tearing or bleeding noted. Right foot by 5th toe, calloused area. Resident had small stool in brief, noted with orange tint and mucous (sample saved). Nurse asked resident if resident felt safe at this time, resident stated that she felt better and wanted a light on in her room, staff left resident lamp on. Resident requested to lay on her back so she could see the door, this was completed and resident resting quietly with eyes closed at this time. On call physician, DON and administrator aware of above. Resident started on UTI (urinary tract infection) monitoring, no new orders at this time. During a telephone interview on 3/7/19 at 10:40 a.m., LPN R reported she was notified by CNA S of the alleged sexual assault on 2/17/19 at approximately 12:30 p.m. LPN R confirmed the written statement noted above was accurate. LPN R said the DON did not instruct her to call the police or preserve the scene for collection of evidence by law enforcement. LPN S reported a male CNA (CNA X) had been working on the other side of the unit until 11:00 p.m. Review of an Incident Report dated 2/17/19 reflected (Resident #104) stated a man came into her room and put himself into her rectum. Notes included in the incident report documented by the DON, dated 2/17/19 reflected Resident stated a man came into her room and put himself into her rectum. Resident was noted to have a large BM (Bowel Movement) after the incident was stated. Resident was assessed by the Nurse Practitioner. DON and Administrator was notified. Investigation in progress. The incident report indicated that the DON had been notified on 2/17/19 at 00:32 (12:32 a.m.), Nurse Practitioner (NP) Q on 2/17/19 at 1:27 a.m., and Resident #104's daughter on 2/17/19 at 12:30 p.m. During an interview on 3/7/19 at 11:10 a.m., the Nursing Home Administrator (NHA) said there was not a separate provision in the facility Freedom from Abuse and Neglect policy to address how to manage an allegation of sexual abuse. The NHA said she did not call the police as soon as the allegation was reported because the resident said she thought she was dreaming. The NHA confirmed she contacted Resident #104's daughter on the afternoon of 2/17/19 and told the daughter that she and the Director of Nursing had decided not to do a rape kit because the resident thought she was dreaming, and they didn't want to traumatize her any further. The NHA also reported that a statement was not obtained from the male CNA (CNA X) who worked on the unit Resident #104 lived on until 11:00 p.m. on 2/16/19 (the time Resident #104 alleged the sexual assault occurred), nor was CNA X removed from duty while an investigation was completed. The Administrator also said no other males were working at the time the allegation was made. Review of the Staffing Sheet for 2/16-2/17/19 reflected CNA X was on duty on part of the unit where Resident #104 lived until 11:00 p.m. on 2/16/19. Another male aide was also on duty 2/16/19-2/17/19 on a different unit. During a telephone interview on 3/7/19 at 12:28 p.m., Family Member (FM) Z reported she had not been notified of the allegation of sexual assault until 14 hours after the incident. FM Z said the NHA told her that her mom (Resident #104) screamed and yelled out at 12:45 a.m. on 2/17/19 and that they (the facility) didn't want to do a rape kit because they didn't want to traumatize her. FM Z said she figured that by the time she found out about what had been reported, Resident #104 would have been cleaned up (peri-care provided) a few times and figured it would be too late to find anything (evidence). FM Z said she was contacted by the Sergeant investigating the allegation the week after Resident #104 was discharged from the facility, who told her that at that point it was too late to do a rape kit, but that they had up to three days to collect evidence if they had been called sooner. FM Z said that she would not have refused such an exam and without it, no one will ever really know what happened. Review of a Statement obtained from Resident #104 on 2/25/19 (eight days after the alleged sexual assault, 6 days after Resident #104 was discharged from the facility) via a telephone call from the DON reflected (Resident #104) was interviewed via phone. Resident stated she didn't know the person that came into her room. She stated she had her back towards the door of her room. She stated she was lying on her right side. She stated, a man put himself into my butt. She denied pain. She stated she felt safe at the facility. She denied seeing the man enter or exit the room. She does not know what he looked like or his skin color. She stated that she may have been dreaming but was not sure. During a follow-up interview on 3/7/19 at 1:21 p.m., the NHA reported that she was the facility Abuse Prevention Coordinator. When asked, the NHA said she did not call the police as soon as the allegation of sexual assault was reported because she did not think there was a reasonable suspicion of a crime. The NHA said she reached out to the non-emergency (County Sheriff) to establish a working relationship with local law enforcement. During a telephone interview on 3/12/19 at 1:16 p.m., Sergeant Y reported that his first contact with the Administrator of the facility was via a telephone call on 2/19/19. Sgt. Y said the initial conversation involved general questions about what, when and to whom reports should be made with the sheriff department. Sgt. Y said that after several questions, the Administrator said she had something that may need to be reported, but that the Administrator didn't have pertinent details about Resident #104, such as date of birth. Sgt. Y then said that the report wasn't made to him until after Resident #104 had discharged from the facility to another living situation in another county. Sgt. Y said that the investigation was very difficult because the Administrator had waited so long to report the alleged sexual assault. Sgt. Y said the Administrator should have called 911 dispatch and a deputy would have been sent out and a kit (an exam completed when there is an alleged sexual assault) completed. Sgt. Y also confirmed he had been told no males had been working at the time the allegation was made. The Nursing Home Administrator and the Director of Nursing were informed on 3/7/18 at 4:09 p.m of an Immediate Jeopardy (IJ) that began on 2/17/19 at 12:30 a.m., as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for one resident (Resident #104) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. During an interview on 3/7/19 at 11:10 a.m., the Director of Nursing and the Administrator said they did talk about having the resident sent out for a rape kit but ultimately decided not to so the resident would not be traumatized any further. In a follow up interview with the Nursing Home Administrator on 3/7/19 at 1:21 PM, she stated that she did not believe the allegation constituted the reasonable suspicion of a crime and that if she felt it was sexual assault she would have called the state survey manager to figure out what to do, resulting in immediate jeopardy for Resident #104, who was her own responsible party and alleged that a man had put himself inside of her the night of 2/17/19, causing the resident to become fearful and asking to be turned so that she could see the door and sleep with the light on. This deficient practice has the potential to affect all vulnerable residents in this facility. The facility implemented the following to remove the high likelihood the identified deficient practice would occur again: 1. 3/7/19. Investigation process continued with interviews of staff on unit providing care on 2/17/19 and CNA X assigned to the neighborhood. 2. 3/7/19. CNA X suspended pending results of the investigation 3. 3/7/19. All currently residing residents with BIMS 7 or less will be audited for behaviors. Those exhibiting behaviors within the last 30 days will have a nursing assessment completed to rule out signs or symptoms of abuse. 4. 3/7/19. All currently residing residents that can be interviewed (BIMS 8 or higher) have been interviewed to identify suspicions of abuse. 5. 3/7/19. An audit of investigative reports in the last 30 days has been reviewed to ensure that witness interviews were conducted per facility policy. No investigative reports in the last 30 days. 6. 3/7/19. Regional Clinical Quality and Risk Director provided Facility Protocol for Managing Sexual Abuse Allegation. 7. 3/7/19. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 8. 3/7/19. All Actively scheduled clinical staff members (this would include licensed nurses and CENA staff) received education on the facility practice in an event of an allegation of sexual abuse. 9. 3/7/19 All actively scheduled clinical leadership positions have been trained on the facility practice related to an allegation of sexual abuse and completion of a full investigation. 10. 3/7/19 Remaining staff will receive education prior to working on next scheduled shift. 11. 3/7/19. Developed a plan to have the Interdisciplinary team review alleged incidents requiring a thorough investigation, including witness interviews, during the Monday - Friday Morning Stand-Up Meeting to ensure a thorough investigation per established policy. 12. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided on Facility Protocol for Managing Sexual Abuse Allegation. 13. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 14. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided Facility Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy. Reviewed and approved by Medical Director. Reviewed and approved by Administrator, per protocol. 15. 3/7/19. 6:44p. Training with clinical managers on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 16. 3/7/19 6:44p. Verified 100% resident interviews completed for residents with a BIMs 8 or higher. No concerns relating to abuse identified. 17. 3/7/19, 6:44p. Verified 100% of resident nursing assessments completed for those individuals that have a BIMs less than 8 and have exhibited any behaviors within the last 30 days. No concerns relating to abuse identified. 18. 3/7/19, 7p. Training completed using abuse policy and protocol for managing sexual abuse allegation with second shift nurses (nurses work 12 hour shifts). 19. 3/7/19, 11p. Training completed using abuse policy and protocol for managing sexual abuse allegation with third shift nursing assistants. 20. 3/8/19, 7am. Training completed using abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 21. 3/8/19, 10a. Retraining completed with first shift nurses and nursing assistants on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 22. 3/8/19, 10a. Meeting with Medical Director on education plan for physician and physician extenders on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. Physician and physician extenders will receive education prior to working on next scheduled shift. 23. 3/8/19, 11a. Training completed with Physician Assistant on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 24. 3/8/19, 11a. Training completed with nursing educator on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 25. 3/8/19. Training initiated with clinical staff on recognizing behaviors, documenting on behaviors, and documenting behavioral interventions with response. 26. 3/8/19. Training initiated with licensed nursing staff on completion of unusual occurrence reports and notifications. 27. 3/8/19. IDT progress note and skin assessment reviews completed for residents within the last 30 days, both current and discharged , to identify any changes in behavior or condition that may indicate an allegation of abuse, misappropriation, or neglect. Additional findings were discovered on 3/8/19 pertaining to the start of the Immediate Jeopardy and are as follows: Resident #103 According to a facility Admission Record dated 3/12/2019, Resident #103 was an [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) quarterly assessment indicated Resident #103 was cognitively impaired and needed extensive assistance from two people for bed mobility, transfers, dressing, toilet use and personal hygiene. During a telephone interview on 3/8/19 at 1:12 p.m., LPN D reported she was aware CNA X was not allowed to care for Resident #103. When asked why, LPN D said that Resident #103 had alleged that CNA X played with his butthole while cleaning him up. LPN D said she reported the allegation to the NHA immediately but didn't think that CNA X had been suspended, just reassigned to care for other residents. When asked, LPN D said she thought the incident had happened three months prior but couldn't be sure. During an interview with the facility Recruiter AA on 3/8/19 at 2:00 p.m., the Employee File of CNA X was reviewed. The file did not reveal any indication CNA X had ever been suspended pending investigation of alleged abuse. Recruiter AA explained that the facility does not track situations where a staff member is involved in an allegation of abuse or neglect and only contains written proof of disciplines or verbal warnings. During an interview on 3/8/19 at 2:20 p.m., the NHA reported that she did have a soft file investigation into an allegation of sexual abuse by CNA X made by Resident #103's wife on 11/17/18. Review of the Soft File investigation into the alleged sexual assault revealed the following: A statement dated 11/17/19, documented by LPN D reflected Was approached by (POA CC), (Resident #103's wife), where she reported an allegation about a possible sexual assault. I spoke with her and she expressed that she did not want to get anyone in trouble and also stated that she did not think it was true. I had her write out a statement of what her husband told her. See attached statement. I immediately reported it to our administrator. Skin and pain assessment done .I spoke to (Resident #103) about the allegation. He stated that and aide for nurses is obsessed with his fanny. When I asked what he meant by that he stated He fingers my rear end for about an hour and goes on to say he just see what he sees. He's in my business. When I asked where his hand was, (Resident #103) states Inside my butt. He is fingering my rear end and I think it excites the high school football and college players (there was a football game playing on the TV at the time of the conversation.) I asked what the person looked like (Resident #103) replied Kind of husky, shaved head, muscular with a weird look in his eyes. It's a weird way to spend a Saturday night. When I asked if this had happened on Saturday night, he stated that Saturday is the only day the game plays. I asked him when was the last time this had happened he stated last night. A handwritten statement made by Resident #103's wife and Power of Attorney (POA) CC dated 11/17/18 reflected (Resident #103, Room number) reported to me that a male aide, who is a big man and bald, when tending (Resident #103) uncovers him, grabs his testicles, rolls him over and sticks a finger in his anus. (Resident #103) tells me this happens several times. Review of a Conclusion of Investigation (undated and unsigned, no author identified) included in the Soft File for the allegation of sexual abuse made by Resident #103 about a male CNA reported on 11/17/19 reflected Resident has a history of being delusional, making inappropriate sexual comments to staff, agitation, yelling out and confusion. Resident has a [DIAGNOSES REDACTED]. (Resident #103's) wife reported on 11/17/19 that the resident told her that a male had put his finger in his anus and grabbed his testicles. She stated I don't believe (it) because he did this in the past at (name of another facility) and nothing happened. She continued to say that he is more confused since his last stroke. (Resident had a stroke on 10/18/18). Resident was interviewed and stated that he was talking about the boys on the field and pointed to the TV. It was noted that there was a football game on the television at the time. When asked if he was afraid or fearful, he stated no. He said that he felt safe. He denied anyone hurting him or doing anything to him. Interview of staff, (CNA X) stated that the resident was incontinent of stool and he provided peri-care. When asked if the resident made any statements to him during peri-care, CNA replied No. Spoke with (POA CC) via phone on 11/19/19. She stated that she thought her husband was done with that stuff. She went on to say that he did not like make care givers in the past. (POA CC) stated that he will continue to make allegations because he prefers female caregivers. (POA CC) agreed to have limited male caregivers for peri-care when possible. Investigation concludes no allegation made. (Resident #103's) spouse reports history of this type of behavior and supports female caregivers. Male care giver reassigned a different assignment. Resident verbalizes feeling safe and no change in condition of care or behaviors. Resident continues on documentation for on-going behaviors. During an interview on 3/8/19 at 2:25 p.m., the NHA said she did not have CNA X suspended, did not call the police to report an allegation of sexual assault and did not report the allegation of sexual assault to the State Agency. During a telephone interview on 3/8/19 at 4:12 p.m., POA CC said she reported the allegation of sexual abuse because she felt it was important to tell the nurse. POA CC said the facility never suggested the police be called and simply reassigned CNA X. When asked, POA CC denied Resident #103 had ever made sexual abuse allegations before. The NHA and DON in the presence of the Regional Nurse Consultant were informed on 3/8/19 at 2:30 p.m. the Immediate Jeopardy began on 11/17/18 as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for a second resident (Resident #103) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. On 3/12/19 the surveyor confirmed the facility implemented to following additional interventions to remove the immediate jeopardy: 1. 3/8/19, 7am. Training completed using abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 2. 3/8/19, 10a. Retraining completed with first shift nurses and nursing assistants on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 3. 3/8/19, 10a. Meeting with Medical Director on education plan for physician and physician extenders on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. Physician and physician extenders will receive education prior to working on next scheduled shift. 4. 3/8/19, 11a. Training completed with Physician Assistant on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 5. 3/8/19, 11a. Training completed with nursing educator on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 6. 3/8/19. Training initiated with clinical staff on recognizing behaviors, documenting on behaviors, and documenting behavioral interventions with response. 7. 3/8/19. Training initiated with licensed nursing staff on completion of unusual occurrence reports and notifications. 8. 3/8/19. IDT progress note and skin assessment reviews completed for residents within the last 30 days, both current and discharged , to identify any changes in behavior or condition that may indicate an allegation of abuse, misappropriation, or neglect. 9. 3/8/19. Submission of Facility Reported Incident (FRI) regarding allegation of sexual abuse made by Resident #103 on 11/17/18. 10. 3/8/19. Full investigation into Resident #103's allegation of sexual abuse initiated. 11. 3/8/19. Review of investigative files to determine if reportable occurrences exist, if so, facility reported incidents (FRI) will be completed. 12. 3/8/19. Police notified of Resident per EJA via 911 dispatch pertaining to alleged event reported by Resident #103 on 11/17/18 Although the Immediate Jeopardy (IJ) was removed on 3/08/19, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the revised policy and procedure, and sustained compliance has not been verified by the state agency.

