Every finding on record at L.M.C.- Extended Care

Based on staff interview, record review, and policy review, the facility failed to provide adequate supervision and assistive devices for one of seven residents identified at risk for falls. Specifically, Resident (R)103, who was assessed as a fall risk, sustained a fall on 04/10/26 while an agency staff was providing care, resulting in a closed, displaced comminuted fracture of the right femur and a closed comminuted supracondylar fracture of the left femur.The findings include: Review of the facility's policy titled, Activity Daily Life, prepared and approved on 06/24/26, revealed that residents were to receive individualized assistance with activities of daily living in a manner that promoted safety, independence, quality of life, care, and dignity. This policy applied to all staff involved in the direct care of residents.Review of the facility's policy titled, Incident and Accident Reports, prepared and approved on 02/27/18, revealed that the facility had a system in place to monitor, record, and implement measures to prevent and minimize accidents and incidents. The procedures outlined in the policy included, but were not limited to conducting treatments, ongoing assessments and monitoring, timely notification, documentation, event analysis, trending, and implementing corrective actions or remedies as needed to achieve desired outcomes. In addition, staff development was responsible for reviewing all Incident Reports and Medication Error Forms to identify areas requiring follow-up.Review of R103's clinical record revealed an admission date of 05/26/23. The resident's admitting diagnoses include cerebrovascular accident (CVA), hemiplegia following CVA affecting the right (dominant) side, muscle weakness, osteoarthritis, and abnormal posture. Review of the most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/3/26, completed prior to the fall, revealed that no Brief Interview for Mental Status (BIMS) score was documented. The MDS identified that R103 had both short and long-term memory impairment but exhibited no mood issues or behavioral symptoms. A range of motion impairment was identified in one upper extremity and both lower extremities. The resident was totally dependent on staff for oral hygiene, toileting, bathing, dressing, footwear, and personal hygiene. The assessment indicated the resident required substantial to maximal assistance for rolling left to right, meaning staff provided more than half of the effort and held the trunk or limbs. The resident did not perform any sit-to-lie, sit-to-stand, chair or toilet transfers, and was totally dependent for tub transfers. The resident was always incontinent of bowel and bladder. The assessment noted that the resident had experienced no falls since admission or readmission.Review of Physician Orders revealed an order dated 03/24/25 for the top side rails to be raised on both sides to define bed boundaries. Review of R103's Activity of Daily Living care plan, with a start date of 05/26/23 and a revision date of 02/18/26, revealed that the resident's interventions included use of top side rails on both sides to assist with bed mobility and positioning. The care plan also specified that the resident required one-person assistance for bed mobility. In addition, the care plan assigned bath days on Tuesdays and Fridays between the hours of 7:00 PM and 7:00 AM.Review of the facility's Fall Five-Day State Report Investigation, dated 04/15/26 at 9:15 PM, revealed that Certified Nursing Assistant (CNA) 1 was performing a bed bath with the bed in the low position and was positioned on the opposite side, behind the resident. When the resident began to slide off the bed, the CNA reported moving to the other side to try to prevent the fall. According to the CNA, the resident did not hit her head. The CNA called for assistance from the doorway. When the nurse entered the room, the resident was found lying on her right side on the floor next to the bed. The nurse assessed the resident and found no apparent bruising, and vital signs were stable. Additional assistance was requested from other CNAs to help return the resident to bed. The supervisor was notified at 9:21 p.m., and the responsible party was notified at 9:23 PM. No bruises were observed during the body audit, and the nurse was unable to determine if the resident was experiencing pain due to the resident being nonverbal.Further review of Physician Orders revealed on 4/10/26, R103 was transferred to the emergency room for evaluation after the fall. Review of the Surgical Discharge/Transfer Summary Note dated 04/20/26 revealed the Active Hospital Problems: Closed comminuted supracondylar fracture of shaft of right femur and Closed comminuted supracondylar fracture of left femur.Interview with Register Nurse (RN) 2, who was the Unit Manager of [NAME] Place, on 08/25/26 at 11:40 a.m., revealed that R103 sustained a fall during care. The Unit Manager stated that the resident had no prior history of falls and assumed the resident was close to the edge of the bed when the incident occurred. She further indicated that CNA1 should have requested assistance when turning and providing care to the resident.An Interview with Assistant Director of Nursing (ADON) #1 on 8/25/26 at 12:45 p.m. revealed that the facility would not provide their fall investigation for review, stating it was a protected document.An attempted telephone interview with agency CNA1, on 8/26/26 at 4:35 PM revealed that CNA1 answered the telephone and identified herself, then she refused to be interviewed regarding the incident. An interview with Licensed Practical Nurse #1 (LPN) #1, on 8/26/26 at 4:50 PM, revealed that she was working the night shift on 04/10/26 when the resident fell. The LPN stated she was employed full-time at the facility during this period but was no longer employed there. She was familiar with the R103's care needs and reported no knowledge of any prior falls. She stated the resident was able to move her non-dominant hand, but she had not observed any movement of the resident's lower extremities. LPN1 recalled being on the unit when the CNA alerted her to the resident's fall. She was unsure if the upper side rails were in the raised or lowered position at the time. Upon entering the room, she found the resident lying on the right side of floor.An Interview with CNA2, on 8/28/26 at 8:20 AM, revealed she had been employed as a CNA for 35 years and had worked at [NAME] Place for 4 years. CNA2 stated she was familiar with R103 since the time of admission. The CNA stated that two staff members were required for transfers because the resident requires a full-body lift. She noted that the resident will resist care from unfamiliar staff and only uses her left hand to move a blanket or push a hand away. The resident was unable to turn herself and did not move her lower extremities. The CNA stated the resident has not previously fallen and that personal hygiene could be provided by one staff member. She explained that staff were trained to provide care to residents assessed as requiring substantial to maximal assistance (where the helper provides more than half the effort and supports the trunk or limbs) by positioning themselves on the side of the resident to act as a shield to prevent sliding or falling out of bed. She further stated that staff were also trained to request assistance from other staff members to ensure resident safety.On 8/28/26 at 8:40 AM, during an interview with the ADON who covered Palmetto Land, Lexington Trace, Crews Pointe, [NAME] Place, and [NAME] Way, ADON 1 stated she was responsible for investigating falls with fractures, including reporting to the State within 24 hours and completing a 5-day follow-up. Her investigation process included speaking with the resident if possible, reviewing employee and nurse statements, and seeking clarification if statements were unclear. Regarding the investigation involving R103 the ADON reviewed the state report and noted the CNA's statement indicated she was giving a bed bath, possibly standing on the opposite side of the bed, but the statement did not specify how the resident fell or whether side rails were up. The ADON stated that, as part of her investigation, she checks for details such as the position of side rails, but this information was missing from the report and statements. She emphasized that staff were trained to keep side rails up during care for bed mobility, to position the patient toward themselves, and to request assistance if needed. Staff were also trained to avoid working in a bed that was too low to prevent injury to themselves and residents. On 8/28/26 at 8:55 a.m., during an interview with the Infection Control nurse, who also assisted with staff development and orientation, stated she has been in this role since 2019. She explained that while she does not personally train agency CNAs on the unit, she provides classroom orientation using a skills checklist. She stated that agency staff begin their orientation with staff development and were instructed to seek assistance if needed. For turning residents, staff were instructed to turn the resident toward themselves (not away), using their own body as a shield to prevent falls, and to keep the bed at waist level for safety.The Infection Control nurse emphasized that for dependent residents, proper technique was essential to prevent falls. She identified possible causes of a dependent resident falling from bed as lack of adequate surface area or room during turning, and the resident's inability to control their torso or limbs.

Based on review of facility policy, record reviews, and interviews the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within two hours for 1 Resident (R)21 of 6 sampled residents reviewed for abuseReview of a facility policy titled, Standard Policy/Procedure, approved 10/21/22, revealed the section titled, DHEC [Department of Health and Environmental Control] Certification and the facility Administrator shall be notified immediately but not later than 2 hours after alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property are made if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R21's Face Sheet revealed the facility admitted R21 on 11/22/24. According toR21's Face Sheet, the resident had a medical history that included diagnoses of depression, cognitive communication deficit, transient ischemic attack, cerebral infarction, and malignant neoplasm of the left breast and brain.Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/25, revealed R21 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial assistance with most activities of daily living (ADLs) except the resident required partial/moderate assistance with upper body dressing and set-up help with eating.R21's Care Plan included a problem statement dated 07/09/25, that indicated the resident required the use of psychotropic/psychoactive medications for diagnoses of depression and glioblastoma brain cancer. Interventions initiated 03/11/25 directed staff to observe and document any changes in cognitive status, which included changes in mood and behavior (i); provide support and monitor for psychosocial concerns; and schedule a psychological consult as needed.R21's Care Plan, included a problem statement dated 06/16/25, that indicated the resident had the potential for behaviors related to a diagnosis of glioblastoma, which included refusal of baths/showers, refusal of meals, making sexual comments about themself and their spouse, delusions, and fabricated stories about staff. Interventions directed staff to approach the resident in a calm and non-threatening manner (initiated 02/17/25); do not place the residentnear another resident who may increase agitation, behavior, and mood (initiated 02/17/25); redirect the resident if they express sexual comments or are aggressive or combative and try to channel the resident in constructive physical and social activities as needed (initiated 03/05/25); two staff members to assist with ADL care (initiated 06/06/25); and redirect and reassure the resident when the resident states, Make sure that resident doesn't get in my bed, when nobody was in their room (initiated 06/13/25).Review of a Five-Day Follow-Up Report, dated 06/10/25, revealed R21 had reported allegations of physical and sexual abuse. The Five-Day Follow-Up Report indicated Certified Nursing Assistant (CNA)1 and Licensed Practical Nurse (LPN)2 were the alleged perpetrators. The Report indicated that on 06/06/25 R21 reported some concerns to Social Worker (SW)12, and SW12 brought LPN8 with her to hear what the resident had to say. R21 stated that they had been talking to a staff member's boyfriend, everyone was talking about it, the staff member learned that R21 was talking to the staff member's boyfriend, and the staff member pinched R21 while providing care. During the investigation of physical abuse, the Assistant Director of Nursing (ADON) 5, who was the Abuse Coordinator, and the Staff Development Director interviewed R21, where R21 repeated the physical abuse allegation and added an allegation of sexual abuse. During this interview, R21 stated that a week or two prior, when the resident used their call light for assistance to be changed, the boyfriend came to their room and while changing the resident's brief fondled the resident. When ADON5 asked R21 the boyfriend's name the resident was unable to state the name; however, R21 described the boyfriend and stated he was a nurse. LPN2 was suspended.The facility's investigation file for R21 did not include an initial report related to the allegation of sexual abuse that was made on 06/09/25. During an interview on 07/24/25 at 11:50 AM, ADON5 stated that she did not submit an initial report regarding R21's second allegation of sexual abuse involving LPN2. ADON5 stated R21 made the allegation on 06/09/25 during the follow-up interview for the Five-day Report, and she considered it to be part of the original allegation. During an interview on 07/25/25 at 4:01 PM, the Administrator stated that usually the initial report was completed immediately within two hours, but they had combined the second allegation of abuse with the first allegation and considered them one investigation. The Administrator stated the Ombudsman was at the facility on the day the Five-Day Report was sent in, and the Ombudsman thought that it was acceptable to mention the second allegation on the Five-Day Report. During an interview on 07/25/25 at 4:44 PM, the Director of Nursing (DON) stated the initial report should be sent within two hours.