This pertains to intake MI 679, and MI 1800 Based on interview and record review, the facility failed to report to the State Agency (SA) alleged abuse and neglect for 1 resident (Resident #102) of 5 residents reviewed for abuse, resulting in pain and emotional distress when rough care was provided by a Certified Nurse Aide (CNA) who neglected to follow a care plan for one resident (Resident #102), and resulting in an Immediate Jeopardy (IJ) that began on 11/17/18, as a result of the facility's failure to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement, an allegation of sexual abuse for one resident (Resident #103). This deficient practice has the potential to affect all vulnerable residents in this facility. Findings include: Review of a facility policy Freedom from Abuse and Neglect last reviewed (MONTH) 16, (YEAR), reflected (Name of Facility) prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. (Facility) is committed to meeting the requirements of all applicable Local, State, and Federal laws and regulations pertaining to any potential resident mistreatment, including all provisions of the Elder Justice Act (EJA). The policy specifies that The Administrator is the Abuse Prevention Coordinator for (Facility Name). Allegations of abuse, neglect, or exploitation will be reported to the Administrator/Abuse Prevention Coordinator immediately, but not later than 2 hours after forming the suspicion, if the events that caused the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not involve abuse and do not result in serious bodily injury. It is the additional responsibility of all employees to immediately report any incident of suspected abuse, neglect, mistreatment, misappropriation, or exploitation of any Center resident to the licensed staff member in charge. In turn, the Administrator or Director of Nursing will report allegations of abuse, neglect, misappropriation of resident property, or exploitation to the (State Agency) as required under State and Federal Regulations. All covered individuals in the facility must also comply with the following Elder Justice Act provision by reporting reasonable suspicions of a crime to both the (State Agency) and the (County Sheriff Department). The policy specifies steps to take to protect residents and indicates The Administrator, Director of Nursing, or their designee will take steps necessary to protect the resident(s) from the potential for abuse while the investigation is in progress and prior to the investigation final conclusions. If an employee is suspected of perpetrating potential abuse, that employee will be asked to leave the facility and will be removed from the schedule until such time that they can be cleared of any wrong-doing. If there is ever a threat of immediate danger to any resident being posed by a visitor, any employee may immediately call (County Sheriff Department) by dialing 911. Resident #102 Review of a Face Sheet for Resident #102 revealed a [AGE] year old female admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had a Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired and required extensive assist of 2 staff for transfers. Review of an incident report dated 1/7/19 for Resident #102 revealed: .Incident Description: right hip hurt during transfer .Immediate Action Taken .removed staff member from cares. Assessed resident's skin and pain. Monitor resident's pain and skin .Injuries Observed at Time of Incident: .Right trochanter (hip) .Level of Pain: PAINAD (Pain Assessment in Advanced Dementia) 4 (Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0=no pain to 10=severe pain) .Detail: Negative vocalization: Repeated, Troubled, calling out, Loud moaning or groaning, crying. Facial Expression: Sad, frightened, frown .Consolabilty: Distracted or reassured by voice or touch .Notes: Resident c/o (complained of) right hip pain while being transferred via Hoyer lift to her w/c (wheelchair). Resident stated that one aide transferred her to her w/c using the Hoyer lift. Staff member was interviewed and removed from cares. Resident was assessed for pain and skin was assessed. Nurse Practitioner to see resident to assess for pain management. Review of a Pain Assessment report dated 1/8/19 was attached to the investigative report from 1/7/19 for Resident #102 revealed: C. Resident rates pain based on a scale of 1-5 .3. Severe pain .Pain site: Right Hip .What appears to increase the resident's pain? Positioning, movement. What is the most likely cause of pain? Arthritis Review of a Staff Interview Summary dated 1/7/19 revealed: Resident #102 was interviewed for a statement of the incident by an unknown source. (Resident #102) states when (CNA Q) was helping her she hurt her leg, her hip, was rough with her. Hoyer lift went okay. Right lower back, right hip hurt. Hurts when lifting leg up. Pain is a 2 right now. Elbow is about a 2. Review of a Staff Interview Summary by Licensed Practical Nurse (LPN) B dated 1/7/19 revealed: (Resident #102) was crying. When I asked her what was wrong, she said aide. I listed the aide's names and she said yes when I came to (CNA Q). I asked if (CNA Q) upset her, she said yes. I asked if she was mean to her (Resident #102) said yes. I asked if she was mean with her words (Resident #102) said no. I asked (Resident #102) if (CNA Q). I asked if she was mean with her body, (Resident #102) said yes. I asked (Resident #102) if (CNA Q) hurt her, she said yes. I asked if she was hurting, she said yes. I asked where, (Resident #102) pointed and said right hip. I asked if there was anywhere else that was hurt, she said yes. I asked where. She pointed and said back and pointed to the right lower back. I asked if there was anywhere else, she said no. I then reported this to (Director of Nursing (DON)). In an interview on 3/6/19 at 2:05 p.m., Licensed Practical Nurse (LPN) B reported that Resident #102 could answer direct questions when asked and reported her statement was accurate. LPN B reported that day after the incident on 1/7/19, she had never seen Resident #102 upset and crying as she did on that day after the incident when CNA Q transferred the resident via Hoyer lift to her wheelchair. Review of a written Statement dated 1/7/19, CNA V reported I did not assist (CNA Q) with transferring (Resident #102). (Resident #102) came out of her room and (CNA Q) was with her and asked me if (Resident #102) was set in her w/c the way (Resident #102) likes. CNA Q has not taken care of (Resident #102) before. I helped her finish getting (Resident #102) comfortable because (Resident #102) was crying and wanted to be repositioned (Resident #102) said she was ok after being repositioned. Review of a Staff Interview Summary dated 1/7/19, CNA Q was interviewed and revealed: Does not usually do (Resident #102) and did not understand her. States (Resident #102) was crying afterward. Transfer went fine with Hoyer lift and (staff) helped with transfer. (Staff) helped to understand her. Scudded up in chair. (Resident #102) came out into hallway and then was crying. First, she said (staff) assisted her with Hoyer. Then she switched it to (another staff) assisted her. (Resident #102) states no one did. Review of a written Statement dated 1/7/19, CNA W reported I did not help get the resident up into the w/c. I did not witness (Resident #102) crying. Review of a written Statement dated 1/7/19, CNA E reported, I did not assist (CNA Q) with transferring the resident from the bed to her electric w/c. I saw (Resident #102) crying and report to (staff) the nurse. In an interview on 3/6/19 at 3:12 p.m., CNA E reported she was told that (CNA Q) transferred Resident #102 with a lift by herself and was rough with her care. CNA E reported she remembered that day of the incident on 1/7/19 when Resident #102 zoomed towards her in her electric wheelchair and she was just balling. She was crying and crying. I had never seen her like that before! CNA E reported she then went to tell the nurse on duty and then CNA Q was immediately removed from the floor and the facility started the investigation. Review of a written Statement dated 1/7/19, Director of Nursing (DON) reported, (Resident #102) was asked if anyone helped (CNA Q) put her in her w/c and she replied no. She stated (CNA Q) swing her legs while in the Hoyer and hit the Hoyer with her feet. When asked if she told (CNA Q) that it hurt, she replied yes. She said (CNA Q) just pulled me up and hurt my hips and back. (Resident #102) stated that her back made a cracking noise when lifted with the Hoyer. (CNA V) helped to boost the resident in her electric w/c in the hall. In an interview on 3/7/19 at 10:20 a.m., Resident #102 was in her room in and in bed. This surveyor asked direct questions and Resident #102 answered by nodding yes and no. Resident remembered the incident when CNA Q transferred her from the Hoyer to her wheelchair. She said she had pain in her knee and her back. She did not see CNA Q since that day and was pleased with the way the facility removed her from her care. Resident #102 felt safe now that CNA Q was no longer at the facility. She felt safe and staff treated her with respect. In an interview on 3/7/19 at 3:30 p.m., Team Leader TL H reported she did not feel that the care provided by CNA Q was neglect or mistreatment but reported she had an attitude. TL H reported that after the incident had occurred, CNA Q was sent home, taken off the schedule and later fired after the investigation. Review of a Nursing/Physicians Comment form dated 1/23/19 for Resident #102 that was attached to the investigation report for 1/7/19 revealed: Nursing comments: c/o (complains of) right hip pain. Dr. (name) will give cortisone shot .Physician comments: Pt (patient) was seen at her fathers and nursing request. She has had chronic right hip pain. She has been seen at the pain clinic in the past for cortisone injections with improvement in her pain .Verbal permission was given by her father .Trochanteric Bursa (Pain outside the hip) injection .[MEDICATION NAME] (corticosteroid) 40 mg (milligrams) /1ml (milliliter) = 4 units .Sacroiliac injection .[MEDICATION NAME] 40 mg .[MEDICATION NAME] total was 8 units .Pt got some reduction of her pain Review of the Bedside Kardex Report for Resident #102 revealed: .Mobility/Transferring: .I transfer with 2 assist Hoyer lift using a medium size sling only . Transfer: I require the use of a Hoyer with 2 people for all transfers Review of an Employee Counseling and/or Disciplinary Report for CNA Q dated 1/7/19 revealed: The details of the incident: Failed to follow care plan intervention as documented on Kardex .Actions Required: Termination .Presented via phone call 1/14/19. Resident #103 According to a facility Admission Record dated 3/12/2019, Resident #103 was an [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) quarterly assessment indicated Resident #103 was cognitively impaired and needed extensive assistance from two people for bed mobility, transfers, dressing, toilet use, and personal hygiene. During a telephone interview on 3/8/19 at 1:12 p.m., LPN D reported she was aware CNA X was not allowed to care for Resident #103. When asked why, LPN D said that Resident #103 had alleged that CNA X played with his butthole while cleaning him up. LPN D said she reported the allegation to the NHA immediately but didn't think that CNA X had been suspended, just reassigned to care for other residents. When asked, LPN D said she thought the incident had happened three months prior but couldn't be sure. During an interview with the facility Recruiter AA on 3/8/19 at 2:00 p.m., the Employee File of CNA X was reviewed. The file did not reveal any indication CNA X had ever been suspended pending investigation of alleged abuse. Recruiter AA explained that the facility does not track situations where a staff member is involved in an allegation of abuse or neglect and only contains written proof of disciplines or verbal warnings. During an interview on 3/8/19 at 2:20 p.m., the NHA reported that she was aware of an allegation made by Resident #103 about CNA X and had a soft file investigation into what had been reported by Resident #103's wife on 11/17/18. Review of the Soft File investigation into the alleged sexual assault revealed the following: A statement dated 11/17/19, documented by LPN D reflected Was approached by (POA CC), (Resident #103's wife), where she reported an allegation about a possible sexual assault. I spoke with her and she expressed that she did not want to get anyone in trouble and also stated that she did not think it was true. I had her write out a statement of what her husband told her. See attached statement. I immediately reported it to our administrator. Skin and pain assessment done .I spoke to (Resident #103) about the allegation. He stated that an aide for nurses is obsessed with his fanny. When I asked what he meant by that he stated He fingers my rear end for about an hour and goes on to say he just see what he sees. He's in my business. When I asked where his hand was, (Resident #103) states Inside my butt. He is fingering my rear end and I think it excites the high school football and college players (there was a football game playing on the TV at the time of the conversation.) I asked what the person looked like (Resident #103) replied Kind of husky, shaved head, muscular with a weird look in his eyes. It's a weird way to spend a Saturday night. When I asked if this had happened on Saturday night, he stated that Saturday is the only day the game plays. I asked him when was the last time this had happened he stated last night. A handwritten statement made by Resident #103's wife and Power of Attorney (POA) CC dated 11/17/18 reflected (Resident #103, Room number) reported to me that a male aide, who is a big man and bald, when tending (Resident #103) uncovers him, grabs his testicles, rolls him over and sticks a finger in his anus. (Resident #103) tells me this happens several times. During an interview on 3/8/19 at 2:25 p.m., the NHA said she did not have CNA X suspended, did not call the police to report an allegation of sexual assault and did not report the allegation of sexual assault to the State Agency. The NHA and DON in the presence of the Regional Nurse Consultant were informed on 3/8/19 at 2:30 p.m. the situation requiring immediate intervention that had been previously identified on 3/7/19 at 4:09 p.m. pertaining to a different resident, began on 11/17/18 as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement and the State Agency, an allegation of sexual abuse for a second resident (Resident #103). This deficient practice has the potential to affect all vulnerable residents in this facility. Due to the previously identified IJs, the facility had already implemented some of the corrective action on 3/7/19. On 3/12/19 the surveyor confirmed the facility implemented to following interventions to remove the immediate jeopardy: 1. On 3/7/19, CNA X was suspended pending results of an investigation pertaining to a different resident who alleged sexual abuse. 2. On 3/7/19 at 6:00p. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 3. On 3/7/19 the Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 4. 3/8/19, 7 am. Training completed using abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 5. 3/8/19, 10a. Retraining completed with first shift nurses and nursing assistants on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 6. 3/8/19. Training initiated with licensed nursing staff on completion of unusual occurrence reports and notifications. 7. 3/8/19. IDT progress note and skin assessment reviews completed for residents within the last 30 days, both current and discharged , to identify any changes in behavior or condition that may indicate an allegation of abuse, misappropriation, or neglect. 8. 3/8/19. Submission of Facility Reported Incident (FRI) regarding allegation of sexual abuse made by Resident #103 on 11/17/18. 9. 3/8/19. Full investigation into Resident #103's allegation of sexual abuse initiated. 10. 3/8/19. Review of investigative files to determine if reportable occurrences exist, if so, facility reported incidents (FRI) will be completed. 11. 3/8/19. Police notified of Resident per EJA via 911 dispatch pertaining to alleged event reported by Resident #103 on 11/17/18. Although the Immediate Jeopardy (IJ) was removed on 3/08/19, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the revised policy and procedure, and sustained compliance has not been verified by the state agency.