Based on review of facility policy, record reviews, and interviews the facility failed to complete a thorough investigation for allegations of staff-to-resident abuse for 1 Resident (R)21 of 6 sampled residents reviewed for abuse. Specifically, the facility investigation did not include staff interviews from the unit where the resident resided.Review of a facility policy titled, Standard Policy/Procedure, approved 10/21/22, revealed the section titled, DHEC [Department of Health and Environmental Control] Certification and the facility Administrator shall be notified immediately but not later than 2 hours after alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property are made if the events that cause the allegation involve abuse or result in serious bodily injury.Review of R21's Face Sheet revealed the facility admitted R21 on 11/22/24. According toR21's Face Sheet, the resident had a medical history that included diagnoses of depression, cognitive communication deficit, transient ischemic attack, cerebral infarction, and malignant neoplasm of the left breast and brain. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/25, revealed R21 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial assistance with most activities of daily living (ADLs) except the resident required partial/moderate assistance with upper body dressing and set-up help with eating. R21's Care Plan included a problem statement dated 07/09/25, that indicated the resident required the use of psychotropic/psychoactive medications for diagnoses of depression and glioblastoma brain cancer. Interventions initiated 03/11/25 directed staff to observe and document any changes in cognitive status, which included changes in mood and behavior (i); provide support and monitor for psychosocial concerns; and schedule a psychological consult as needed. R21's Care Plan, included a problem statement dated 06/16/25, that indicated the resident had the potential for behaviors related to a diagnosis of glioblastoma, which included refusal of baths/showers, refusal of meals, making sexual comments about themself and their spouse, delusions, and fabricated stories about staff. Interventions directed staff to approach the resident in a calm and non-threatening manner (initiated 02/17/25); do not place the resident near another resident who may increase agitation, behavior, and mood (initiated 02/17/25); redirect the resident if they express sexual comments or are aggressive or combative and try to channel the resident in constructive physical and social activities as needed (initiated 03/05/25); two staff members to assist with ADL care (initiated 06/06/25); and redirect and reassure the resident when the resident states, Make sure that resident doesn't get in my bed, when nobody was in their room (initiated 06/13/25). Review of a Five-Day Follow-Up Report, dated 06/10/25, revealed R21 had reported allegations of physical and sexual abuse. The Five-Day Follow-Up Report indicated Certified Nursing Assistant (CNA)1 and Licensed Practical Nurse (LPN)2 were the alleged perpetrators. The Report indicated that on 06/06/25 R21 reported some concerns to Social Worker (SW)12, and SW12 brought LPN8 with her to hear what the resident had to say. R21 stated that they had been talking to a staff member's boyfriend, everyone was talking about it, the staff member learned that R21 was talking to the staff member's boyfriend, and the staff member pinched R21 while providing care. During the investigation of physical abuse, the Assistant Director of Nursing (ADON) 5, who was the Abuse Coordinator, and the Staff Development Director interviewed R21, where R21 repeated the physical abuse allegation and added an allegation of sexual abuse. During this interview, R21 stated that a week or two prior, when the resident used their call light for assistance to be changed, the boyfriend came to their room and while changing the resident's brief fondled the resident. When ADON5 asked R21 the boyfriend's name the resident was unable to state the name; however, R21 described the boyfriend and stated he was a nurse. LPN2 was suspended. The facility's investigation file for R21's allegations of abuse included statements from the two alleged perpetrators, CNA1 and LPN2, and written statements from SW12 and LPN8 related to the interview they conducted with the resident. The facility's investigation included 20 signed statements from the residents who lived on the same unit as R21. The facility's investigation file did not include any interviews from other staff who had recently worked on the unit where R21 lived. During an interview on 07/24/25 at 11:50 AM, ADON5 stated as far as staff interviews, she only interviewed the alleged perpetrators, CNA1 and LPN2. ADON5 stated SW12 and LPN8 wrote statements about what R21 reported to them concerning the allegation. During an interview on 07/24/25 at 2:16 PM, SW12 revealed she wrote a statement about her interview with R21. During an interview on 07/25/25 at 4:01 PM, the Administrator stated that after an allegation they normally interviewed the staff who were present on the shift. The Administrator stated she felt some staff interviews may have been missing. During an interview on 07/25/25 at 4:44 PM, the Director of Nursing (DON) stated she expected the staff to be interviewed who worked on the unit where the allegation was made.

Based on interview and record review, the facility failed to refer Resident (R)4 for a Preadmission Screening and Resident Review (PASARR) Level II, after the resident received a new diagnosis of a severe mental illness, for 1 of 2 residents reviewed for PASARR.Review of R4's Face Sheet indicated the facility admitted R4 on 09/30/2019. According to the Face Sheet, the R4 had a diagnosis of bipolar disorder, dated 07/30/21. Review of R4's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/25, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated R4 had a diagnosis of bipolar disorder. Review of R4's Care Plan, included a problem statement started 12/12/2023, that indicated the resident had diagnoses of a cardiovascular accident (CVA), bipolar disorder, anxiety, and dementia that required the use of psychotropic/psychoactive medications. Interventions directed staff to administer medications as ordered; approach the resident in a calm, non-threatening manner; observe and document any changes in cognitive status, including changes in mood and behavior necessitating medications; observe for side effects; provide comfort measures and distractions prior to administering as-needed medications; provide support and monitor for psycho-social concerns; schedule psychiatric consultations as needed and follow-up as indicated; and review medications monthly and as needed, provide medication trial reductions every six months and as needed. A South Carolina Department of Health and Human Services PASARR Level I Screening Form, dated 09/23/19, indicated R4 had no diagnosis of a mental illness. During an interview on 07/24/25 at 11:00 AM, the Director of Nurses (DON) stated the hospitals were responsible for completing the Level I PASARRs, and if they needed to be updated the facility's social services took care of that. During a follow-up interview on 07/25/25 at 11:59 AM, the DON stated R4's original admission date was 09/30/19, and their mental illness diagnosis after admission should have been updated on the Level I PASARR and resubmitted to the state. The DON indicated that she had a new Director of Social Services who was responsible for the process currently. During an interview on 07/25/25 at 12:10 PM, the Administrator stated the Level I PASARR for R4 should have been updated with the new mental illness diagnosis and resubmitted to the state.

Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)191's medical record included documentation they were offered the pneumonia vaccine for 1 of 5 sampled residents reviewed for immunizations.Review of a facility policy titled, Immunization, dated 05/1123, specified, [Facility Name] will offer the pneumonia immunization at admission if there is no history of prior immunization; and immunize against pneumonia unless medically contraindicated or immunization is refused by the resident or the resident's legal representative. Review of R191's Face Sheet revealed the facility admitted R191on 02/23/24. According to R191's Face Sheet, the resident had a medical history that included diagnoses of dementia and chronic obstructive pulmonary disease. Review of R191's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/25, revealed R191had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Review of R191's Continuity of Care Document, created 07/25/25, revealed no indication the resident had a pneumococcal immunization. During an interview on 07/25/25 at 11:26 AM, the Infection Preventionist (IP) stated she looked at the immunization record of residents when they were admitted to the facility and paid close attention to the Centers for Disease Control (CDC) guidance about pneumonia vaccines. The IP stated she did not have the pneumonia vaccine consent for R191 as the consent was mailed out. The IP stated that R191 not receiving the pneumonia vaccine was a significant failure. During an interview on 07/25/25 at 1:07 PM, the Director of Nursing (DON) stated that a consent or a refusal for a vaccine came from the resident or the responsible party if the resident was not their own person. The DON stated a letter, and education was sent to the responsible party, and the responsible party would either mail the consent back to the facility or drop it off when they visited the resident. The DON stated the facility would continue to try to reach out to R191's responsible party to obtain the consent. The DON stated her expectation was for the consent to be done and the follow-up to be completed.