This pertains to intake MI 1661 and MI 1800 Based on interview and record review, the facility failed to prevent the liklihood for ongoing abuse and neglect and further abuse and neglect for 2 residents (Resident #103 and Resident #104) of 5 residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) that began on 11/17/18, as a result of the facility's failure to thoroughly investigate an allegation of sexual abuse for two residents (Resident #103 and #104). Record review reflected they did not have appropriate facility policies and procedures to address investigating allegations of sexual abuse. This deficient practice has the potential to affect all vulnerable residents in this facility. Findings include: Review of a facility policy Freedom from Abuse and Neglect last reviewed (MONTH) 16, (YEAR), reflected (Name of Facility) prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. (Facility) is committed to meeting the requirements of all applicable Local, State, and Federal laws and regulations pertaining to any potential resident mistreatment, including all provisions of the Elder Justice Act (EJA). The Purpose of the policy is To describe the facility programs, policies and procedures in place to ensure appropriate resident protection from abuse, neglect, misappropriation of personal property, or exploitation. The facility Freedom from Abuse and Neglect policy and procedure included the following definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Physical Abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Neglect is the failure of the facility, its employees or service providers to provide the goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Covered Individual under the Elder Justice Act means each individual who is an owner, operator, employee, manager, agent, or contractor of a long-term care facility. Law Enforcement Entity under the Elder Justice Act means a police department or sheriff department of a political subdivision, i.e. a city, county, township or village. The policy specifies that The Administrator is the Abuse Prevention Coordinator for (Facility Name). Allegations of abuse, neglect, or exploitation will be reported to the Administrator/Abuse Prevention Coordinator immediately, but not later than 2 hours after forming the suspicion, if the events that caused the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not involve abuse and do not result in serious bodily injury. It is the additional responsibility of all employees to immediately report any incident of suspected abuse, neglect, mistreatment, misappropriation, or exploitation of any Center resident to the licensed staff member in charge. In turn, the Administrator or Director of Nursing will report allegations of abuse, neglect, misappropriation of resident property, or exploitation to the (State Agency) as required under State and Federal Regulations. All covered individuals in the facility must also comply with the following Elder Justice Act provision by reporting reasonable suspicions of a crime to both the (State Agency) and the (County Sheriff Department). The policy specifies steps to take to protect residents and indicates The Administrator, Director of Nursing, or their designee will take steps necessary to protect the resident(s) from the potential for abuse while the investigation is in progress and prior to the investigation final conclusions. If an employee is suspected of perpetrating potential abuse, that employee will be asked to leave the facility and will be removed from the schedule until such time that they can be cleared of any wrong-doing. If there is ever a threat of immediate danger to any resident being posed by a visitor, any employee may immediately call (County Sheriff Department) by dialing 911. Resident #104 Review of a facility Admission Record dated 2/18/19 reflected Resident #104 was an [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #104 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7/15 and needed extensive assistance from two people for bed mobility, transfers, dressing, and toilet use. Review of a Facility Investigation Summary reported to the State Agency (SA) on 2/17/19 reflected [AGE] year-old female admitted to the center for rehabilitation and return to the community alleged she felt as if a man had put himself inside of her while patting on her backside . Review of Nursing/Physician Comments (a physician progress notes [REDACTED]. Last evening, patient stated to nurse that a male came into her room and sexually assaulted her. When questioned about this today patient tells me I was half awake. I don't know what I said. When asked specifically about the event she states, I don't remember that happening; I don't know. Denies any pain or discomfort specifically in the GU ([MEDICAL CONDITION]) region. BM (bowel movements) this AM were normal, without blood per staff. Urinating without difficulty. There were concerns re: loose stools x3 with foul odor however no BM yet today. No abdominal pain/discomfort. Patient is oriented to person only at baseline. The Assessment and Plan (A/P) noted: 1. Abuse allegation-no current signs-continue to monitor for new symptoms. During an interview on 3/7/19 at 8:45 a.m., Nurse Practitioner (NP) Q reported she had been on-call over-night 2/17/19 and was contacted by Licensed Practical Nurse (LPN) R who reported that Resident #104 had made a sexual allegation. NP Q said LPN R did not tell her that Resident #104 said, a man put himself inside her. NP Q said she asked a few more questions about who Resident #104 was and if there were any other complaints. NP Q said she told the nurse she would be in later that morning and examine Resident #104. NP Q said when she arrived at the facility on 2/17/19 there was no information in the progress notes about what had been alleged, the day shift nurse didn't know much about it and suggested she could find more details in an incident report. NP Q said she didn't have access to incident reports. NP Q said if she had been told Resident #104 alleged sexual assault, she would have contacted her supervising physician for guidance regarding a physical exam or what steps needed to be taken. Review of a written statement provided by Certified Nurse Aide (CNA) S reflected During my nightly rounds at approximately 12:30 in the morning, I heard resident in room (Resident #104's room) yelling out for help. When I entered the room, I could hear and smell that she was having problems with gas so I assumed she would ask to be changed. The resident stated, A man hurt me. I asked her to repeat what she said, and she replied a man hurt her. I then asked where and how a man hurt her and she said, I can't see it, but it's right here .as she moved her hand to touch her backside right below her wound vac. I then asked, How did he hurt you? She replied, He put himself in there. As she tapped on her bottom. I asked her to say it again to make sure I had heard her and understood her correctly. She stated, I can't say it; you know .when a man puts himself inside you. I then asked her to hold on one moment so I could get the nurse. I told her I would be right back. I ran to get the nurse and we returned to her room and clarified her statement of the incident she had reported to me. Attempts were made to contact CNA S on 3/7/19 via telephone and were unsuccessful due to the number provided did not allow messages to be left. Review of a written statement dated 2/17/19 timed 0045 (12:45 a.m.) documented by Licensed Practical Nurse (LPN) R reflected CNA called nurse to room. Nurse in and (Resident #104) stated to nurse that A man was here, and he put it in there, resident pointed to rectal area. Director of Nursing (DON) notified by (CNA S). Nurse completed skin, pain assessments and interviewed resident. Resident stated, His parts when asked what was put in there. Resident denied pain at this time stating, It doesn't hurt anymore, he took it out. Resident stated that she did not look and the man and did not recognize his voice. Resident stated she was lying on left side facing the wall. During interview, resident stated, I don't think it was a dream (nurse had not asked about this). Nurse then asked resident if resident had had dreams like this in the past and resident stated that she had, but not as bad as this. Resident stated that incident was about an hour and a half ago. Nurse asked resident what was happening just before incident to better establish a timeline (lunch, dinner, sleeping .). Resident stated that she had been in bed sleeping. Resident stated that the room was dark with only a faint light. The statement provided also included the following assessment: Skin check: Several small red areas on resident mid/lower back. Left shin with dry dark area. VAC dressing in place to right buttock. Hemorrhoids, but no rectal tearing or bleeding noted. Right foot by 5th toe, calloused area. Resident had small stool in brief, noted with orange tint and mucous (sample saved). Nurse asked resident if resident felt safe at this time, resident stated that she felt better and wanted a light on in her room, staff left resident lamp on. Resident requested to lay on her back so she could see the door, this was completed and resident resting quietly with eyes closed at this time. On-call physician, DON, and administrator aware of above. Resident started on UTI (urinary tract infection monitoring, no new orders at this time. During a telephone interview on 3/7/19 at 10:40 a.m., LPN R reported she was notified by CNA S of the alleged sexual assault on 2/17/19 at approximately 12:30 p.m. LPN R confirmed the written statement noted above was accurate. LPN R said the DON did not instruct her to call the police or preserve the scene for collection of evidence by law enforcement. LPN S reported a male CNA (CNA X) had been working on the other side of the unit until 11:00 p.m. Review of an Incident Report dated 2/17/19 reflected (Resident #104) stated a man came into her room and put himself into her rectum. Notes included in the incident report documented by the DON, dated 2/17/19 reflected Resident stated a man came into her room and put himself into her rectum. Resident was noted to have a large BM (Bowel Movement) after the incident was stated. Resident was assessed by the Nurse Practitioner. DON and Administrator was notified. Investigation in progress. The incident report indicated that the DON had been notified on 2/17/19 at 00:32 (12:32 a.m.), Nurse Practitioner (NP) Q on 2/17/19 at 1:27 a.m., and Resident #104's daughter on 2/17/19 at 12:30 p.m. During an interview on 3/7/19 at 11:10 a.m., the Nursing Home Administrator (NHA) said there was not a separate provision in the facility Freedom from Abuse and Neglect policy to address how to manage an allegation of sexual abuse. The NHA said she did not call the police as soon as the allegation was reported because the resident said she thought she was dreaming. The NHA confirmed she contacted Resident #104's daughter on the afternoon of 2/17/19 and told the daughter that she and the Director of Nursing had decided not to do a rape kit because the resident thought she was dreaming, and they didn't want to traumatize her any further. The NHA also reported that a statement was not obtained from the male CNA (CNA X) who worked on the unit Resident #104 lived on until 11:00 p.m. on 2/16/19 (the time Resident #104 alleged the sexual assault occurred), nor was CNA X removed from duty while an investigation was completed. The Administrator also said no other males were working at the time the allegation was made. Review of the Staffing Sheet for 2/16-2/17/19 reflected CNA X was on duty until 11:00 p.m. on 2/16/19. Another male aide was also on duty 2/16/19-2/17/19 on a different unit. During a telephone interview on 3/7/19 at 12:28 p.m., Family Member (FM) Z reported she had not been notified of the allegation of sexual assault until 14 hours after the incident. FM Z said the NHA told her that her mom (Resident #104) screamed and yelled out at 12:45 a.m. on 2/17/19 and that they (the facility) didn't want to do a rape kit because they didn't want to traumatize her. FM Z said she figured that by the time she found out about what had been reported, Resident #104 would have been cleaned up (peri-care provided) a few times and figured it would be too late to find anything (evidence). FM Z said she was contacted by the Sergeant investigating the allegation the week after Resident #104 was discharged from the facility, who told her that at that point it was too late to do a rape kit, but that they had up to three days to collect evidence if they had been called sooner. FM Z said that she would not have refused such an exam and without it, no one will ever really know what happened. Review of a Statement obtained from Resident #104 on 2/25/19 (eight days after the alleged sexual assault, 6 days after Resident #104 was discharged from the facility) via a telephone call from the DON reflected (Resident #104) was interviewed via phone. Resident stated she didn't know the person that came into her room. She stated she had her back towards the door of her room. She stated she was lying on her right side. She stated, a man put himself into my butt. She denied pain. She stated she felt safe at the facility. She denied seeing the man enter or exit the room. She does not know what he looked like or his skin color. She stated that she may have been dreaming but was not sure. During a follow-up interview on 3/7/19 at 1:21 p.m., the NHA reported that she was the facility Abuse Prevention Coordinator. When asked, the NHA said she did not call the police as soon as the allegation of sexual assault was reported because she did not think there was a reasonable suspicion of a crime. The NHA said she reached out to the non-emergency (County Sheriff) to establish a working relationship with local law enforcement. During a telephone interview on 3/12/19 at 1:16 p.m., Sergeant Y reported that his first contact with the Administrator of the facility was via a telephone call on 2/19/19. Sgt. Y said the initial conversation involved general questions about what, when and to whom reports should be made with the sheriff department. Sgt. Y said that after several questions, the Administrator said she had something that may need to be reported, but that the Administrator didn't have pertinent details about Resident #104, such as date of birth. Sgt. Y then said that the report wasn't made to him until after Resident #104 had discharged from the facility to another living situation in another county. Sgt. Y said that the investigation was very difficult because the Administrator had waited so long to report the alleged sexual assault. Sgt. Y said the Administrator should have called 911 dispatch and a deputy would have been sent out and a kit (an exam completed when there is an alleged sexual assault) completed. Sgt. Y also confirmed he had been told no males had been working at the time the allegation was made. The Nursing Home Administrator and the Director of Nursing were informed on 3/7/18 at 4:09 p.m of an Immediate Jeopardy (IJ) that began on 2/17/19 at 12:30 a.m., as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for one resident (Resident #104) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. During an interview on 3/7/19 at 11:10 a.m., the Director of Nursing and the Administrator said they did talk about having the resident sent out for a rape kit but ultimately decided not to so the resident would not be traumatized any further. In a follow up interview with the Nursing Home Administrator on 3/7/19 at 1:21 PM, she stated that she did not believe the allegation constituted the reasonable suspicion of a crime and that if she felt it was sexual assault she would have called the state survey manager to figure out what to do, resulting in immediate jeopardy for Resident #104, who was her own responsible party and alleged that a man had put himself inside of her the night of 2/17/19, causing the resident to become fearful and asking to be turned so that she could see the door and sleep with the light on. This deficient practice has the potential to affect all vulnerable residents in this facility. The facility implemented the following to remove the high likelihood the identified deficient practice would occur again: 1. 3/7/19. Investigation process continued with interviews of staff on unit providing care on 2/17/19 and CNA X assigned to the neighborhood. 2. 3/7/19. CNA X suspended pending results of the investigation 3. 3/7/19. All currently residing residents with BIMS 7 or less will be audited for behaviors. Those exhibiting behaviors within the last 30 days will have a nursing assessment completed to rule out signs or symptoms of abuse. 4. 3/7/19. All currently residing residents that can be interviewed (BIMS 8 or higher) have been interviewed to identify suspicions of abuse. 5. 3/7/19. An audit of investigative reports in the last 30 days has been reviewed to ensure that witness interviews were conducted per facility policy. No investigative reports in the last 30 days. 6. 3/7/19. Regional Clinical Quality and Risk Director provided Facility Protocol for Managing Sexual Abuse Allegation. 7. 3/7/19. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 8. 3/7/19. All Actively scheduled clinical staff members (this would include licensed nurses and CENA staff) received education on the facility practice in an event of an allegation of sexual abuse. 9. 3/7/19 All actively scheduled clinical leadership positions have been trained on the facility practice related to an allegation of sexual abuse and completion of a full investigation. 10. 3/7/19 Remaining staff will receive education prior to working on next scheduled shift. 11. 3/7/19. Developed a plan to have the Interdisciplinary team review alleged incidents requiring a thorough investigation, including witness interviews, during the Monday - Friday Morning Stand-Up Meeting to ensure a thorough investigation per established policy. 12. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided on Facility Protocol for Managing Sexual Abuse Allegation. 13. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director nurse trained Administrator and Director of Nursing on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 14. 3/7/19. 6:00p. Regional Clinical Quality and Risk Director provided Facility Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy. Reviewed and approved by Medical Director. Reviewed and approved by Administrator, per protocol. 15. 3/7/19. 6:44p. Training with clinical managers on the Facility Abuse & Neglect Policy, Elder Justice Act, Completing a Thorough Investigation, Facility Protocol for Managing Sexual Abuse Allegation. 16. 3/7/19 6:44p. Verified 100% resident interviews completed for residents with a BIMs 8 or higher. No concerns relating to abuse identified. 17. 3/7/19, 6:44p. Verified 100% of resident nursing assessments completed for those individuals that have a BIMs less than 8 and have exhibited any behaviors within the last 30 days. No concerns relating to abuse identified. 18. 3/7/19, 7p. Training completed using abuse policy and protocol for managing sexual abuse allegation with second shift nurses (nurses work 12 hour shifts). 19. 3/7/19, 11p. Training completed using abuse policy and protocol for managing sexual abuse allegation with third shift nursing assistants. 20. 3/8/19, 7 am. Training completed using abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 21. 3/8/19, 10a. Retraining completed with first shift nurses and nursing assistants on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 22. 3/8/19, 10a. Meeting with Medical Director on education plan for physician and physician extenders on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. Physician and physician extenders will receive education prior to working on next scheduled shift. 23. 3/8/19, 11a. Training completed with Physician Assistant on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 24. 3/8/19, 11a. Training completed with nursing educator on abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 25. 3/8/19. Training initiated with clinical staff on recognizing behaviors, documenting on behaviors, and documenting behavioral interventions with response. 26. 3/8/19. Training initiated with licensed nursing staff on completion of unusual occurrence reports and notifications. 27. 3/8/19. IDT progress note and skin assessment reviews completed for residents within the last 30 days, both current and discharged , to identify any changes in behavior or condition that may indicate an allegation of abuse, misappropriation, or neglect. Additional findings were discovered on 3/8/19 pertaining to the start of the Immediate Jeopardy and are as follows: Resident #103 According to a facility Admission Record dated 3/12/2019, Resident #103 was an [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) quarterly assessment indicated Resident #103 was cognitively impaired and needed extensive assistance from two people for bed mobility, transfers, dressing, toilet use, and personal hygiene. During a telephone interview on 3/8/19 at 1:12 p.m., LPN D reported she was aware CNA X was not allowed to care for Resident #103. When asked why, LPN D said that Resident #103 had alleged that CNA X played with his butthole while cleaning him up. LPN D said she reported the allegation to the NHA immediately but didn't think that CNA X had been suspended, just reassigned to care for other residents. When asked, LPN D said she thought the incident had happened three months prior but couldn't be sure. During an interview with the facility Recruiter AA on 3/8/19 at 2:00 p.m., the Employee File of CNA X was reviewed. The file did not reveal any indication CNA X had ever been suspended pending investigation of alleged abuse. Recruiter AA explained that the facility does not track situations where a staff member is involved in an allegation of abuse or neglect and only contains written proof of disciplines or verbal warnings. During an interview on 3/8/19 at 2:20 p.m., the NHA reported that she did have a soft file investigation into an allegation of sexual abuse by CNA X made by Resident #103. Review of the Soft File investigation into the alleged sexual assault revealed the following: A statement dated 11/17/19, documented by LPN D reflected Was approached by (POA CC), (Resident #103's wife), where she reported an allegation about a possible sexual assault. I spoke with her and she expressed that she did not want to get anyone in trouble and also stated that she did not think it was true. I had her write out a statement of what her husband told her. See attached statement. I immediately reported it to our administrator. Skin and pain assessment done .I spoke to (Resident #103) about the allegation. He stated that an aide for nurses is obsessed with his fanny. When I asked what he meant by that he stated He fingers my rear end for about an hour and goes on to say he just see what he sees. He's in my business. When I asked where his hand was, (Resident #103) states Inside my butt. He is fingering my rear end and I think it excites the high school football and college players (there was a football game playing on the TV at the time of the conversation.) I asked what the person looked like (Resident #103) replied Kind of husky, shaved head, muscular with a weird look in his eyes. It's a weird way to spend a Saturday night. When I asked if this had happened on Saturday night, he stated that Saturday is the only day the game plays. I asked him when was the last time this had happened he stated last night. A handwritten statement made by Resident #103's wife and Power of Attorney (POA) CC dated 11/17/18 reflected (Resident #103, Room number) reported to me that a male aide, who is a big man and bald, when tending (Resident #103) uncovers him, grabs his testicles, rolls him over and sticks a finger in his anus. (Resident #103) tells me this happens several times. Review of a Conclusion of Investigation (undated and unsigned, no author identified) included in the Soft File for the allegation of sexual abuse made by Resident #103 about a male CNA reported on 11/17/19 reflected Resident has a history of being delusional, making inappropriate sexual comments to staff, agitation, yelling out and confusion. Resident has a [DIAGNOSES REDACTED]. (Resident #103's) wife reported on 11/17/19 that the resident told her that a male had put his finger in his anus and grabbed his testicles. She stated, I don't believe (it) because he did this in the past at (name of another facility) and nothing happened. She continued to say that he is more confused since his last stroke. (Resident had a stroke on 10/18/18). Resident was interviewed and stated that he was talking about the boys on the field and pointed to the TV. It was noted that there was a football game on television at the time. When asked if he was afraid or fearful, he stated no. He said that he felt safe. He denied anyone hurting him or doing anything to him. Interview of staff, (CNA X) stated that the resident was incontinent of stool and he provided peri-care. When asked if the resident made any statements to him during peri-care, CNA replied No. Spoke with (POA CC) via phone on 11/19/19. She stated that she thought her husband was done with that stuff. She went on to say that he did not like make caregivers in the past. (POA CC) stated that he will continue to make allegations because he prefers female caregivers. (POA CC) agreed to have limited male caregivers for peri-care when possible. Investigation concludes no allegation made. (Resident #103's) spouse reports history of this type of behavior and supports female caregivers. Male caregiver reassigned a different assignment. Resident verbalizes feeling safe and no change in condition of care or behaviors. Resident continues on documentation for on-going behaviors. Further review of the Soft File pertaining to the alleged sexual assault reported on 11/17/18 did not reflect any documentation other than what was written in the document labeled Conclusion of Investigation that the resident felt safe. Review of Progress Notes for the date range 11/13/18-11/19/18 did not reflect any mention of the allegation of sexual assault reported on 11/17/18 by Resident #103's POA. No documentation to support Resident #103 verbalized he was talking about a television program or report of verbalizing safety was found. Review of a Care Plan initiated on 8/23/18 indicated Resident #103 has Behavior disturbances related to living in nursing facility, loneliness, and feelings of abandonment by my wife and children, [MEDICAL CONDITION], impulsive, anxious, may relive previous fracture of arm, packs belongings, tearful, may threaten to throw myself on floor, will also put self on floor after threat, speaking inappropriately, be verbally aggressive with staff (call them names, swear at them) and make frequent false allegations for attention. He removes splint at times. Interventions in the care plan included: I will have no evidence of behavior problems and I will be easily redirected. The intervention of No male caregivers was not added to the care plan until 3/11/19. During an interview on 3/8/19 at 2:25 p.m., the NHA said she did not have CNA X suspended, did not call the police to report an allegation of sexual assault and did not report the allegation of sexual assault to the State Agency. During a telephone interview on 3/8/19 at 4:12 p.m., POA CC said she reported the allegation of sexual abuse because she felt it was important to tell the nurse. POA CC said the facility never suggested the police be called and simply reassigned CNA X. When asked, POA CC denied Resident #103 had ever made sexual abuse allegations before. The NHA and DON in the presence of the Regional Nurse Consultant were informed on 3/8/19 at 2:30 p.m. the Immediate Jeopardy began on 11/17/18 as a result of the facility's failure to thoroughly identify, investigate, and report to law enforcement, an allegation of sexual abuse for a second resident (Resident #103) and record review reflected they did not have appropriate facility policies and procedures to address allegations of sexual abuse. On 3/12/19 the surveyor confirmed the facility implemented to following additional interventions to remove the immediate jeopardy: 1. 3/8/19, 7 am. Training completed using abuse policy and protocol for managing sexual abuse allegation with first shift nurses and nursing assistants. 2. 3/8/19, 10a. Retraining completed with first shift nurses and nursing assistants on abuse policy