Based on review of the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)3 was treated with respect and dignity when Licensed Practical Nurse (LPN)2, used profanity in and/or around the resident's presence. Findings include: Review of the facility policy titled Abuse/Neglect/Misappropriation/Elder Abuse, last revised 10/21/22, states: .All staff is expected to be in control of their own behavior, behave professionally and appropriately, and understand how to work with the nursing home population. Any substantiated incident will result in employee discipline, which may include termination from the job. Review of R3's Face Sheet revealed, R3 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, severe with agitation, osteoarthritis, anxiety disorder, type 2 diabetes mellitus with hyperglycemia, and disorientation. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/24 revealed R3's Brief Interview for Mental Status (BIMS) could not be assessed due to being rarely/never understood. Review of R3's care plan with a revision date of 03/27/25, revealed, Potential for behavior problems [Related to] r/t dx unspecified dementia with behaviors as evidenced by [History] hx eloping from home, altercation with other residents, combative with staff, packs up her belongings, declines [Activities of Daily Living] adls and weights .02/09/23- Resident has become aggressive and combative every morning with staff providing care. Review of Certified Nurse Aide (CNA)1's Witness Statement Form dated 03/02/25 revealed, I was giving care to another resident when I heard some noise next door. I step in the doorway and see the nurse (LPN2) fighting with the resident (RM120) . He then mumbled something about her children, and she said if he messed with me or my children, she was going to f--- him up. I called [CNA2] to witness what was going on, and we both checked on the resident to see if she was alright and she said again that if he messed with her kids (her dolls), she was going to f--- him up, and she was breathing hard and was upset. We wrote statements and reported to the supervisor . Two attempts were made to contact CNA1 on 04/08/25 at 11:09 AM and 11:18 AM, which were unsuccessful. A detailed message was left for a return phone call. Review of LPN1's Witness Statement Form dated 03/02/25 revealed, To whom it may concern: This morning during shift change, CNA2 came into the supervisor's office and handed me 2 handwritten statements. I read the statements, then asked CNA2 to tell me what he saw aloud, he stated the same as his statement that he overheard the nurse LPN2, call the resident [R3] a b----. I called the unit LPN2 was assigned to, Palmetto Lane, to find out if he was still in the building. He was handing his assignment over to the oncoming shift. I instructed him to come to the supervisor's office immediately. When he came in the office, the oncoming supervisor and I questioned him about the alleged events, he stated he may have said something under his breath. We informed him that he was suspended pending the investigation and that he would have to leave the building immediately. He signed his suspension paperwork and wrote his statement then exited the facility. The [Director of Nursing] DON and [Assistant Director of Nursing] ADON were notified via phone. The dayshift supervisor and I went to the patient's room to ensure her safety and interview her r/t the alleged events. Resident was sitting up in bed eating her breakfast in pleasant mood. Body Audit completed. Notes collected. [Resident Representative] RP was notified via phone call. On call [Medical Director] MD notified, no new orders. Public safety notified and case number requested. During a phone interview on 04/08/25 at 2:11 PM, LPN1 confirmed her witness statement. According to LPN1, the resident could not recall the incident and was unable to describe exactly what happened. Review of CNA2's Witness Statement Form dated 03/03/25, revealed, At around 0600, on Palmetto Lane, I was waived over to RM120 due to some commotion between the resident and the assigned nurse [LPN2]. I didn't hear the entire conversation, but I clearly heard him call the resident a b---- because he was trying to wrassle her arm for blood sugar, and she refused. Followed up with the resident for her safety . During a phone interview on 04/08/25 at 3:24 PM CNA2 confirmed her witness statement. CNA2 stated that was the first occurrence he witnessed with LPN2 and the resident. CNA2 stated that LPN2 sounded annoyed because he could not obtain a finger stick. Review of LPN2's staff file revealed a Suspension Anecdotal Record for Misconduct dated 03/02/25 revealed, supporting details: report of possible abuse situation, witnessed by 2 staff members. Supervisor Recommendation: Immediate suspension, pending investigation. Review of LPN2's Discharge Anecdotal Record for Misconduct dated 3/13/25 revealed, [LPN2], on 03/02/25, you were suspended pending investigation of an alleged abuse. During the seek to understand, you stated that you may have used profanity words in the presence of the residents; two witnesses overheard you cursing at or around a resident. To ensure all employees share in their responsibility for keeping the facility in full compliance with all applicable laws, regulations, and policies governing business practices. You have violated this code of conduct by not keeping with the basic principles and standards of behavior expected in the workplace. This is a violation of our Service Expectations policy. [LPN2] is being released from Lexington Medical Center Extended Care immediately for violation of policy. During an interview on 04/08/25 at 11:40 AM, RN1 stated, the perpetrator (LPN2) was asked what happened and was informed he was going to be suspended pending investigation. RN1 stated that LPN2 made a broad statement and stated he was attempting to get a blood sugar on the resident and that she had spilled juice on him. RN1 stated that LPN2 was dumbfounded and was unaware of what the situation was. RN1 further stated the resident was assessed, she was fine, no injuries, and didn't remember what the situation was. RN1 stated she was unsure what happened to the perpetrator, and to her knowledge, he did not return. During an interview on 04/08/25 at 11:53 AM, the DON stated, on 03/02/25, staff reported an alleged abuse to the supervisor, stating a nurse called a resident b----. The DON stated she spoke with the alleged perpetrator, and he stated the resident became resistant and combative and was grabbing and pulling on his lab coat. LPN2 stated he was trying to encourage her to be compliant with her blood sugar and offered her apple juice to distract her. The resident slapped the juice out of the LPN2's hand, knocking it all over him causing a startled reaction mumbling Son of a B---- under his breath. The DON stated she spoke to the witnesses, and both stated they heard the perpetrator call her b---. [LPN2] was suspended and let go for customer service concerns. During an interview on 4/08/25 at 4:24 PM, the Facility Administrator (FA) stated, LPN2 could not recall what he mumbled under his breath in front of a resident, LPN2 thought he said, Son of a b----. The FA stated that either way, staff overheard him use the word' b----. FA stated they were unsure if [LPN2] directed it at [R3] or said it aloud. Regardless, he should not use that language in front of residents. He was terminated for customer service concerns. During an interview on 04/08/25 at 4:29 PM, the Social Worker (SW) revealed she had knowledge of the event. The SW stated the Unit Manager and supervisor told her that a reportable was made, and she needed to follow up on it. The SW stated she followed up with the resident for three days. The resident is not alert and oriented, and she stated she was doing well and spoke with staff but didn't report anything new. The SW stated she asked the resident what occurred, and she could not recall for all three days what happened with the staff member. Three attempts were made to contact LPN2 on 04/08/25 at 12:32 PM, 12:37 PM and 1:10 PM, all which were unsuccessful. A detailed message was left for a return phone call.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a privacy bag was provided to Resident (R)178's catheter bag, for 1 of 5 residents reviewed. The deficiency disregarded the resident's privacy, dignity, and respect and had the potential to cause psychosocial harm. Findings include: Review of the facility's policy titled, Standard Policy/Procedure with Subject: Catheterization of Female/Male with an approved by date of 07/13/12, revealed, Procedure- 4. Explain the procedure to the patient. Perform hand hygiene. Maintain the patient's privacy and dignity. Review of R178's Face Sheet revealed R178 was admitted to the facility on [DATE], with diagnoses including but not limited to: paroxysmal atrial fibrillation, depression, chronic combined systolic (congestive) and diastolic (congestive) heart failure, retention of urine, acute respiratory failure with hypoxia, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, and essential (primary) hypertension. Review of R178's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out 15, indicating R178 is cognitively intact. Review of R178's Physician Orders dated 06/12/24, indicated, Indwelling catheter/suprapubic, 18 FR/10 ml, for urinary retention. During an observation on 06/18/24 at 12:21 PM, R178's foley catheter bag was observed without a privacy bag in R178's room. During an observation on 06/20/24 at 10:14 AM, R178's foley catheter bag, still did not have a privacy bag. During an interview on 06/20/24 at 10:16 AM, Certified Nursing Assistant (CNA)9 revealed the bag should be covered when the resident is up in the chair. CNA9 did not know if the foley catheter bag should be covered when the resident is in the bed. CNA9 confirmed that R178's foley catheter bag was not covered. During an interview on 06/20/24 at 10:19 AM, Licensed Practical Nurse (LPN)9 verified that to maintain dignity for a resident with a foley catheter a privacy bag would be used. This would be used no matter where the resident is located, either in their room or outside their room. During an interview on 06/20/24 at 10:22 AM, LPN9 verified that R178's foley catheter bag was not covered. During an interview on 06/20/24 at 10:49 AM, Registered Nurse (RN)3 stated that to provide dignity to a resident with a foley catheter, the bag should be covered. During an interview on 06/20/24 at 11:02 AM, the Assistant Director of Nursing (ADON) stated staff expectations would be to provide a dignity bag for any residents with a foley catheter. It was confirmed that the dignity bag for privacy should be in place whether the resident is inside or outside of their room.

Based on record review, facility policy review, and interviews, the facility failed to ensure Resident (R)73 and R96 had a physician's order for the code status of 2 of 5 residents reviewed for Advance Directives. Findings include: Review of the facility's policy titled, Do Not Resuscitate (DNR) with an approved by date of 09/08/23, revealed, Procedure: 1. On admission, the Social Worker will determine the desires of the resident and responsible party related to the DNR status. 2. The Social Worker/Speech Therapist will establish resident cognitive status by completing the BIMs tool. 3. If the resident or his/her legal representative wishes to initiate a DNR order, the Code Status form and Emergency Medical Services DNR order will be initiated. 4. If the resident is not considered their own responsible party and has a BIMS score of =<12, then the responsible party as well as two physician signatures are required to establish DNR status. 5. If the resident is considered competent and has a BIMS score of =>13 then only one physician's signature is required. 6. A written order will be obtained from the physician. The physician will sign the Code Status form at this time. 1. Review of R73's Face Sheet revealed R73 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia and generalized anxiety disorder. Review of R73's Physician Order initially revealed no order for Code Status. Further review of R73's Physician Order revealed an order with a start date of 06/19/24, which documented, CODE STATUS: DNR. The order for code status was updated during the survey. 2. Review of R96's Face Sheet revealed R96 was admitted to the facility on [DATE], with diagnoses including but not limited to: depression. Review of R96's Physician Order initially revealed no order for Code Status. Further review of R96's Physician Order revealed an order with a start date of 06/19/24, which documented, CODE STATUS: DNR. The order for code status was updated during the survey. During an interview on 06/19/24 at 9:26 AM, the Assistant Director of Nursing (ADON)1 stated all residents are considered full code upon admission until a code status can be determined. Orders should be completed on the same day as the Code Status form. The ADON1 reviewed R73's chart and did not see the DNR order listed, although there was a signed Code Status Form and the banner indicated DNR. The ADON1 asked Licensed Practical Nurse (LPN)2 to review the orders section and LPN2 stated I don't see it. During an interview on 06/19/24 at 10:57 AM, the ADON1 stated she had spoken to the Director of Nursing (DON), who was out sick, and no order is written for full code residents. The Administrator stated that the Code Status form served as the physician's order and Medical Doctor (MD) had 30 days to write the order. The Administrator then reported that the order for R73 was able to be found, but in review, the order was created on 06/19/24 at 10:23 AM (during the survey).

Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)20 was free from verbal abuse for 1 of 4 residents reviewed for abuse. Findings include: Review of the facility policy dated 10/21/22 and titled Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Responsibilities/Obligation to Report revealed under the policy, Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability. Examples include threats of harm or saying things to frighten a resident. Review of the facility Customer Service Training, no date, titled, Excellent Customer Service Matters, Internal vs. External revealed under the training, Going above and beyond to ensure customers are happy and satisfied with their products and services. It involves being timely, pleasant, and efficient, and building strong relationships with customers. It also means exceeding expectations, rather than just meeting them. Residents were listed as the first customers in a list of who are our customers. Under Customer Service Attitude, revealed under the training, Your voice, tone, word usage. It's not what you say, but how you say it, and body language. Review of R20's Face Sheet revealed the facility admitted R20 on 09/09/22 with diagnoses including but not limited to: essential hypertension, muscle weakness, anemia, chronic systolic congestive heart failure, and mild dementia. Review of R20's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/24, revealed R20 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. Review of R20's Progress Note dated 04/17/24 at 5:15 PM, revealed, Nurse Supervisor: Notified by daughter that resident called her and was upset. During an interview on 06/19/24 at 1:55 PM, R20's daughter stated, My mom called me and she was mad. She told me an aid told her, She wished she would go home and die. I called the facility right after and I think I spoke to the head nurse. I don't remember the facility calling me back with their findings. During an interview on 06/19/24 at 2:20 PM, the Interim Director of Nursing (IDON) stated, The CNA no longer works here due to customer service. She was not reported for abuse. During an interview on 06/19/24 at 3:00 PM, the Social Worker (SW) stated, I remember this. Something happened with the CNA saying some words to [R20]. I also interviewed [R20], she was able to tell me what the staff member said and what she looked like, I knew who the perpetrator was by her description. A few days later, [R20] was still able to recall what the CNA had said to her. This was verbal abuse, demoralization, and putting the resident down. During an interview on 06/19/24 at 4:24 PM, Licensed Practical Nurse (LPN)1 stated, I took the call that day, it was [R20's] daughter. She asked for the nurse manager. She said, my mom called me and said someone came in her room and said, I wish you would go home and die. I put her on hold and went to [R20's] room. [R20] repeated what her daughter said. I came back up the hall, spoke to her daughter and told her that her mom repeated what she had told her. I then contacted the nursing supervisor who was still here, so I transferred the phone to her. The resident said, I think its the CNA who was behind me when I went to her room. I've not known [R20] to complain like that. During an interview on 06/20/24 at 11:45 AM, IDON stated, We do not tolerate abuse. We have to report to our supervisor, ensure the patient is safe. We would remove the person from the building and immediately begin in-services and investigation. We will call the board if the person is found guilty, we report to the agency responsible for licensing. During an interview on 07/03/24 at 2:03 PM, the Director of Nursing (DON) stated, The 3-11 supervisor got a phone call from [R20's] daughter. It was reported to her the CNA said she should just die and get out of here. We went ahead and decided it was a reportable and I decided to send the CNA home. [R20] had never reported anything to that extent. After reviewing her file, I noted this is a trend here with poor customer service. So we decided to go ahead and terminate her. It's hard to say if it happened, but there was a trend here. I don't know if she was just burned out or what. She was terminated for poor customer service. During an interview on 07/03/24 at 2:28 PM, Supervisor Registered Nurse (RN) stated, I got a phone call from [R20's] daughter. She said she had a few concerns. One was they were trying to get her (mom) in bed and get her in her pajama's and she did not want to change into them then. She went on to say her mom said, the CNA told me Why don't you just leave and die. I went down to the unit and spoke to [R20]. She was laying on the bed, she again repeated what her daughter said, almost verbatim, Why don't you just leave and die. It occurred at 5-5:30 PM. I discussed this with my DON. The CNA was suspended. The CNA told me she had gone to the resident, to put her in her pajama's and she refused and she put her in bed without changing into her pajama's. The CNA did not know it, but I had already spoke to [R20], she told me the exact same thing, it matched exactly. [R20] was so clear about it. For her to tell me almost verbatim says something. During an interview on 07/03/24 at 3:10 PM, R20 stated she could not remember what happened, but said, The facility took care of it. During an interview on 07/03/24 at 2:58 PM, the CNA stated she was terminated for customer service, and also stated, I did not say that to her.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure medications were properly stored for Resident (R)73 for 1 of 2 residents reviewed. Findings include: Review of the facility policy titled, Subject: Medication Guidelines with an approved by date of 04/25/23 revealed, Policy: Medications are given per physician's order to treat resident's acute and chronic illness. Handling of Non-Controlled Medication: 28. Residents may self-administer a medication based upon physician order, self-administration assessment completed by nurse and review and approval by the interdisciplinary team which determines appropriateness. Review of the undated facility policy titled, Self-Administration of Medications revealed, A. Policy: The facility shall permit residents who are competent and physically able to self-administer their medications if the following conditions are met: 1. Self-administration of medications by residents is permitted only on the specific written orders of the resident's physician or other legally authorized prescriber and documented in the resident's medical record . B. Procedure: 1. Residents who request approval to self-administer shall be assessed by the interdisciplinary team to determine if the resident is competent. 2.The interdisciplinary team will assess the resident's cognitive, physical, and visual ability to carry out this responsibility. Facility staff may use the medication self-administration form (Form #161) or a facility developed mechanism to document this assessment. If the team determines that the resident is competent, the attending physician shall be contacted to request a specific order for self-administration of the medication. 3. If the resident demonstrates the ability to self-administer medications, a further assessment of the safety of the bedside medication storage shall be done. Bedside medication storage is only permitted when it does not present a risk to confused residents who wander into the rooms of or who room with residents who self-administer. 5. Medications stored at bedside shall be secure from other residents. The medications provided to the residents for bedside storage are kept in containers dispensed by the provider pharmacy. Self-administration of medications by residents is verified by direct contact with the resident by a licensed nurse and recorded on the MAR by that same person. Verification and documentation shall occur at the same frequency as the medication is taken. The MAR will reflect self-administration orders and will be addressed in the care plan. Facilities may elect to prohibit self-administration. The facility shall not allow residents to self-administer controlled substances. Review of R73's Face Sheet revealed R73 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia and generalized anxiety disorder. Review of R73's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/05/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R73's cognition is intact. During an observation on 06/18/24 at 1:29 PM, Systane Hydration drops (a medication is used to relieve dry, irritated eyes) was on the overbed table in the emesis basin. During an interview on 06/18/24 at 1:39 PM, Licensed Practical Nurse (LPN)10 verified there were no order for the Systane Hydration drops. LPN10 also verified the medication in R73's room and stated, It's eye drops. R73 stated, I have no idea where it came from. You can buy them over the counter at the drug store. LPN10 removed the medication and asked if the resident would allow her to check the drawers. Upon opening the top drawer, LPN10 retrieved Tums Chewy Bites Assorted Berries Extra Strength 750 mg. During an interview on 06/20/24 at 12:38 PM, the Assistant Director of Nursing (ADON)1 stated medications should not be left at the bedside. If the resident is able to self-administer medications, they must be assessed to ensure self-administration is appropriate. Next, the physician would be notified for an order. The ADON1 confirmed that even over the counter (OTC) medications should not be left at bedside even if they are not ordered for the resident. It was confirmed that it is not acceptable for the family to leave medications at the bedside and if observed the nurse should check the drawers in the resident's room as an intervention. The medications would need to be removed and education would be needed for the resident and or family.

Based on review of facility policy, record review, observation, and interview, the facility failed to proper store and label respiratory equipment for 3 of 5 residents reviewed for respiratory care, Resident (R)73, R99, R263. Findings include: Review of the facility's policy titled, Subject: Oxygen Therapy Protocol with an approved by date of 05/12/11, revealed, Protocol: 1. The Oxygen Protocol will be initiated on residents by a written order from the physician for any type of oxygen therapy . Routine Oxygen Administration and Documentation: .Documentation will be done by nursing on the Medication Administration Record . Review of R73s Face Sheet revealed R73 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia and generalized anxiety disorder. Review of R73's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/05/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R73 was cognitively intact. Review of R73's Medication Administration Record (MAR) for 06/01/24 - 06/18/24, revealed an order: O2 @ 2L VIA NASAL CANNULA at rest and may increase to 3L with activity D/T HYPOXIA and Shortness of Breath and Change O2 tubing and humidifier bottle weekly on Sunday. Review of R73's Care Plan with a start date of 05/30/24, documented, Problem: Potential for alteration in respiratory status r/t hypoxia. Documented goal, Will be free of complications r/t disease process through next review. Documented approach revealed, O2 as ordered. Monitor O2 sats and keep above 90%. Review of R73's Physician Order with a start date of 06/04/24 documented, O2 @ 2L VIA NASAL CANNULA at rest and may increase to 3L with activity D/T HYPOXIA and Shortness of Breath and another physician order with a start date of 05/30/24, documented, Change O2 tubing and humidifier bottle weekly on Sunday. During an observation on 06/18/24 at 1:29 PM, R73 was observed with oxygen at 3L/min via NC, however the oxygen tubing was not labeled. An oxygen tank was also observed across from the bed in a holder with tubing that was not covered. During an observation and interview on 06/18/24 at 1:39 PM, Licensed Practical Nurse (LPN)10 confirmed that oxygen tubing was not labeled. LPN10 also confirmed that the oxygen tank in its holder should not have tubing hanging from the holder but instead should be covered. During an interview 06/20/24 at 12:36 PM, the Assistant Director of Nursing (ADON)1 stated the oxygen tubing is changed every week on Sunday and tubing should be dated. Review of R99's Face Sheet revealed R99 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia pulmonary hypertension, chronic diastolic (congestive) heart failure, unspecified atrial fibrillation, anxiety disorder, other specified chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of R99's Admission MDS with an ARD of 06/12/24, revealed a BIMS score of 14 out of 15, indicating R99 was cognitively intact. Review of R99's MAR for 06/01/24 - 06/20/24, revealed an order for O2 2L via NC at HS for hypoxia with an order date of 06/06/24. Review of R99's Care Plan with a start date of 06/06/24 documented, Problem: Potential for alteration in respiratory status r/t acute on chronic resp failure, pna, copd, osa and pulmonary htn. Documented goal revealed, Will be free of complications r/t disease process through next review. Documented approach revealed, O2 AS ORDERED. MONITOR O2 SATS AND KEEP ABOVE 90%. Review of R99's Physician Order with a start date of 06/06/24 documented, O2 2L via NC at HS for hypoxia. During an observation on 6/18/24 at 1:45 PM, R99's oxygen was at 2L/min. via NC. Oxygen tubing was observed not dated. During an observation and interview on 06/18/24 at 1:52 PM, oxygen was observed at 2 L/min via nasal canula, and tubing was not dated. LPN10 confirmed that tubing was not dated. R99 stated that oxygen tubing was changed on Sunday night. LPN10 confirmed that the tubing should have been dated when changed. During an interview 06/20/24 at 12:36 PM, ADON1 stated the oxygen tubing is changed every week on Sunday and tubing should be dated. Review of R263s Face Sheet revealed R263 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and shortness of breath. Review of R263's Admission MDS with an ARD of 05/13/24, revealed a BIMS score of 15 out of 15, indicating R263 was cognitively intact. Review of R263's MAR for 06/01/24 - 06/20/24, revealed an order for Change nebulizer tubing and administration set every Sunday. Special Instructions: on night shift; ensure machine is covered with a bag when not in use. Review of R263's Care Plan with a start date of 06/10/24 and target date of 06/30/24 documented, problem Potential for alteration in respiratory status r/t COPD, asthma, OSA, emphysema. Documented goal revealed, will be free of complications r/t disease process through next review. o2 at 2L min via NC. Documented intervention revealed, o2 as ordered. Monitor o2 sats and keep above 90%. Review of R263's Physician Order with a start date of 06/07/24 documented, Change nebulizer tubing and administration set every Sunday. Special Instructions: on night shift; ensure machine is covered with a bag when not in use. During an observation on 06/18/24 at 11:30 AM, the nebulizer mask was observed to be dated for 06/09/24 and in a bag. During an observation on 06/20/24 at 10:24 AM, the nebulizer mask was observed to be dated for 06/09/24 and not in bag. During an interview on 06/20/24 at 10:26 AM, LPN8 verified that the resident had an order for nebulizer treatments and the medication had been administered this morning. LPN8 stated that the mask should be kept in a bag daily and tubing and mask was to be changed weekly. The mask should be rinsed after each use then placed in a bag. LPN8 verified order to change nebulizer mask weekly on Sunday. During an interview and observation on 06/20/24 at 10:40 AM, Registered Nurse (RN)3 reported that nebulizer masks and tubing is changed on Sundays on nightshift. Staff should take a new mask/tubing set to the room and be sure to dispose of the previous mask/tubing set to complete the ordered task. Once the new mask/tubing is replaced the nurse performing the task should date the tubing. RN3 stated that the date should reflect either 06/16/24 or 06/17/24 depending on the time the task was completed on nightshift. Upon entering the room, RN3 confirmed that the mask was not in the bag and the date on the mask was 06/09/24. RN3 stated that it looked like the mask/tubing was not changed on last Sunday. RN3 verified on the administration history that a nurse signed on 06/16/24 as completing the task. During an interview on 06/20/24 at 11:05 AM, the Assistant Director of Nursing (ADON)1 and ADON2 verified that the nebulizer mask/tubing is changed weekly usually on Sunday and as needed. ADON1 confirmed that during the task of changing the mask/tubing, the staff is to write the date on the mask. 50085