Based on observation, interview, and record review the facility failed to implement and follow care plan in 1 of 10 sampled resident (Resident #10), reviewed for falls, from a total sample of 15 resident, resulting in multiple unwitnessed falls with harm and injury, and the potential for further injury. Findings include: Review of the Fall Prevention Program dated 5/19/17, reflected Purpose The purpose of the Fall Prevention Program is to describe a systematic process for assessing a resident's risk for falls, developing a comprehensive plan to address the problems associated with falls, implement an organized approach to falls management, and evaluate the residents's plan of care for effective ness. The Fall Management Program will include on-going monitoring, analysis, and management of resident fall occurrences and fall care plans while taking a proactive approach with resident and/or responsible party education related to fall interventions. Post Fall Review: A post fall comprehensive review will be completed by the Interdisciplinary team IDT for each resident who falls to ensure post fall interventions and further preventative measures are completed. The IDT with completed the NOCC ( Post Fall Investigation review form and direct recommendations as needed to prevent further falls. Review of the Admission Record revealed Resident #10 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #10 with a reference date of 3/14/17, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated that the resident was moderately cognitively intact. Resident #10 required one to two staff member assist for bed mobility, dressing, toileting, bathing, or walking (moving) in her room. The MDS Section J reflected that Resident #10 had a fall in the last month prior to admission to the facility. Review of the Fall dated 3/28/17 at 21:54 (9:54 p.m.), Resident #10 ambulating independently in hallway with wheeled walker. Bent down to pick something off floor and fell down as witnessed by nurse. Resident stated O reach for something and fell / Review of the Fall Care Plan dated 3/8/17, reflected I am high risk for falls related to weakness, dementia, impulsive, self-transfers. Review of the Interdisciplinary (IDT) Progress Notes dated 3/28/17 at 11:13 a.m., reflected .Contributing factors: dementia, weakness. Intervention: 30 minute checks for 48 hours to establish a pattern and added elation at 4 p.m. for sundowners. Care Plan and kardex updated. Review of Fall dated 3/29/17 dated 11:00 a.m., Resident #10 found in room near bathroom door by admissions coordinator lying supine. Assessed for obvious injuries pain, and orientation. Resident was awake and alert and aware that she had fallen. Was unable to state why she had fallen Wheelchair was approximately 5 feet behind. vitals assessed and within normal limits. Stated I don't know what happened.Was attempting to keep her head off the ground. A pillow was provided for comfort as she was left in the location she fell for further assessment. Complained of back pain and was asking if her sweater was bunched up underneath her. It was not. Upon inspection an 2 cm . 4 cm shallow abrasion was identified on right mid rib cage lateral to the thoracic spine area. Clean dressing applied. A red area to the left of thoracic spine and coccyx was also observed. Physician and family notified Injury type Abrasion, Mobility: Wheelchair bound, Predisposing Physiological Factors: Confused, Gait imbalance, impaired memory, Predisposing Situation Factors: Ambulation without Assist., no witnesses found. Review of the Interdisciplinary (IDT) Progress Notes dated 3/30/17 at 11:39 a.m., reflected IDT review of fall on 3/28/17(DIC): observed lying supine on floor in room. Contributing factors: dementia, weakness. Intervention: 15 minute checks for 48 hours to establish a pattern and added anti-rollbacks added to wheelchair. Care Plan and kardex updated. Review of the Fall dated 3/31/17 at 9:36 p.m., reflected Resident fell self-transferring to toilet, Resident stated I fell . I had to go to toilet/ No injury observed, Predisposing Physiological Factors: Confused, Gait imbalance, impaired memory, Predisposing Situation Factors: Ambulating without assist, wanderer, no witnesses found. Review of the Interdisciplinary (IDT) Progress Notes, reflected no review of this fall. Review of the Fall dated 4/3/17 at 2:53 a.m., reflected Resident requested pain medication after being toileted by Certified Nursing Assistant (CNA). I was on my way to Resident #10's room with medication when I heard a loud thump/bang. the CNA and I entered the resident's room and she was laying on the ground, with her left arm underneath her, next to her bed. She reported falling and hitting her face. VS were taken and were within normal limits Decreased ROM (Range of motion) as resident reported left arm pain and hip pain. Notified the physician assistant on call and received verbal order to send her to the emergency room for further evaluation. After paramedics arrived, they sat her on the edge of the bed and we noticed a large skin tear on hr left forearm and large bump/hematoma on her forehead. Resident state she was just sitting up on the edge of the bed and does not know how she fell . She state she had hit her face on the floor. Injures: Hematoma, face, skin tear, Mobility: Ambulatory with assistance, Predisposing Physiological Factors: Confused, Gait imbalance, impaired memory, Predisposing Situation Factors: Ambulating without assist, no witnesses found. Review of the Interdisciplinary (IDT) Progress Notes dated 4/3/17 at 4:56 p.m., reflected IDT review of fall on 4/3/17: Contributing factors: dementia, weakness. Intervention: Increase melatonin to 6 mg for sundowners, gripper sock or shoes on at all times, lock wheelchair at bed side when in bed. Care Plan and kardex updated. Review of the Restorative Progress Note dated 4/6/17 at 4:30 p.m., reflected Tinetti 19/28. High fall risk. Step symmetry impaired. During eyes closed test with narrow base of support she exhibited loss of balance. Review of the Fall dated 4/10 17 at 1:45 p.m., reflected Called to room by nurse aide. Resident laying on right side with back up against wall across from the bathroom. Nurse aide stated resident just finished lunch and went to the bathroom and wanted to be in her chair. Nurse aide offered to lay her down but resident declined. Resident stated I was tired and I'm comfortable laying on my side Immediate Action Taken Assisted back to wheelchair, no new injury, denies pain, VSS. New intervention is to offer resident to ambulated when anxious, Predisposing Physiological Factors: Current UTI, Gait imbalance, impaired memory, Predisposing Situation Factors: Ambulating without assist, no witnesses found Review of the Interdisciplinary (IDT) Progress Notes dated 4/11/17 at 10:01 a.m., reflected IDT review of fall on 4/10/17: Contributing factors: dementia, weakness. Intervention: offer activity or visiting with other residents after lunch, offer walks when appears restless. Care Plan and kardex updated. Review of the Restorative Progress Note dated 4/20/17 at 2:05 p.m., reflected Orthostatic blood pressure completed. Noted systolic drop from sitting to standing. Denies any dizziness or being lightheaded. her balance on initial standing is unsteady. Review of the Fall dated 4/23/17 at 9:29 p.m., reflected Resident #10 sitting on floor next to bed approximately 3-4 feet from wheelchair. Resident stated I stood up and fell on my butt. Resident stated wheelchair slid from behind her causing her to fall onto floor. Predisposing Physiological Factors: Confused Predisposing Situation Factors: Ambulating without assist, Improper footwear, no witnesses found, other information: Resident #10 was using wheelchair without anti-tip backs. Review of the Interdisciplinary (IDT) Progress Notes dated 4/24/17 at 9:54 a.m., reflected IDT review of fall on 4/23/17: Contributing factors: dementia, weakness. Intervention: offer to go to bed earlier and add anti -rollbacks to new wheelchair. Care Plan and kardex updated. Review of the Restorative Progress Note dated 4/27/17 at 12:02 p.m., reflected Fluctuations noted in her blood pressure. Nursing notified. Repeated tinetti. Review of the Fall dated 5/9/17 at 8:05 p.m., reflected this nurse observed resident standing in front of her closet when she stepped back, lost her balance and fell to the ground before nurse could reach resident. Resident landed on her butt, then fell backwards bumping the back of head on the floor. Resident stated I don't know what happened, I just fell Immediate Action Taken: Assessed for injuries, none noted at this time. Neuro checks initiated per protocol. 2 staff assisted resident into wheelchair. Predisposing Physiological Factors: Confused, Gait imbalance, impaired memory, Predisposing Situation Factors: Ambulating without assist. Review of the Interdisciplinary (IDT) Progress Notes dated 5/10/17 at 10:00 a.m., reflected IDT review of fall on 5/09/17: New Intervention: restorative to work with resident on balance. Review of the Fall Care Plan Intervention, reflected, date initiated 5/16/17 I am working with restorative staff. Review of the Fall dated 5/15/17 at 6:47 p.m., reflected This nurse was sitting at the nurses station waiting to get report when resident leaned over towards another residents chair and fell sideways onto her hip, Predisposings Physiological Factors: Confused, impaired memory, weakness/fainted, recent change in medication/new, Predisposing Situation Factors: other. Review of the Interdisciplinary (IDT) Progress Notes dated 5/16/17 at 11:19 a.m., reflected IDT review of fall on 5/15/17: New Intervention: resident to have snacks at dining room table. Fall care plan reviewed and updated. Review of the Restorative Progress Note dated 5/18/17 at 12:33 p.m., reflected Restorative is focusing on balance. She has loss of balance with stopping and turning. The use of her walker has been inconsistent. Does not improve safety. Her follow through with safety is impaired related to cognition. Factors limiting progress: Poor safety awareness, Impulsive. Review of the Fall dated 5/25/17 at 2:10 p.m., reflected This nurse was alerted to residents room by CNA stating resident was witnessed lying on floor This nurse witnessed resident lying on her left side. Resident had rubber sole slippers on both feet. Resident appeared to have a skin tear on her right elbow Resident stated she was trying to get out of bed. Immediate Action Taken this Nurse had CNA obtain vitals. This nurse looked over resident for visible injuries. Resident denies pain until had resident straighten legs. Resident stated she was unable to due to increase in pain to left hip. Resident stated she was unsure if she hit her head. Physician was notified. Order obtained to send resident to emergency room for evaluation. Predisposing Environmental Factors: Poor lighting, Predisposing Physiological Factors: Confused, impaired memory, weakness/fainted, Predisposing Situation Factors: ambulating without assist, no witnesses found. Review of the Interdisciplinary (IDT) Progress Notes reflected there was no review of this fall. Review of the Restorative Progress Note dated 5/25/17 at 11:36 a.m., reflected The rail ambulation with stopping and turning repeats has been completed. She had 1 loss of balance episode with 6 sessions of 50 feet. She has been able to stop and hod onto the walker and pick up items however it has been noted that her peripheral vision appears to be impaired . Factors limiting progress: Poor safety awareness, Impulsive. Visual impairment. Plan: discontinue restorative program. Recommend functional maintenance ambulation program and frequent monitoring. Review of the Fall dated 5/30/17 at 5:00 a.m., reflected Was at the nurses station when the sound of a walker falling was heard. Upon entering residents room she was found sitting on the floor by her sink up against the wall next to her end table with her walker in front of her. Resident stated that she was looking for her glasses (which were in her hands), and she sat down on the ground. Predisposing Physiological Factors: Confused, impaired memory, gait imbalance Predisposing Situation Factors: improper footwear, ambulating without assistance, recent room change, using walker, other information: resident stated that she was looking for her glasses which she was putting on as this nurse entered room. Her glasses are kept on her night stand, not near where she fell , no witnesses found. Review of the Immediate Interventions Implemented Post-Fall to Prevent Future Falls call light education, non skid footwear. resident needs alarms. During an interview on 8/1/17 at 8:40 a.m., DON B reported that Resident #10 was not independent with a walker in her room and the root cause of the incident may have not been where the glasses were placed. Review of the Interdisciplinary (IDT) Progress Notes dated 5/3117 at 10:10 a.m., reflected IDT review of fall on 5/30/17: New Intervention: to keep glasses and personal items in reach on bedside table and to offer AM care on last rounds (night shift) if resident awake. Review of the Fall Care Plan Intervention reflected, date initiated 5/30/17, Night shift offer AM assistance if I am awake. Review of the Fall dated 6/2/17 at 8:30 p.m., Staff heard a yell for help, found resident on the floor. Bleeding from bridge of nose, skin tear to back of left hand, and large goose egg above left eye, complain pain in left shoulder and left hip, stated I fell because no one came fast enough for me admits to trying to walk alone. Immediate Action Taken: Vitals Checked Covered left hand skin tear with non stick pad and wrapped with kerlix, staff member at side, order to send to emergency room . Predisposing Physiological Factors: Confused, impaired memory, gait imbalance Predisposing Situation Factors: other, no witnesses found. Review of Post-Fall Investigation CNA statement not signed, not dated Came out of 212, saw she was fussing with her clothes, not needing help. About 10 min later heard help, found on floor in front of her TV. Review of the Interdisciplinary (IDT) Progress Notes dated 6/5/17 at 4/30 p.m., reflected IDT review of fall on 6/2/17: New Intervention: 15 minute checks; 8PM bedtime routine - HS care at this time and offer resident to lay down; lower clothes bar in resident closet to be at wheelchair height. During an interview on 8/2/17 at 1:15 p.m., CNA M reported that on 6/2/17 she had just toileted Resident #10 for another CNA prior to her fall and Resident #10 self propelled to her room, said she had stood up to get something out of her closet when they found her on the floor. CNA M reported that when Resident #10 was in her group she takes her from lunch to an activity, if she lets her out of sight she will go wanding in her room or someone else's. Review of the Fall Care Plan Intervention reflected, date initiated 6/3/17, Assist resident with HS