Based on facility policy review, observation, and interview, the facility failed to label/store and ensure medications were not expired for 3 of 4 units observed for medication storage. Findings include: Review of the facility policy titled, Nursing Medication Guidelines dated [DATE], revealed under the policy, Medication labels must be correct and legible, check medications for expiration dates and return to the pharmacy. Review of the facility policy titled, Medication Storage dated ,d+[DATE], revealed under the policy, The temperature of the refrigerators containing medication shall be maintained between ,d+[DATE] degrees F. On [DATE] at 9:10 AM, an observation of [NAME] Place Unit Medication Room with Registered Nurse (RN)2 revealed the medication refrigerator checklist dated [DATE] had 5 days that the refrigerator temperature was not checked, they were blank. The blank dates were [DATE], [DATE], [DATE], [DATE] and [DATE]. RN2 confirmed the dates were blank. RN2 stated, I was off on some of these dates. I am the one who checks these. Further observation revealed the treatment cart located in the medication room was observed to have Cotton Tipped Applicator with an expired date of ,d+[DATE], Lot #92499, 5 packets of 2 in each packet. Stock medication Vitamin D with an expiration date of ,d+[DATE], lot #133353, of 3 bottles. RN2 confirmed the expiration dates and stated these should have been pulled from the medication room and destroyed or sent back. On [DATE] at 9:30 AM, an observation on Crews Pointe Unit Medication Room with RN1 revealed a bottle of Tuberculin Purified Protein Derivative Dilute Aplisol, 5 TU/0.1 ml in the original box with an open date of [DATE]. RN1 stated, This expires 30 days after opening it. RN1 agreed it was expired and removed it from the refrigerator to discard. Additionally, on top of the treatment cart located in the medication room revealed, 5 vacutainers with Lot #3111759 with expiration date of [DATE], a Light Blue Top vacutainers with Lot #3111759 expired on [DATE], Purple Top Vacutainers x2 with Lot #2259029 with expiration date [DATE]. An opened bottle containing an unknown substance without a label, no name, date or lot number. RN1 stated, This appears to be betadine, this should be labeled with something. RN1 removed the opened bottle from the treatment cart. On [DATE] at 10:15 AM, an observation on Lexington Place Unit with Licensed Practical Nurse (LPN)3 revealed, Assure Dose Control Solution, Lot #00523A with no open date. LPN3 confirmed there was not a date and stated it should be dated when opened. During an interview on [DATE] at 11:45 AM, the Interim Director of Nurses stated, All medication and treatments should have a label to identify what is in the bottle, or else how would you know what is in it. All of the medication and treatment carts supplies have to be within date, or else if it is expired and it needs to be discarded. I expect the nurses to check for expired meds daily. Everything should be dated after opened as well. The med room refrigerators should be checked daily for the temperature. We have a range to be sure the temperature in within that range, if not, if it's low, what did you do and who did you tell, the same for the high temperatures, what did you do and who did you tell? I expect the nurses to tell someone, the unit managers, so we can get someone to look at it. Medications have to be in a certain range and we need to ensure we are meeting that range.

Based on facility policy review, observation, and interview, the facility failed to ensure staff served meal trays under sanitary conditions to prevent the spread of disease and infection. Findings include: Review of the facility policy dated 12/23/20, titled, Nursing Hand Hygiene: Staff and Residents revealed under the policy, Situations that require staff hygiene; before and after handling food, after performing your own personal hygiene, before and after assisting a resident with meals. Review of the facility policy dated 10/01/97, titled, Nursing Uniforms revealed under the policy, Hair of any length must be neatly trimmed, hair must not contaminate the work environment. During an observation on 06/18/24 at 12:07 PM, Certified Nursing Assistant (CNA)5 was passing meal trays, on the lower number 200 hall. While CNA5 took trays from the food cart, her hair touched the tops of the items on each of the meal trays. This continued for all the meal trays CNA5 delivered to the rooms. CNA5 touched her hair after sanitizing her hands, then took the meal tray into room [ROOM NUMBER]. CNA5 needed assistance with pulling the resident up in bed. CNA5 put on gloves to assist. After the resident was assisted up in the bed, CNA5 kept the gloves on and began to feed the resident. During an interview on 06/18/24 at 12:25 PM, CNA5 stated, I'm supposed to tie my hair back, but my rubber band broke. I'm supposed to sanitize my hands after I touch my hair. During an interview on 06/18/24 at 12:32 PM, Registered Nurse (RN)1 stated, It is not ok for [CNA5]'s hair to touch and fall into the meal trays as she is passing trays. She should also sanitize her hands after she touches the meal trays. I will educate her on that. During an interview on 06/20/24 at 3:55 PM, the Interim Director of Nurses stated, The staff are supposed to pull their hair up when they are passing meal trays or providing care. They should wash their hands after they touch their hair, before they pull another meal tray.

Based on interviews, record reviews, and review of the facility policy, the facility failed to ensure a significant medication error did not occur for 1 of 3 residents reviewed for medication administration. Specifically, Resident (R)1 received the medications intended for R6. R1 did not receive any of her prescribed medications. This resulted in R1 experiencing a drop in blood pressure which required hospitalization . On 09/26/23 at 2:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/26/23 at 2:00 PM, the survey team provided the Administrator and Director of Nursing (DON) with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/17/23. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 09/26/23 at 2:00 PM, the Administrator and DON were notified that the failure to ensure a resident received the correct medications per physician orders constituted IJ at F760. On 09/26/23 at 4:27 PM, the facility provided an acceptable IJ Removal Plan. The survey team, validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at past non-compliance dating back to 09/18/23. An extended survey was completed in conjunction with the Complaint Survey for noncompliance at F760, constituting substandard quality of care. Findings include: Review of the facility policy titled, Handling of Non-Controlled Medication, Number 20 states, Identify each resident by name and picture in MAR (Medication Administration Record). Administer medication in accordance with the six (6) rights of Medication Administration: RIGHT RESIDENT, RIGHT DRUG, RIGHT DOSE, RIGHT FORM, RIGHT TIME AND RIGHT ROUTE. Review of R1's, Face Sheet, revealed the facility admitted R1 on 02/06/23, with diagnoses including, but not limited to, urinary retention, cognitive communication deficit, neurogenic bladder, congestive heart failure and chronic kidney disease. Per the medical record, R1 no longer had a diagnosis of hypertension and was receiving Hospice Care and Services for a diagnoses of congestive heart failure. R1 was admitted to hospice on 02/27/23. Review of R1's Physician Orders revealed R1 was supposed to receive the following medications: Zofran disintegrating 4mg 1 po q6 hours prn, Zoloft 50mg 1 po qd, Lorazepam 0.5mg 1 po q6 hours prn, Melatonin 10mg 1 po qhs, Glycopyrrolate 1mg 1 po qid prn, Bisacodyl Suppository 10mg qd as needed, Artificial Tears tid prn, Acetaminophen 650 suppository q4 hours PRN, Albuterol Sulfate duo nebs q4 hours PRN, Hydrocodone - acetaminophen 5-325mg 1 po q6 hors prn. Review of R6's MAR dated 09/17/23 revealed R1 was administered, Acetaminophen 500 mgs, Amlodipine 10 mgs, Aspirin 81 mgs, Carvedilol 6.25 mgs, Gabapentin 400 mgs, Hemocyte Plus 106 mgs, Miralax 17 grams, Plavix 75 mgs, Potassium Chloride 20 milliequivalents (meqs), Prozac 20 mgs, Torsemide 20 mgs and Zyrtec 10 mgs. These medications were intended for R6 and not R1. Review of R1's vital signs recorded on 09/17/23 at 09:30 AM revealed a blood pressure of 101/61. At 9:45 AM revealed a blood pressure of 96/58 and a heart rate of 75. At 10:00 AM the blood pressure was 89/50 and the heart rate was 74. There was no blood pressure charted at 10:15 AM but the heart rate was documented as 68. At 10:30 AM the blood pressure was 92/56 and the heart rate was 65. At 10:33 AM the blood pressure was 85/55 and the heart rate was 65. Review of R1's Progress Notes dated 09/17/23 at 11:40 AM states, Ambulance came to pick up resident at 10:50 AM. Resident is alert and oriented x3, vital signs were taken every 15 minutes and documented, and fluids were pushed prior to leaving via ambulance. Review of R1's hospital records indicated that R1 was received in the emergency roiagnom on [DATE] at 11:16 AM. R1 was eventually sent to the Intensive Care Unit (ICU). The reason for admission is listed as hypotension and the report states, A [AGE] year old female presents to the emergency department for evaluation of medication ingestion. Further review of the hospital record revealed R1's blood pressure was recorded as 85/48 with a heart rate of 67. During an interview on 09/26/23 at 10:58 AM, the Director of Nursing (DON) stated that when the nurse reported the incident we started taking the vital signs every 15 minutes and after 45 minutes we sent her out to the hospital. The DON stated that the nurse is a new nurse. The next day we put arm bands on all residents unless they refused to wear them. Residents are care planned for the arm bands and the refusals. During an interview on 09/26/23 at 11:25 AM, LPN1, the nurse that administered the medications in error, stated, I was working on the unit and I did not know the residents. [R1] required her medications to be crushed, so I gave [R1's] roommate her medications first, she takes them whole. So to save time, I pulled [R6']s medications and when I went back to the medication cart, I saw [R1's] picture still green on the screen, indicating that she was to receive the medications I had pulled. So I crushed the medications and carried them into [R1]. I was looking at [R1] on the report sheet. [R1] received the medications that were meant for the resident next door [R6]. I recognized the error immediately, and panicked and called the nursing supervisor. We started taking the vital signs every 15 minutes. The supervisor contacted the physician and the resident's personal representative and then assisted me with taking the vitals and monitoring the resident. When the blood pressure dropped down the supervisor made the decision to send the resident to the hospital. During an interview on 09/26/23 at 2:00 PM, the Administrator stated that the resident had received the wrong medication. She also stated at this time, we have done all the in services and things were put into place to ensure this does not happen again. During an interview on 09/26/23 at 3:35 PM, the Medical Director (MD) stated, I do not know how this resident could have received the wrong medication. I ordered for the staff to monitor her closely and if her blood pressure started to drop to send her to the emergency room . On 09/26/23 at 4:27 PM, the facility provided the following removal plan: Allegation of Compliance 09/26/2023 Medication Administration Error Action Plan 09/18/2023 Root Cause Analysis: New Grad Nurse assigned to a new unit for the first time on Sunday. Following a consecutive line of medication administration/failed to identify resident using the 5 (five) rights. 1. Nurse was provided orientation on hire. (Start Date 06/12/2023) on orientation until 07/14/2023 (1:1). Nurse was re-educated on 09/17/2023 on the 5 Rights and Medication Administration and received a written anecdotal related to her missing patient identification prior to administering medications. a. Nurse will be provided with a re-education action plan where she receives additional orientation from the Nurse Manager/Pharmacy Consultant related to medication administration. (Continues, complete 09/27/2023) b. Supervisor was notified by nurse, MD was notified, RP was notified. Orders obtained to do vital signs Q15 minutes x 2 hours as well as push fluids. (send to ER if condition worsens) c. Resident was sent to the ED related to a BP of 85 systolic. 2. All resident location verified by admissions related to census and ensured door signs accurate 09/18/2023. 3. All nurses received remedial education related to Medication Administration started 09/18/2023. 4. Pharmacy Consultant to continue periodic Med Pass Observations with Nurses. a. Nurse Manager will conduct Med Pass Audits on each unit weekly x 4 weeks (results of those audits will be reviewed by leadership and nurse specific education will be provided to address any concerns.) 5. Pictures in the EMAR were verified by the Unit Secretary. 6. Audits were conducted on all current residents 09/18/2023 to ensure that door labels were correct as well as arm bands were in place. (Completed by Admissions on 09/18/2023) 7. Audit of existing residents for accurate door signs, and picture in the EMAR weekly x 4 weeks by ADON and Unit Managers. 8. Orientation updated to include med pass observation skill check off for new nurses. (Staff Development)

Based on review of the facility policy, record review, and interviews, the facility failed to provide necessary care and services for a dialysis resident that was diagnosed with pseudo-aneurysm (a leakage of arterial blood from an artery into the surrounding tissue). Specifically, on [DATE] at 5:15 AM Resident (R)1 was found by Nurse (N)1 lying in bed surrounded by blood with a large amount of blood observed on floor. R1 had no pulse and was unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. R1 was pronounced dead at 5:54 AM by Emergency Medical Services (EMS). On [DATE] at 4:40 PM, the Administrator was notified that the failure to provide necessary care and services to a resident diagnosed with pseudo-aneurysm constituted Immediate Jeopardy (IJ) at F600. On [DATE] at 4:40 PM, the surveyor provided the Administrator with a copy of the CMS Immediate Jeopardy Template and informed the Administrator that IJ existed as of [DATE]. On [DATE], at 7:40 PM, the facility provided an acceptable IJ removal plan. The immediacy of the IJ was removed on [DATE]. The IJ was lowered to a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the Facility's policy titled Abuse/Neglect/Misappropriation/ Elder Justice Act with a prepared by date of [DATE] revealed, Residents has the right to be free from abuse, neglect . This also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the Facility's policy titled Care of the Resident Receiving Hemodialysis with a prepared by date [DATE] revealed, To provide optimal maintenance and preventive care for the resident who is receiving Hemodialysis. Procedure 2. Inspect the access site daily . 4. Upon Return (Post-Treatment) from Dialysis: Review of Residents condition. a. Note information sent from Dialysis Center. b. Document required information on Dialysis Resident Communication Report form. c. Note resident's condition/complaints. e. Check Vascular Access site (Shunt or Central Line): Observe site for bleeding, pain, tenderness, discharge . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: End Stage Renal Disease, hypertension, major depression, Type 2 Diabetes Mellitus, hypothyroidism and morbid obesity. Further review of R1's Face Sheet revealed, R1 has a Full Code advance directive. Review of R1's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R1 had mildly impaired cognitive status. Review of R1's Physician Orders revealed R1 receives dialysis three times weekly, on Tuesdays, Thursdays, and Saturdays for diagnosis of End Stage Renal Disease. Review of R1's Dialysis Resident Communication Report dated [DATE] revealed, Questions, Problems, Concerns, New Orders: pseudoaneurysm on LUA (Left Upper Arm) access . Physicians office was notified on [DATE]. Further review revealed, R1 was stable, alert and oriented, and access site was clear. Review of R1's Nurses Progress Note dated [DATE] at 5:15 AM revealed, Approximately at 5:15 am, during rounds patient was found lying in bed full of fresh blood, blood on the floor on the left side of the bed and shirt full of blood with blood sitting on her chin; Patient was checked, and the patient was not breathing or responding to name being called or to touch. An interview with Certified Nursing Assistant (CNA)1 on [DATE] at 11:31 AM revealed, CNA1 last checked on R1 around 3:30 AM and gave her a peanut butter and jelly sandwich and a blanket because R1 stated she was hungry and cold. An interview with Registered Nurse (RN)1 on [DATE] at 11:47 AM revealed, RN1 heard the code being called, she got the crash cart, pulled out the back board and began CPR. RN1 further revealed, when she arrived in the room, she observed a lot of blood in R1's bed and on the floor. An interview with the Director of Nursing (DON) on [DATE] at 2:47 PM revealed, the DON did not know what a pseudo- aneurysm was. The DON stated she follows the standard procedures when residents return from dialysis. An interview with Licensed Practical Nurse (LPN)1 on [DATE] at 2:52 PM revealed, LPN1 did not work with R1 the night in question but as an ex-dialysis nurse if she had seen the concern for a pseudo-aneurysm, she knew that was bad and she would have sent the resident to emergency room . An interview with LPN2 on [DATE] at 4:23 PM revealed, LPN2 checked R1 in from dialysis on [DATE]. LPN2 stated she read the concerns on the communication report and was aware pseudo-aneurysm was noted, but she was not aware of anything else that she could do. LPN2 further stated she saw where the dialysis clinic was making a doctor's appointment, so she did not know if there was any monitoring other than what she had already done for the resident. The Facility's Removal Plan included the following: Supplies: Location of Crash Carts - The team evaluated the current location of all facility crash carts which are located at . After discussion the crash cart from [NAME] will be relocated to Crews Point. 1. Units without a crash cart - An adult back board and ambu bag containing a small and adult mask will be placed on those units. These will be placed in a bag within the nursing station. 2. Tourniquet - Will discuss with medical director the recommendation of placing a tourniquet on the crash cart. A. Orders 1. Revise Order Set 2. Revise communication tool between facility/dialysis agency. B. Communication 1. Revised Communication Tool to be between facility and dialysis agency. 2. Communication books to be uniform. A. Notebooks to be with cover to include resident's name, dialysis center, schedule, transport company with pick up time, chair time. B. Content 1. Face Sheet 2. Code Status 3. Physician Order to include dialysis agency, days/week. 4. Daily Communication tool with most recent document forward. D. Education 1. Revised Order Set 2. Revised Communication Tool 3. Location of Crash Carts 4. Care of the dialysis patient a. Observation of AV site daily and after dialysis b. Review of communication forms and orders/Diagnosis/MD consults. E. All current Dialysis patients were reviewed for diagnosis of Dialysis site complications for the past 30 days: a. [R2] no complications b. [R3] no complications c. [R4] no complications d. [R5] no complications e. [R6] no complications f. [R7] no complications g. [R8] no complications F. Dialysis communication sheets and Site assessments will be reviewed weekdays in IDT meeting to ensure no Site complications are evident.