care and bedtime clothes around 8 pm and offer to lay down at that time. Review of the Fall dated 6/9/17 at 10:00 p.m., reflected Staff heard resident calling for help, found sitting on floor next to bed. Aide had taken her to the bathroom 30 minutes prior I get dizzy when I turn around. So, I turned around and got dizzy, and down I went. Immediate Action Taken: Assessed for Injuries, none noted Staff reminded resident to use call light for assistance, resident states sure, but I couldn't reach it after I fell . Predisposing Environmental Factors: other, Predisposing Physiological Factors: gait imbalance Predisposing Situation Factors: ambulating without assist, no witnesses found. Review of the Interdisciplinary (IDT) Progress Notes dated 6/15/17 at 12:30 p.m., reflected IDT review of fall on 6/9/17: New Intervention: physician assessed resident at this time and updated on residents noted dizziness and loss of balance with turns. new order for antivert. Review of the Restorative Progress Note dated 6/15/17 at 2:56 p.m., reflected Resident Response to Treatment: She has refused x 1. She has demonstrated increased impulsivity with transfers. Her balance is unsteady. Tinetti score is a 20/28 now compared to previous program when reached 25/28. Refused to complete nu step .Factors limiting progress: Poor safety awareness, impulsive, unsteady balance. Review of the Fall dated 6/19/17 at 7:25 p.m., reflected heard resident call for help. entered room and observed resident sitting on the floor at the foot of her bed, wheelchair in front of her. I was going to brush my teeth and I fell . Immediate Action Taken: Assessed for injuries resident states I bumped my head on the bed. neuro check WNL. 2 staff assisted resident up off the floor and into her wheelchair. Predisposing Physiological Factors: gait imbalance confused, impaired memory, Predisposing Situation Factors: ambulating without assist, no witnesses found. Review of the Interdisciplinary (IDT) Progress Notes dated 6/20/17 at 030 p.m., reflected IDT review of fall on 6/19/17: New Intervention: to remain with resident till HS care complete; continue to work with restorative and recent therapy screen completed. Fall care plan updated. Review of the Restorative Progress Note dated 6/22/17 at 2:57 p.m., reflected factors limiting progress: Impulsive. Has poor safety awareness and impaired balance. During an interview on 8/3/17 at 3:10 p.m., CNA EE reported Resident #10 on 6/2/17 Resident #10 went in her room by herself, staff need to know she was in there and keep an eye on her. CNA EE though she could walk to the sink by herself. CNA EE reported that Resident #10 was not safe to self transfer, but she though she could and she has transferred herself to bed a couple times since the fall, but what do you do when she was already in bed and sound asleep. CNA EE reported that she has not informed any staff that Resident #10 continues to self transfer to bed. Review of the Fall dated 7/2/17 at 2:45 a.m., reflected this nurse heard a noise from room. observed resident on floor next to door on her right side. resident denies hitting head. checked resident head to toe. complained pain right elbow when checked skin tear noted. Resident stated she was going to the bathroom and slid. Immediate Action Taken: ROM, WNL. Physician notified neuro started. Resident assisted into wheelchair. Predisposing Environmental Factors: poor lighting, Predisposing Physiological Factors: impaired memory, weakness/fainted, Predisposing Situation Factors: ambulating without assist, no witnesses found. Review of Post-Fall Investigation dated 7/3/17 at 7:45 p.m., reflected Resident #10 was in her room self transferring from her wheelchair to her bed, mental status prior to the fall: was confused, agitated, forgetful, footwear/assistive device at time of fall: shoes, Resident room observations: call light functioning, call light within reach, last toileted 1 hour prior, resident interview: I was going to get into bed and my feet got all tangled up. CNA statement Resident fell asleep in wheelchair and fell out due to leaning forward, Nursing Statement: poor safety awareness, attempted self transfer, Immediate Interventions implemented post-fall to prevent future falls remind resident not to self transfer, to call for assist, ensured call light in reach and functioning properly, Post-fall review by IDT: Therapy to focus on vertigo. Review of Post-Fall Investigation dated 7/22/17 at 5:00 a.m., reflected Resident #10 was in her room in bed, responding to toileting need, mental status prior to fall: alert and confused, environmental factors at time of fall: poor lighting, footwear/assistive device at time of fall: none, Resident interview It's my knees that give out, and I guess I should have pushed that button to call you, Nursing statement confusion, forgetting to use call light, muscle weakness, Immediate interventions implemented Post-fall to prevent future falls: Assessed for injuries initiated Assisted to bathroom-noted to be steadier on feet than at bedtime. Post-Fall Review by IDT Night shift to offer AM assistance if awake. Review of Post-Fall Investigation dated 7/28/17 at 3:00 p.m., reflected Resident #10 was in her room in bed, sleeping got self up and slid out of bed, mental status prior to fall alert to self, confused, agitated, environmental factors at time of fall: not normal naptime, footwear/assistive device at time of fall: none, resident room observations: incontinent: urine, call light within reach, sleeping prior to fall, toileted prior to lunch, Immediate interventions implemented post-fall to prevent future falls: reviewed care card, educated to staff to resident care card, will keep wheelchair at bedside, post fall review by IDT, sleep study x 72 hours. In an observation on 8/1/17 at 2:35 p.m., this surveyor was called to room 201 by Resident #10, she was sitting in her wheelchair dressed with rubber soled slippers, 15 feet from her bed. The call light was on the side of the bed. Resident #10 stated I been waiting for someone to come and put me to bed, they just made the bed, but didn't come back, I am (name). Can you help me, just push that button over there. she pointed to the call light on the bed. At 2:45 p.m. the surveyor left the room Licensed Practical Nurse (LPN) R was at her nursing cart. LPN R reported that Resident #10 was very confused and staff reassured her and assisted her to a common area. During an interview on 8/2/17 at 12:50 p.m., CNA V reported that Resident #10 tried to self transfer all the time, you had to keep an eye on her, and remind her not to transfer herself. CNA V reported that she would keep Resident #10 where she could see her and redirect her to activity or snacks if she would start to self propel somewhere. During an interview on 8/2/17 at 3:16 p.m., CNA FF reported that Resident #10 gets up in her room on 3rd shift often, without alarms preventing and alerting she takes herself to the bathroom often on her own, even with frequent checks. During an interview on 8/2/17 at 2:55 p.m., Restorative Aid (RA)MM reported that Resident #10 was impulsive, had very little carry over for safety, would not recall 5 minute later to push the call light prior to getting up, and visual aids did not help. RA MM reported that recommendations were made that Resident #10 wear grippy socks at all times, the bed be at hip height, not low, and that Resident #10 be kept in a visual area where she was visual to staff.

This citation pertains to MI 697. Based on observation, interviews, and record review, the facility failed to provide supervision to prevent a fall with injury for 1 resident (#104) and provide supervision to prevent multiple falls without injury and implement and evaluate interventions to prevent falls for 1 resident (#103) of 5 residents reviewed for falls, from a total sample of 7 residents, resulting in right fractured ribs 10 and 11 and a fractured lumbar vertebra for Resident #104 and 13 falls without injury for Resident #103. Findings include: Resident #104 Based on the Minimum Data Set (MDS) assessments, dated 7/5/15 and 10/5/15, Resident #104 was an [AGE] year old moderately cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the MDS dated [DATE] Resident #104 required one staff assistance for transfers, toileting and ambulation. The same assessment reflected a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. Fall Risk assessments dated 7/16/15 and 8/27/15 reflected Resident #104 was at moderate risk for falls with scores of 11 and 10 respectively. A score of 10 or greater indicates a risk for falls. The care plan titled I am high risk for falls ., dated 1/12/14 and revised on 6/22/15, reflected the intervention, dated 6/22/15, Ambulation: 1 staff assist with gait belt and 2 wheeled walker as resident is able to tolerate. The care plan titled I have impaired cognition . reflected the intervention, dated 4/17/15, I have a gait belt in my room that is used when I transfer. The Resident Care Card, used by CNAs when giving care reflected Resident #104 was to have contact guard assist (assisting staff with hands on the Resident/gait belt) and gait belt with transfers and ambulation using a 2 wheeled walker. Review of the facility policy Safe Resident Lifting, Transferring, and Handling, dated 11/18/13 and reviewed 2/17/13, reflected under Available Lifting Devices: Gait Belts are to be used in all resident transfers unless medically contraindicated as assessed and written in the care plan and resident care guide by the nurse. The gait belt provides a secure firm hold to stabilize and manage residents during ambulating and transfers and is a reminder of our 'hands off' techniques. (Never lift a resident by the arms, hands or under the arms.). Review of a facility incident report, dated 9/24/15 at 4:45 PM, reflected a Certified Nursing Assistant (CNA) (identified by the facility as CNA A) was assisting Resident #104 to stand from her wheelchair while the Resident was holding onto her walker. Based on the incident report, Resident #104 had a gait belt (canvas belt applied around the waist and held onto by staff during transfers/ambulation to assist with balance) on and immediately upon standing the Resident lost her balance and fell backwards resulting in severe pain in the lower back, right hip, leg and side and mild pain in the back of her head. The above report reflected Resident #104 stated I stood up to start walking and just fell over. My legs don't work right. Based on the nursing progress notes dated 9/24/15, Resident #104 was transferred to the emergency room for evaluation and returned with the [DIAGNOSES REDACTED]. On 10/27/15 at 4:21 PM, CNA A was interviewed and stated that on 9/24/15 the CNA was preparing to assist Resident #104 to walk to the dining room for dinner. CNA A stated she applied a gait belt around Resident #104's waist and held onto it with both hands while standing behind the Resident while the Resident stood up from her wheelchair holding onto her walker. CNA A stated Resident #104 was wobbly and let her stand to get her balance and Resident #104 said the CNA could let go of the gait belt. CNA A stated that as soon as she took her hands of the gait belt Resident #104 plopped over to the right side between the chair and the stand with the radio on it hitting her head and back on the wall. CNA A stated that normally she would have had one hand on the gait belt and one on the wheelchair following Resident #104 as she walked with the walker. CNA A stated Resident #104 did not always allow the CNA to hold the gait belt as it made her (Resident #104) paranoid and the CNA had notice no problems with Resident #104's balance prior to the fall. CNA A stated Resident #104 had increased difficulty getting up after the fall. On 10/27/15 at 8:40 AM, Resident #104 was observed in her wheelchair in her room putting on a sweatshirt. When asked if she had had any falls in the last two months Resident #104 had no recollection of any falls. On 10/28/15 at 4:30 PM, Team Leader (TL) Registered Nurse (RN) B stated CNA A had been counseled to always have a hand on the gait belt as ordered on the Resident Care Card. During the same interview, Clinical Rehabilitation Manager C stated that when contact guard assist is prescribed as an intervention staff should always have their hands on the gait belt worn by the resident. Both staff B and C agreed the facility policy for gait belt use had not been followed by CNA A during the fall for Resident #104 on 9/24/15. Resident #103 Based on the Minimum Data Set (MDS) assessments, dated 8/7/15 and 9/7/15, Resident #103 was an [AGE] year old moderately cognitively impaired male whose [DIAGNOSES REDACTED]. Resident #103 was admitted to the facility on [DATE] following a rehabilitation at another facility. Based on both MDS assessments, Resident #104 required staff assistance for transfers, toileting and ambulation. A Brief Interview for Mental Status (BIMS) score of 4/15 on the 8/7/15 MDS indicated severe cognitive impairment. The staff assessment of mental status on 9/7/15 was 2 indicating an improvement to moderate cognitive impairment. Twelve Fall Risk assessments dated between 8/1/15-10/9/15 reflected Resident #103 was at high risk for falls with scores between 17-30. A score of 10 or greater indicates a risk for falls. Resident #103 was observed propelling himself in his wheelchair throughout the unit on 10/27/15 at 1:00 PM and 10/28/15 at 12:00 noon and 4:40 PM. Review of the nursing progress notes and facility incident reports from 8/1/15-10/29/15 reflected 13 falls without injury; 1) 8/3/15 at 6:00 AM-found on the floor next to the bed. Resident stated he had to go to the bathroom. Interventions were a laser motion sensor on the right side of the bed and toileting at 11:00-11:30 PM and 7:00 AM, 2) 8/4/15 at 8:00 PM-on buttocks on the floor at the bedside. Resident stated he didn't know what happened. Intervention was every 30 minute checks. 3) 8/5/15 at 12:30 AM-Resident observed sliding out of bed to floor mat. Resident wanted closet door shut, alarms sounding. Interventions on 8/6/15 after review of 8/4 and 8/5 falls were to discontinue ineffective 30 minute checks, soft touch call light, bed extension to increase space at the end of the bed and an evening snack related to low blood sugar levels at night. 