Amended 04/07/23 Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure adequate supervision was provided to prevent accidents/hazards for 1 of 3 Residents (R)14, reviewed. On 03/12/23, R14 had a successful elopement from the facility. On 03/12/23, at approximately 7:00 AM, R14 eloped from the facility through a gated courtyard between the [NAME] Circle Unit and Camelia Court Unit. At approximately 7:42 AM on 03/12/23, R14 was found alongside the back of the facility, and returned unharmed. R14 was dressed in full street clothing, to include a long-sleeved shirt, pants, and shoes. The weather was noted to be overcast at about 50-60 Degrees Fahrenheit. On 03/14/23, at 12:52 PM, the Administrator was presented with an Immediate Jeopardy (IJ) template indicating IJ existed at F689 with a start date of 03/12/23 and an end date of 03/14/23. The facility presented an acceptable removal plan on 03/14/23. Implementation of the plan was verified through observation, staff interviews, and record reviews. Observation verified that all door alarms were functioning successfully. Documentation review revealed staff was educated on wandering/elopement policy and procedures and immediacy on responding to door alarms. This failure constituted substandard quality of care, resulting in the completion of an extended survey. Additional review revealed the facility failed to provide adequate supervision to protect 1 of 4 Residents, R8 from sustaining injuries during falls within the facility. Findings include: Review of the facility's policy titled, Missing Resident Plan: Code Purple revised on 03/14/23 revealed It is the policy of this facility to respond immediately with emergency procedures when a resident has been identified as missing. R14 was admitted to the facility on [DATE] with diagnoses including but not limited to vascular dementia, muscle weakness and unsteadiness on feet. Review of R14's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/23 revealed R14 has a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive impairment. Review of Section E of the MDS related to Behaviors indicated R14 had not exhibited any behaviors of wandering. Review of Section G of the MDS indicated R14 required limited to extensive assistance with locomotion on the unit with the assist of one person, physically. Review of R14's Admission Elopement Assessment completed on 02/23/23 revealed R14 to be evaluated as not an elopement risk. Following his successful elopement, a second assessment was completed on 03/13/23, indicating he is now an elopement risk. Review of R14's Physician Orders indicated an order dated 03/14/23 revealing, Secure care bracelet and move to secure unit due to elopement, dementia and per family phone call 3/12, history of wandering. Review of R14's progress notes indicated a nursing note timed and dated 03/12/23 at 7:10 AM which revealed, Nurse supervisor: Notified by staff that resident cannot be found and that it was noted that gate between [NAME] Circle and Camellia Court was open. Code purple immediately called. Administrator called. Public safety at LMC called and 911 called. Additional nursing notes revealed on 03/12/23 at 7:42 AM, Nurse supervisor: Resident has been located at the back of the facility. Pant legs were wet. Resident easily assisted back to his room. Nurse at bedside. An additional note on 03/12/23 at 7:58 AM read, Assess resident. No new injuries noted. Peg tube noted to abd. Dsg to sacrum in placed [sic]. Wet shoes and wet pants to shin noted. Resident stated he accidently stepped in the pond. Took off wet socks and replaced with dry socks. Resident refused to change pants and didn't want hospital pant. An additional note in the medical record dated and timed as 03/12/23 at 08:07 AM read, Resident stated he's going to wait until the sun is up to go outside near the pond to get his car tire air in [sic]. Secure bracelet placed on L ankle. During an interview with the Lead Floor Technician (LFT) on 03/14/23 at 11:34 AM revealed on 03/12/23 at approximately 7:00 AM, he clocked in to work. Shortly after, the nursing supervisor called a code purple. He immediately began searching and later found R14 near the trash compactor, time was unknown/undocumented, but he thinks it was around 8:00 AM. The LFT stated he calmly approached R14 and asked him where he was going. R14 stated to him that he was trying to get back to his shop, but everything was locked up. The LFT stated he then noticed R14's pants to be wet and asked him what happened. R14 stated he was near the pond and stepped in a hole. At this time, R14 began walking back towards the facility with the LFT and he was handed off to the nursing staff, who helped him into the facility and assessed him. During an interview with the Director of Facilities and Property Services (DOFPS) on 03/14/23 at 11:45 AM, he led a tour of the believed trail R14 took to exit and return to the facility. The tour revealed areas that included parking lots, rugged traverse, and muddy areas. The DOFPS revealed he was able to map out the trail due to cameras that were placed alongside the buildings on the facility's property. He also provided copies of the video surveillance to the survey team. During an observation and interview on 03/15/23 at 9:52 AM with R14 revealed him sitting up in his bed with staff present. R14 appeared clean and calm. He stated he was getting ready to go to his shop. When asked where his shop was, he stated, It's down the street, but they have it locked up. When asked if he remembered the incident of the elopement and what happened, he stated, I walked out the building to get to my shop, but every door I went to was locked. I need to go and get back to work, because people are going to be waiting for their cars. He stated he did not get hurt, but he did remember stepping in the pond and when he got back to the facility, they gave him clean and dry clothes. During an interview with Licensed Practical Nurse (LPN)1 on 03/15/23 at 9:58 AM, LPN1 stated he was R14's nurse for today. He stated R14 had not expressed to him any concerns or ideas related to wanting to leave the building at this time. During an interview on 03/15/23 at 10:15 AM, Registered Nurse (RN)1 revealed she was the nurse in charge when the incident occurred. It was right at shift change when she received a call from the unit that said R14 was not in his room. At that time, 2 night shift supervisors got up to assist in locating R14. RN1 stayed in the room to complete the staffing sheets for shift change. She then received a call saying the gate was open. At that time, she immediately activated a Code Purple, called the Administrator, Public Safety and 911. When she remembered she had access to the facility's surveillance cameras, she returned to the office so that she could pinpoint a timeframe of when R14 left. Using the cameras, she was able to determine R14 had gotten out of the building. RN1 stated some staff members had gotten in their cars to drive along the roads to see if they had seen R14. When the staff alerted R14 had been found, a wheelchair was taken to the nearest door to assist in returning R14 to his room to be assessed. RN1 stated after the assessment and when no injuries were noted, the Physician was called to give an update. At that time, she (RN1) received a PRN (as needed) for Ativan. She then began conducting in-services immediately on Code Purple and Elopements. RN1 stated the weather that morning was a little warmer, around the 50s possibly and it was not raining. She stated R14 was properly dressed in a long-sleeved shirt and long pants with sneakers, but he did not have on a jacket. During an interview with the Administrator on 03/15/23 at 10:45 AM, she confirmed again that staff had acted properly upon the facility's policies. She stated she herself had walked the area and path taken by R14 and could not understand how he was able to maneuver without getting hurt. She stated the facility maintains ongoing in-services to ensure this does not happen again to any other residents. The facility's plan revealed: A. Equipment a. Exits- Check all gates daily prior to leaving- started 3/12/23. i. Log to be completed daily by Maintenance. b. Cameras- Aided in locating resident. (Resident located ~40 minutes after he exited the facility) Resident never left the Extended Care property. B. Environment a. Fencing- Ensure fence integrity around body of water- Vendor assessment completed 3/13/23 by Maintenance. C. People a. Code Purple was called 3/12/23 at 6:58 AM, Administrator notified. b. Search conducted-all available staff assisted in the search (~30 people, 911, LMC Public Safety, Medical Director and RP notified). c. Resident- hx of elevated ammonia- repeated labs 3/14/23 completed by Nursing. i. Body audit completed 3/12/23 ~8:07 AM ii. Will repeat Braden skin risk assessment once weekly x 4 weeks. iii. Review activities programming for resident provide 1:1 as needed iv. Code Purple education provided to all staff starting on 3/12/23. v. Staff present during the incident were educated about recognizing residents at risk for elopement where to search, and how to page the alert on 3/12/23. vi. Admin staff were educated on and used the Fishbone Diagram to identify root causes analysis of the incident. Completed on 3/13/23. d. Policy i. Update Code Purple Policy to include LYNX notifications. ii. Elopement risk assessment completed at admission and quarterly and as needed. iii. New admissions for the past 30 days will be re-assessed for elopement risks. This began on 3/14/23. e. Process i. Admissions assessments BIMS score=12 (No indication of elopement risk). Alert and oriented x2, chair alarm implemented due to fall risk. ii. Admission Elopement assessment did not indicate a need for wander guard bracelet. (No exit seeking or verbalization of wanting to leave). iii. Care Plan- New process to include assessment of resident during admission for prior substance use, prior elopement history. Completed by Social Services Director iv. Change type of elopement assessment by 3/17/23 to more clearly establish elopement risk f. Other i. Enable staff to enter and exit with a card reader through Camelia Court to ensure they are not using undesignated exits throughout the facility. Completed by Maintenance ii. Continue to use wanderguard notebooks for each unit and both visitor exits to better identify residents who are at risk for elopement. Completed by Nurse Managers and HIM on 3/12/23. 42424 Review of the facility policy titled, Standard Policy/Procedure: Fall Prevention Program last revised 2/14/23, revealed The facility will endeavor to reduce resident falls through a comprehensive fall evaluation and prevention program. Residents at risk for accidents and/or falls shall be identified and have care plans and procedures in place to reduce the falls and injuries related to falls. Fall risk observations are to be completed on new admissions, re-admissions, quarterly and annually. R8 was admitted to the facility on [DATE] with diagnoses including; but not limited to; fracture of right femur, unsteadiness on feet, type 2 diabetes, and dementia with behavioral disturbances. Review of the Quarterly MDS with an ARD of 12/6/22, revealed R8 has a BIMS score of 13 out of 15, which indicates she is cognitively intact. R8 requires extensive assistance with most activities of daily living (ADL). Further review revealed R8 has a bed alarm in use daily during this assessment period. An observation and interview on 3/15/23 at 8:30 AM revealed R8 in her room, at the end of the unit, with slight confusion, fall mats noted on both sides of the bed. R8 was attempting to get out of bed during the interview, but was easily redirected. Record review on 3/14/23 at 1:00 PM of a Progress Note dated 12/12/22 at 3:30 AM revealed while in another resident's room, yelling heard from the end of the hall. A Certified Nursing Assistant (CNA) checked on the resident and resident was noted on the floor. I enter the room and noted resident on knees leaning against the bed. Resident stated she was trying to get her pillow, knees red, no open skin. Resident denies hitting contact with head, supervisor called to assess resident. Resident then placed back in bed and personal care provided, bed in the lowest position and call light within reach. Resident Representative notified with voice message and Medical Director. Review of a Care Plan with a revision date of 3/9/23 revealed At increased risk for falls/injury related to history of falls at previously while living at an assisted living facility with a left femoral neck fracture. 12/12/22 fall with no injury; 2/6/23 in room injury; 3/7/23 noted sitting on floor mat. A phone interview on 3/15/23 at 10:00 AM with Resident Representative (RR) for R8 revealed the resident has had numerous falls and has a history of falls. Prior to being admitted to this facility the resident was in assisted living and had fallen there as well, when the resident gets anxious she believes that she is still able to walk and normally falls and hurt herself. When R8 was admitted , I expressed these concerns about her prior history of falling with staff. I visit the resident fairly often and have not witnessed the resident with a fall mat or the bed lowered until the resident broke her femur in February (2/6/23). I don't know why they didn't make any interventions or put any fall mats/protection next to her bed to prevent her from injuring herself until it actually happened. An interview on 3/15/23 at 10:21 AM with RN1 revealed, I assessed R8 after her fall on 2/6/23 and on that day the resident had no complaints of pain at that time. The next day the resident told other staff that she was having knee pain and was later sent and it was determined the resident had a right femur fracture. RN1 further stated our policy for fall prevention is that we start with smaller interventions at first such as lowering the bed or maybe adding a bed alarm then move to bigger interventions such as bed mats or moving the residents' room closer to the nurse's station for more observation. RN1 stated she was not familiar with R8 and was unsure if R8 had previous falls. Review of R8's Progress Note dated 02/06/23 at 5:40 PM revealed, resident found of the floor on the left side of the bed. Per resident, she was attempting to clean crumbs on the nightstand. Fall was not witnessed by staff; resident was assessed, and no visible signs of injuries were noted. Resident noted with no pain or injury and Range of Motion (ROM) is normal for this resident. Fall vital with head contact ordered due to being unwitnessed, supervisor and RR notified. Review of R8's Progress Note dated 02/06/23 at 5:58 PM revealed ,Nurse supervisor called to assess resident in bed after fall, denies any pain and is able to move extremities to her personal limits. States knees hurt, but that they always hurt, respirations even, no sign of distress. Review of R8's Progress Note dated 02/07/23 at 11:13 AM revealed, resident complaining of right knee pain, slight redness noted to the right knee, resident had a fall at 5:15 AM this morning. Resident noted with increased confusion and is a high fall risk due to decreased safety awareness related to dementia. Xray of right knee ordered will obtain urine analysis (UA) and bilateral floor mats have been initiated. RR and Medical Director (MD) notified related to new orders. Review of R8's Progress Note dated 02/07/23 at 5:14 PM revealed, MD notified of Xray results showing fracture of right femur supracondylar (thigh bone broken at the knee) with 14-millimeter displacement. New orders received to send to hospital for further evaluation and treatment. Review of a Progress Note dated 03/07/23 at 10:45 AM revealed, resident found on floor, upon entering the resident's room bed [NAME] [sic] alarming. Observation revealed resident on floor mats on the side of the bed closest to the door. Resident stated I can't get up, and unable to recall how they had fallen or if she hit her head. Resident noted to be incontinence with stool, resident placed back in bed and incontinence care provided. Resident sent to hospital per MD due to unable to complete right femur and right knee Xray, RR notified. Review of a Progress Note dated 03/08/23 at 11:40 AM revealed, resident will be transported back to the facility via transportation, Xray for right knee and right hip results negative of any fractures. An interview on 03/15/23 at 10:35 AM with RN2 revealed, I was not here when the resident fell , but staff reported to me that they found her kneeling by her bedside, but when staff assessed her the resident had no major complaints of pain at the time. The next day when I came to work, the resident complained of knee pain, so we ordered a X-RAY for the resident and confirmed the resident broke her right femur. Interventions we use to prevent a resident from falls with injury is discussed as a team and with family members during care plan meetings We also start with small interventions, such as; more supervision then move other interventions such as floor mats, bed alarms, or room changes for closer supervision o reduce the number of falls with injury.