4) 8/7/15 at 8:20 AM-found on floor on back at bedside with a red mark on the back of his head. Resident #103 was sent to the emergency room for evaluation. There was no incident report for this fall and the Antigravity Form reflected alarms were in place and not sounding.The Interdisciplinary Team (IDT) Summary on the form reflected Interventions not in place at time of fall. Recommend coaching and mentoring with assigned staff related to rounds (CNA shift to shift report given at the bedside so residents are observed and care given as needed) and pressure and laser alarms being in place. 5) 8/18/15 at 3:30 AM- on knees at bedside, Resident did not know what he was trying to do. The intervention was a larger (bariatric) bed. 6) 8/22/15 at 8:00 PM-on floor at bedside. Report reflected Resident has poor safety awareness and agreed to wait for assistance before self transferring. IDT intervention was to assist to bed after evening snack. 7) 8/23/15 at 1:57 PM on floor in bathroom after left alone. IDT intervention was to not leave Resident alone in the bathroom. CNA was counseled related to supervision of Resident #103 in the bathroom. 8) 9/6/15 at 6:20 PM-lowered to the floor during a transfer related to bed wheels not being locked. IDT intervention was staff education on use of manual brakes on the bariatric bed. 9) 9/7/15 at 3:00 AM-found on floor with sheet and bed pad behind his back. Resident had a temperate of 99.4 degrees Farenheit. The Resident was sent to the hospital by 8:00 AM with a temperature of 102.7 degrees. Intervention was adding a non-skid pad (Dycem) under the floor mat to prevent it from sliding, 10) 9/22/15 at 6:07 PM-found on the bathroom floor. Resident stated he was trying to stand up. IDT interventions were physical and occupational therapy for strengthening and a bathroom door sensor. 11) 10/1/15 at 4:15 AM-found on floor at bedside after overhead calling out for help. Resident stated he was trying to go to the bathroom. IDT interventions were staff education on checking alarms, toileting every 2 hours and monitoring for a urinary tract infection. 12) 10/5/15 at 4:05 PM-found on floor at bedside. IDT intervention was to have Resident out of bed by 3:00 PM if laid down in the afternoon. 13) 10/9/15 at 2:11 AM-found on floor at bedside. IDT intervention was to initiate hourly checks from 7:00 PM-7:00 AM for 3 days to figure out a pattern. Six falls occurred on the 10:30 PM-6:30 AM shift, two on the 6:30 AM-2:30 PM shift and five on the 2:30-10:30 PM shift. Review of the nursing progress notes reflected Resident #103 was attempting to transfer himself without assistance on 8/9/15 at 12:14 PM, 8/20/15 on the day shift, 8/24/15 on the night shift, 8/27/15 and 8/29/15 on the day shift, and 9/1/15 on the afternoon shift. The progress notes on 8/26/15 at 10:15 PM reflected Resident #103 did not always use the call light and on 10/4/15 3:04 PM, the progress notes reflected poor safety awareness and impulsivity with transfers. The care plan for impaired mobility with high risk related to a history of falls, stroke and aphasia (difficulty forming words), dated 8/1/15 and reviewed on 10/12/15, reflected Resident #103 required one-two staff assist for transfers, a low bed with floor mats, a bed alarm (all on 8/1/15), laser monitor at right side of the bed, bed extender (to increase length of bed) and soft touch call light added on 8/5/15, evening snack of peanut butter, graham crackers and chocolate milk added 8/6/15, assist to bed after evening snack around 8:00 PM and do not leave alone in the bathroom added 8/24/15 and make sure bed brakes are locked and wheels are turned inward to prevent unlocking added on 9/6/15. The interventions for toileting at 11:00-11:30 PM and 7:00 AM from 8/3/15, toileting every 2 hours from 10/1/15 and the bathroom door alarm from 9/22/15 were not on any care plan. The Resident Care Guide (RCC), undated, included the following interventions; bed alarm, wheelchair alarm, motion sensor on right side of bed, Dycem (non-skid material) under right side floor mat, bed in lowest position when occupied, soft touch call light, keep assist rails down unless in use, bed extender, assist to bed after evening snack, evening snack of one peanut butter and one package of graham crackers with chocolate milk, one person assist for transfers to strong left side, do not leave alone on toilet and toilet every 1.5 hours. On 10/28/15 at 3:00 PM, TL RN D stated the current RCC had been recopied on 10/12/15 and the previous RCC could not be located. It was unknown if the interventions for toileting at 11:00-11:30 PM and 7:00 AM from 8/3/15, toileting every 2 hours from 10/1/15 and the bathroom door alarm from 9/22/15 were on the previous RCC. There was no bathroom door alarm observed at anytime during the survey between 10/26/15/and 10/29/15. On 10/29/15 at 10:20 AM the above falls were reviewed with the Interim Director of Nursing, TL RN B and TL RN D. TL RN B stated there was no documentation available that supported Resident #103 being toileted at 11:00-11:30 PM and 7:00 AM between 8/3/15 and 10/1/15 as prescribed on IDT intervention. TL RN D stated it was unclear from the available documentation for the 8/7/15 fall whether the alarms were not in place or not turned on. The Coaching and Mentoring Forms for two CNAs, dated 8/7/15, reflected the alarms were not turned on. On 10/28/15 at 2:30 PM TL RN D was asked if Resident #103 should have been left alone in the bathroom on 8/23/15 at 1:57 PM she answered probably not. On 10/29/15 at 10:20 AM TL RN D stated it was unclear by the fall documentation whether Resident #103's alarms were functioning on 10/1/15 at 4:15 AM but based on the fact that a sweep of all alarms in the facility was conducted she surmised the alarms were not functioning. In addition, TL RN D stated the IDT had not really addressed the fact that Resident #103 frequently attempted to transfer himself from the wheelchair to the bed when he was alone in his room. On 1/28/15 at 2:30 PM TL RN B stated that when she and TL RN D had visited Resident #103 in his previous facility they had recognized he would be at an increased risk for falls related to his cognition and the transition to a new facility. TL RN B stated that during the visit with Resident #103 at the previous facility he would appear to be engaged in the conversation then suddenly attempt to stand up to address a need he had, even with family present. On 10/28/15 at 2:30 PM, Activity Director (AD) E stated the facility had attempted to keep Resident #103 busy with activities and he had attended some groups. AD E also stated the family was here for some meals and would read to him. In addition, he was in therapy during the day for many weeks. On 10/29/15 at 10:45 AM, AD E stated Resident #103 had just started attending some group activities after daily therapy had stopped. AD E also stated activities that Resident #103 could do individually would usually require someone to sit with him to assist him. AD E stated activity supplies were available on the unit and the activity staff were in the building until 5:00 PM five days a week and until 8:00 PM two days a week. The Activity Attendance Record reflected one to one visits and family/friend visits as the primary activity from 8/1/15-10/23/15. One to one visits were documented on 9 of 31 days in 8/2015, 11 of 24 days in 9/2015 and 7 of 28 days in 10/2015. Group activity attendance did not begin until 10/24/15. The facility policy Injury/Fall Prevention Program, dated 3/6/14, reflected in the Post Fall Protocol section item 4. The licensed nurse will complete a incident report . This was not done for the 8/7/15 fall. The Post Fall Review section of the same policy reflected that a comprehensive review would be completed the IDT for each resident who falls and the IDT would complete the Antigravity review form. This was not done for the falls on 8/4/15, 8/5/15 and 8/7/15. ( )

This citation pertains to intake number MI 511 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall, for 1 out of 4 sampled residents (Resident # 503), out of a total sample of 4 residents, resulting in Resident #503 falling and obtaining a left hip fracture. Findings include: Per the facility face sheet Resident #503 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14. The MDS revealed Resident #503 required limited assistance for transfers and ambulation. Review of incident reports revealed Resident #503 had a fall on 2/3, 3/9, 3/28, 4/4, 4/6, 4/7 times 2, 4/9, 4/11, 4/19, 4/23, 4/24, 4/26 times 3, with the first fall occurring at 2:15 PM, the second at 4:00 PM, and the last one at 6:15 PM when Resident #503 was transferred to the hospital for left knee pain. Review of an incident report dated 4/26/2013 revealed Resident #503 complained of left knee pain. The report revealed that Resident #503 was ordered to be sent to the emergency room for evaluation. Review of hospital records revealed a physician progress notes [REDACTED].#503 had a fracture of her left hip. The note revealed that Resident #503 was admitted to the hospital for surgical repair of the left hip. Review of a care plan originally dated 1/28/2015 revealed an intervention dated 4/24/2015 for Resident #503 to be in view of staff when out of her room. The care plan also revealed that Resident #503 was not put on 1:1 supervision until 4/28/2015 upon her return from the hospital, and after the fracture of her left hip. In an interview on 5/19/2015 at 10:00 AM, Director of Nursing (DON) #1 said Resident #503 had wheeled herself from the dining area of the unit to her room. DON #1 said Resident #503's care plan reflected that Resident #503 needed to be in a common area while up in her wheelchair for supervision. DON #1 said when Resident #503 was in her room she was to be put down into her bed. In an interview on 5/19/2015 at 10:35 AM, Certified Nurse Aid (CNA) #2 said she had taken Resident #503 to the dining room table that was located in Resident #503's unit. CNA #2 said she was sitting at the table with Resident #503 and another resident. CNA #2 said that she and a nurse were the only two staff on the floor at the time due to meal time in the main dining room. CNA #2 said the other 2 CNAs were in the main dining room at the time. CNA #2 said two residents had returned from the meal in the main dining room, when they both turned their call lights on for assistance to the bathroom. CNA #1 said when she went to assist the other two residents no other staff members were around to watch Resident #503. In an interview on 5/19/2015 at 11:35 AM, Registered Nurse (RN) #3 said it was during the supper meal that Resident #503 was at the table in the unit. RN #3 said she could not remember what she got up for, but stated that she got up to do something and left Resident #503 alone without any other staff in the unit dining area. RN #3 said she was aware Resident #503 was at the dining table. RN #3 said Resident #503 should not have been left alone while sitting out in the unit at the dining table. Observation of the unit and dining area Resident #503 lived on was conducted on 5/19/015 at 10:35 AM. It was observed that the table Resident #503 sat at was directly across from Resident #503's room and in view. It was also observed that the 2 rooms call lights that CNA #2 had answered were behind a wall that contained a fire place, and therefore blocked a direct view to Resident #503 ( )

This citation pertains to intake number MI 527. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices (fall alarms turned on and functioning) in 3 of 4 sampled residents (#101, #103 and #104), resulting in Resident #101 having a fall with a Fractured Cervical Vertebra (C 2 neck fracture) after a self-transfer and her fall alarm was turned off and Resident #103 and #104 being observed with their fall alarms turned off on 10/16/12 resulting in the potential for serious injury. Findings include: Resident #101 Review of the closed, clinical record Face Sheet revealed Resident #101 was a [AGE] year old woman, who was admitted to the facility on [DATE] from the hospital where she was treated for [REDACTED]. Review of the Physician orders [REDACTED].#101 and to check her every 15 minutes. Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was cognitively impaired (Brief Interview of Mental Status was 3 out of 15), had [DIAGNOSES REDACTED]. Review of the fall risk assessment dated 9/18/12, revealed Resident #101 was a high risk for falls. Review of the Care plan dated 8/15/12 under the problem titled, "Impaired Mobility with high risk related to recent fall and fractured humerus and Dementia", revealed an intervention for Resident #101 to be provided a "Wheelchair alarm". Review of the Nurse Aide Resident Care Card dated 8/16/12 under the section titled, "Safety" was marked with an X, "Wheelchair Alarm", which indicated Resident #101 required the placement of an alarm on her wheelchair. Review of the Facility's incident reports dated 9/3/12 at 1:25 PM, revealed Resident #101 fell when attempting to self-transfer out of bed. On 9/15/12 at 2:19 PM, Resident #101 was found on the floor. Incident report dated 10/11/12 at 6:30 PM revealed Resident #101's roommate's husband came to the nurse's desk to report Resident #101 was on the bathroom floor. The report documented Resident #101 had a bloody nose, was restless and would not lay still or stay on the floor and she tried to get up herself. Review of the handwritten Nurse's notes for Resident #101 dated 10/11/12 at 6:30 PM and signed by Licensed Practical Nurse (LPN) #3 revealed Visitor #1 came to the nurse's desk to inform her that Resident #101 was on the floor in the bathroom. LPN #3 documented she went into the bathroom and saw Resident #101, on the floor with her pants half down, on her right side, bleeding from her nose. LPN #3 wrote she "checked her over for injuries and took her vital signs but she would not lay still and wanted to get up. Vital signs recorded as blood Pressure 187/76 (normal 120/80), Pulse 121 (normal 60-100) and Respirations 22 per minute (normal 16-20). LPN #3 said she and another Nurse got Resident #101 off the floor and onto to the toilet. LPN #3 said the other nurse stayed with Resident #101 and she went back to the desk to call the Assistant Director of Nursing (RN #11), the Physician, the Ambulance and Family. LPN #3 wrote Neurological tests were started and continued until the ambulance arrived. LPN #3 wrote Resident #101 did not complain of any pain until after she was transferred to bed. At that time she complained of neck pain. Review of the Neurological Assessment Record dated 10/11/12 revealed Resident #101's first recorded Neurological test was at 6:32 PM and were taken and every 15 minutes until 7:15 PM, due to the ambulance did not arrive until 7:15 PM (45 minutes after Resident #101 was observed on the floor with head injuries). Review of the transfer record dated 10/11/12 at 7:15 PM revealed Resident #101 was transferred to the hospital due to head injuries from a fall in the bathroom. In an interview on 10/16/12 at 2:35 PM, LPN #3 said she worked on 10/11/12 on the 3-11 Shift and was the Nurse in charge of Resident #101 and also was orientating LPN #7. LPN #3 said between 6:00 PM and 6:15 PM she observed Resident #101, in the common area, attempting to stand and LPN #3 said she told Resident #101 a couple times to "stay sitting". LPN #3 said she did not check Resident #101's fall alarm to assure that it was on and functioning. LPN #3 said she then went to a different hall to do a Respiratory treatment that took her 15 minutes. LPN #3 said there were no staff visible, in the common area where she left Resident #101 at approximately 6:15 PM. LPN #3 said at 6:30 PM, she was sitting at the Nurse's station charting when Resident #102's Husband (Visitor #1) approached her and said Resident #101 was on the floor. LPN #3 said she went into Resident #101's bathroom and found Resident #101 on the bathroom floor with her nose bleeding and asking to get up and to urinate. LPN #3 said she took a wash cloth to Resident #101's nose because blood was dripping all over. LPN #3 said Resident #101 kept asking to get up and attempting to get up so she and LPN#7 lifted Resident #101 from the floor to the toilet without a gait belt. LPN#3 said she took Resident #101's vital signs and said her pulse was high (121 beats per minute). LPN #3 could not remember her other vital signs. LPN #3 said Resident #101's wheelchair alarm was not sounding and it was in the off position when she checked it after the fall. In an interview on 10/18/12 at 9:30 AM, LPN #7 said she was a new nurse and worked on 10/11/12, the 3-11 shift and was orienting with LPN #3. LPN #7 said at 6:30 PM, a gentleman (Visitor #1), came out of Resident #101's room and said Resident #101 was on the floor, in the bathroom. LPN #7 said she and LPN #3 went in right away and observed Resident #101 on the bathroom floor. LPN #7 said she needed to move the wheelchair to get into the bathroom. LPN #7 said the fall alarm for Resident #101 was not sounding. LPN #7 said Resident #101 was on her stomach, and a little on her right side and she had a bloody nose. LPN #7 said Resident #101 had blood all over her hand and hair. LPN #7 said Resident #101 was asking to get up so LPN #3 said to get her up and the two of them lifted Resident #101 onto the wheelchair, then onto the toilet. LPN #7 said they got her vital signs when she was on the toilet and LPN #3 left to make calls and she stayed with Resident #101, who appeared to be hurt but was saying she wasn't in pain then after about a minute she complained of neck pain. LPN #7 said Certified Nurse Aide (CNA) #4 transferred Resident #101 to bed while she was at nurse's desk. LPN #7 said she went back to Resident #101's room and stayed with her until the ambulance came. LPN #7 said LPN #3 came in the room one time, and said we probably shouldn't have moved her. LPN #7 said she did not write a statement but DON #2 interviewed her. In an interview on 10/16/12 at 3:20 PM, CNA #4 said she worked a double shift on 10/11/12 and was assigned to Resident #101. CNA #4 said she took Resident #101 to supper around 5:00 PM. CNA #4 said she took Resident #101 to the bathroom about 4:45 PM and turned her alarm off while she was on the toilet. CNA #4 said Resident #101 urinated and had no idea why her alarm was off when she fell at 6:30 PM because she "always had the alarm on". In an interview on 1016/12 at 3:50 PM, CNA#5 said she worked on 10/11/12 the 3-11 shift. CNA #5 said she did not take care of Resident #101 but took Resident #102 to the bathroom before 6:30 PM and saw Resident #101 in the common area near the nurse's desk. CNA #5 said she went on her supper break at 6:30 PM and when she returned at 7:00 PM she found out Resident #101 had fallen in the bathroom. CNA #5 said she did not turn Resident #101's fall alarm off and did not check her fall alarm at all that evening. CNA #5 said she did not hear any alarms just before 6:30 PM on 10/11/12. Review of the Facility's every 15 minute checks for Resident #101 dated 10/11/12 revealed from 6:00 PM until 7:15 PM in 15 minute increments was written "in unit" with no signatures or initials and no indication that Resident #101 was in bed or in the bathroom as indicated on the prior lines. This Surveyor requested all October Nurse's notes for Resident #101 from the Director of Nursing (DON) #2. Review of the closed record electronic nurse's notes dated 10/11/12 for Resident #101 revealed no documentation after 1:55 PM which was written, "spoke with family in regards to residents general decline. Family requesting hospice evaluation and admittance if appropriate. Doctor (named DO #12) called and order given for hospice to evaluate and admit if appropriate. Face sheet given to Hospice intake." Review of the Hospital Emergency record dated 10/11/12 (no time), revealed Resident #101 presented to the emergency department with complaints of a fall. Review of the Emergency Department Course revealed the Orthopedic Surgeon and spine surgeon on call discussed and agreed to a transfer to the hospital where the Surgeon was available. Resident #101 was placed in a Miami J collar (neck immobilizer) and transferred to a second hospital in stable condition. According to the report Resident #101 had bruising over her chin and her neck was tender to palpation. Review of the Hospice Discharge Record dated 10/15/12 revealed Resident #101 was admitted on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 10/18/12 at 11:10 AM, Medical Director of Hospice (DO) #12 stated, when asked if Resident #101 had an autopsy said, "I don't think so. Not that I'm aware of." When asked what the cause of death was DO #12 said, "General Debility, Failure to thrive." DO #12 said Resident #101 was seen by an Orthopedic Surgeon and Spine Surgeon, however the family thought because she was [AGE] years old she was too frail for surgery and she wasn't paralyzed. DO #12 said when she came to Hospice she had a "little bit of pain" but she didn't eat or drink. DO #12 said Resident #101 was dying before the fracture happened. Resident #103 Review of the Face Sheet revealed Resident #103 was an [AGE] year old woman, admitted to the facility on [DATE]. Review of the fall risk assessment dated [DATE], revealed Resident #103 was a high risk for falls. Review of the Care plan dated 10/3/12 under the problem titled, "Impaired Mobility with high risk related to increased pain due to cervical spine injury, weakness and poor balance", revealed an intervention for a wheelchair alarm. During an observation on 10/16/12 at 12:45 PM, while in the dining room, Resident #103's wheelchair fall alarm was noted to be turned off. In an interview on 10/16/12 at 12:45 PM, Registered Nurse (RN) #9 (Team Leader), said Resident #103's wheelchair alarm should have been turned on and she did not know why it was off. Resident #104 Review of the Face Sheet revealed Resident #104 was a [AGE] year old man, admitted to the facility on [DATE]. . Review of the fall risk assessment dated [DATE], revealed Resident #104 was a high risk for falls. Review of the Care plan dated 9/4/12 under the problem titled, "I am high risk for falls related to poor safety awareness, decreased mobility, impaired balance and history of falls", revealed an intervention for wheelchair alarm to be on at all times. During an observation on 10/16/12 at 12:36 PM, while in the dining room, Resident #104's wheelchair fall alarm was turned off. In an interview on 10/16/12 at 12:36 PM, RN #9 stated Resident #104's wheelchair alarm should have been turned on and she did not know why it was off. #

This citation pertains to intake MI 781 Based on observation, interview, and record review the facility failed to ensure residents were free from abuse in 1 of 29 sample residents (Resident #125), from a total of 29 sampled resulting in physical pain and emotional distress evident when the resident to refuse a shower days due to fear. Findings include: Record review of a facility "Admission Record" dated 04/07/2011 and a Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #125 was a [AGE] year old woman originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of stroke), anxiety and depression. Resident #125 required extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toileting, and personal hygiene. A Brief Interview for Mental Status (BIMS) score for Resident #125 was 13 out of 15, indicating she was cognitively intact. Record review of a "Facility Investigation Report-5 Working Days" dated 9/30/2011 revealed Resident #125 alleged Certified Nurse Aide (CNA) #46 had been rough during transfers, intentionally sprayed her in the face with a shower nozzle and lifted her bad arm twice and the resident complained of pain both times. The investigation revealed other resident's have stated they don't enjoy showers given by CNA #46 and often will refuse showers when CNA #46 is giving them. During an interview conducted during the facility investigation by the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #21, on 9/26/2011, CNA #46 denied anything had occurred during the shower she gave Resident #125. A second telephone interview on 9/29/2011, conducted by the ADON and RN # 37, CNA #46 was able to recall she did hear Resident #125 say 'Ouch' twice, once when she washed under her lame arm, and again when she dried her off. CNA #46 explained the was spraying up when she rinsed the resident's shoulders off with the shower nozzle and the resident put both her hands up to protect her face. The facility terminated CNA #46 on 9/30/2011, as a result of progressive disciplinary action and for not reporting to the charge nurse Resident #125's complaint of pain. During an interview on 10/05/2011 at 2:10 p.m., Resident #125 stated a black shower aide wearing a turban turned a hose on her face at full force when she asked to have her face washed and that she also pulled her right arm up during the shower causing the resident pain. Resident #125 said, "She pulled my arm way up and I said 'Ouch!' and then she did it again, it happened two times!" Resident #125 reported the aide was rough and 'stuck up' when she had to get out of bed. Resident #125 demonstrated the action by placing her left hand on her right forearm and could only lift her right arm a few inches away from her body and was unable to reach her face with her right hand. During the resident's account of the incident, she sighed, clenched her hands together, was shaking her head from side to side, looked away from the surveyor and furrowed her brow, and appeared to demonstrate anxiety, frustration, anger and helplessness. An interview on 10/12/2011 at 12:20 PM, CNA #33 revealed she was the first staff member to learn about the incident. She worked from 2:30 PM to 11:00 PM and learned Resident #125 had been asking for her all day. CNA #46 had gone home for the day at 1:30 PM and was no longer in the facility. CNA #33 reported Resident #125 was upset and fearful about making a complaint because she was worried CNA #46 would retaliate. An interview on 10/12/2011 at 11:15 AM, RN #37 stated she had interviewed Resident #125 on 9/25/2011, a day after the incident, and Resident #125's statement remained consistent. RN #37 also reported Resident #125 had a negative reaction when approached a few days later by another aide for a shower. When asked by this surveyor if it was unusual for Resident #125 to refuse showers, RN #37 stated, "Yes, that's what convinced us something must have happened." An interview on 10/12/2011 at 11:30 AM, Social Worker #20 revealed she had interviewed Resident #125 a day after the incident on 9/25/2011 and her report of the incident was consistent with what had been reported to CNA #33 and RN #37. An interview on 10/12/2011 at 12:30 PM, Licensed Practical Nurse (LPN) #34 reported it was unusual for Resident #125 to refuse a shower. When asked to describe what CNA #46 looked like, she stated she was a tall, medium build African-American woman with medium brown skin, with short hair that she would often cover with a scarf. In an interview on 10/12/2011 at 12:45 p.m., CNA #35 stated she had worked at the facility for 8 years and had cared for Resident #125 on several occasions. When asked to describe how she showers Resident #125, she stated she very carefully lifts her right arm at the elbow, and only far enough to tuck a hand under her arm for cleaning and drying. CNA #35 reported Resident #125 is 'pretty with it' and can tell you what she wants. CNA #35 stated that she had been caring for Resident #125 a few days after the incident and was surprised when the resident refused to have a shower. CNA #35 immediately reported the resident's refusal to LPN #34 who advised her to reproached the resident a little later. When asked if it was unusual for the resident to refuse a shower, CNA #35 stated, "Yes. She had never refused a shower that I can recall. I was worried about her and when I asked her again if she wanted a shower, she asked me if I was going to be giving it. When I told her that I was, she said she would have a shower." In an observation of the shower room where the incident occurred on 10/12/2011 at 12:45 PM, in the presence of RN #23, a shower chair was noted in the shower area and a hand held nozzle with several feet of hose was secured in a handle on the wall. RN #23 was asked by this surveyor to turn the water on full force. The water was found to be gentle yet full. The handheld nozzle did not have adjustable settings and it appeared unlikely there would be a significant 'over spray' or splash back as described by CNA #46. RN #23 also reported that it could not have been that the resident was getting water in her face from a shampoo because she rarely washed her hair in the shower, preferring to have it done by the beautician at the facility every other week. A review of a facility policy "Freedom from Abuse and Neglect" last revised 8/2011, reflected that "it is the facilities policy to prohibit the mistreatment of [REDACTED]. Residents will be cared for in a manner free of verbal, mental, sexual, or physical abuse or neglect of any kind." Several attempts were made on 10/12/2011 to contact CNA #46 via telephone and she could not be reached.