Based on observations, interviews, and record review the facility failed to provide care and services for one resident (R)197 of five residents reviewed for limited range of motion out of the sample of 78 residents. The failure to apply splints to the resident's contractures has the potential for increased contractures and/or pain. Findings include: Review of R197's undated Face Sheet located in R197's electronic medical record (EMR) under the Face Sheet tab, indicated R197 was initially admitted to facility on 01/25/10 with a readmission on 03/16/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R197's quarterly Minimum Data Set (MDS) located in R197's EMR under the Resident Assessment Instrument (RAI), tab with an Assessment Reference Date (ARD) of 04/20/22, revealed R197's Brief Interview for Mental Status (BIMS) was not attempted due to resident is rarely/never understood. R197 is dependent for all activities of daily living (ADLs). R197, according to the MDS assessment look back period, did not receive any restorative nursing programs, to include the application of splints or braces. Review of R197's Orders located in R197's EMR under the Orders tab revealed an open-ended order dated 06/20/19 which indicated, .resident to wear bilateral small carrot hand positioned as tolerated to prevent further contracture and promote hand hygiene. Nursing to remove for hand hygiene and skin checks per policy. Review of R197's Care Plan dated 11/05/19, located in R197's EMR under the RAI tab instructed staff to apply bilateral small carrot hand positioned splint as tolerated to prevent further contracture .provide appropriate personal hygiene daily every shift. Hand rolls bilaterally every (sic) except for hygiene check heels every shift. Observations of R197 conducted on 05/25/22 at 2:28 PM, on 05/26/22 at 3:15 PM, and on 05/27/22 at 12:02 PM revealed R197 has bilateral hand contractures which did not have the small carrot devices in the palms of both of her hand contractures. During an interview on 05/27/22 at 12:11 PM, Certified Nurse Aide (CNA)1 and Licensed Practical Nurse (LPN)2 were questioned if R197 is supposed to have small carrot devised placed in the palms of her hands. Both CNA1 and LPN2 responded, they were not sure if R197 is supposed to have splints in her hands. During an interview conducted on 05/27/22 at 12:12PM, Registered Nurse Unit Manager (RNUM)1 was questioned if R197 is supposed to have small carrot devices placed in the resident's contracted hands? RNUM1 responded she was unsure what was ordered for the resident. RNUM1 searched R197's room for the small carrot devices and confirmed that she could not locate the small carrot devices in the R197's room. RNUM1 confirmed that R197 did not have small carrot devices in the palms of her hands. An interview on 05/27/22 at 12:31 PM, the Director of Nursing (DON) stated the facility did not have the small carrot device in the palms of R197's contracted hands. The DON was asked what her expectations was related to the application of the small carrot devices for R197. The DON responded if it is ordered and care planned, it should be done. The facility was unable to provide a policy related to the application of splints for contractures.

Based on record review, interviews and review of the facility abuse policy and procedures, the facility failed to ensure an allegation of neglect was thoroughly investigated for 1 of 5 sampled residents reviewed. Resident #4 allegedly received skin tears during transfer with inconsistent information as the location of the skin tears. The findings included: The facility admitted Resident #4 on 7/15/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 8/25/21 at 12:15 PM with Licensed Practical Nurse (LPN) #1 revealed when s/he entered Resident #4 room, it was noticed that Certified Nursing Aide (CNA) #1 transferred the resident using a hoyer lift unassisted. LPN #1 stated s/he observed Resident #4 suspended on the lift, with the back of the resident's leg bleeding on to the floor. An interview on 8/25/21 at 12:21 PM with LPN#2 revealed when s/he entered the resident's room, Resident #4 was noted with skin tears behind both legs. A review of the medical record on 8/25/21 at 12:55 PM revealed a nurse's note written by LPN #1 that indicated CNA #1 used lift and Resident #4 sustained bilateral skin tears to back of legs. CNA #1 was observed applying pressure to back of both legs with paper towels. Two medium size skin tears and 3 small tears. A nurse's note by LPN #2 revealed Resident #4 had 3 skin tears behind left calf, 1 small skin tear to left knee and 1 skin tear to right calf. There was no documentation in the nurse's notes or body audit that gave measurements. A review of the facility investigation on 8/25/21 at approximately 2:30 PM revealed Resident #4 received injuries to left shin area 1 cm (centimeter) x (times) 0.5 cm, 2.5 cm x 1.5 cm and 1.5 cm x 1 cm. The injuries to right shin area 2.7 cm x 2 cm. Further review of the facility investigation revealed LPN #1 witness statement revealed he/saw a pool of blood under the resident. There was no witness statement from the resident who was documented as having a Brief Interview of Mental Status Score (BIMS) of 15. An interview on 8/25/21 at 2:35 PM with LPN # 1 revealed s/he did not see blood on the hoyer lift of resident's chair and that they did not know how the injury occurred. An interview on 8/25/21 at 2:38 PM with Assistant Director of Nursing (ADON) confirmed there was no documentation in the medical record to indicate the skin tears were measured with location of the injuries. The ADON further stated the shin as documented on the investigation sheet was incorrect because the injuries occurred on the resident's calf. An interview on 8/25/21 at 3 PM with the ADON revealed there was no bleeding noted on the chair that was assigned for Resident #4 use. The ADON further stated they do not know what caused the injuries to the resident's calves. A review of the facility's abuse policy and procedures indicated under V. Investigation of Alleged Abuse, Neglect and Exploitation #5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. #6. Providing complete and thorough documentation of the investigation.

Based on observation, interview and review of facility policy, the facility failed to properly discard spoiled produce food items in the walk-in cooler in 1 of 1 main kitchens observed during the survey. During initial tour of the kitchen on 05/04/21 at approximately 11:00 am with the Dietary Manager (DM) #1, observation of the walk-in cooler revealed four (4) spoiled tomatoes, four (4) spoiled green peppers, and two (2) bags of spoiled lettuce, four in each bag. The tour also identified a can opener with gunk, oil, and food particles. During the revisit tour of the kitchen on 05/06/21 at approximately 11:00 am with DM #1 and DM #2, observation of the walk-in cooler identified a box of spoiled green peppers, three (3) spoiled cucumbers, and three (3) spoiled tomatoes. The revisit tour also identified two (2) packs of hotdog bun packs with a use by date of May 04, 2021, and two (2) packs of hamburger buns with a use by date of May 05, 2021. Review of the facility's policy on Food Service stated: 3. As each item is received, cases are opened to verify weight, count, and condition of merchandise. Damaged goods and dented cans are not accepted. Code dates of perishable products are checked, and outdated goods are not accepted. *Produce - Items are weighed and/or counted. Only fresh, undamaged products are accepted. An interview and follow-up visit with DM #1 on 05/06/21 at approximately 12:00 PM, revealed a box of spoiled green peppers, three (3) spoiled cucumbers, and three (3) spoiled tomatoes in addition to two (2) packs of hotdog bun packs with a use by date of May 04, 2021, and two (2) packs of hamburger buns with a use by date of May 05, 2021. The DM confirmed the presence of the outdated and spoiled items stored in the kitchen and the can opener was not clean.

Based on observation, interview, and record review the facility failed to provide and treat each resident with respect,dignity, and care for each resident. The findings include: Resident #240 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Resident #240 and Resident #516 on 05/05/21 at 09:19 AM revealed that C.N.A. #1 entered the room without knocking and stated that they were Looking for something. When Resident #516 stated, I need help, C.N.A. #1 stated What do you want in a rude tone. C.N.A #1 then stated that they helping another resident and exited the room. An interview with Resident #240 on 05/05/21 at 9:24 AM revealed that some of the C.N.A's always treat us like that here. A review of the facility policy titled Resident Rights on 05/06/21 at 2:30 PM revealed that The resident has the right to considerate and respectful treatment.

Based on observation, interview, record review, and review of facility policies and documentation, the facility failed to ensure one of 23 sampled residents (Resident #7) received adequate supervision to prevent a fall resulting in injury. On 06/13/20 at 7:20 PM, Certified Nursing Assistant (CNA) #8 reported Resident #7 fell out of the bed while CNA #8 was assisting the resident with personal care. The failure of CNA #8 to provide adequate supervision resulted in Resident #7 sustaining a facial fracture and a laceration requiring sutures above the left eye. This failure has the potential to affect other residents in the facility requiring assistance with bed mobility which could result in injuries from unnecessary falls or accidents. Review of the facility's policy titled, Fall Prevention Program, dated 02/26/16, stated, Residents at risk for accidents and/or falls shall be identified and have care plans and procedures in place to reduce the number of falls and injuries related to falls. Review of a facility procedure document titled, Safe Patient Handling, dated 06/15/20, stated, Safe Patient handling reduces the risk of injury for both healthcare workers and residents while improving quality care. The document further stated facility staff should ensure that when taking eyes off resident that hand contact remains and positioning is optimal to prevent further movement on own, which could lead to potential injury if falling from a high surface. In addition, the procedure requires staff to ensure resident, if in bed, is positioned in the center of the bed and not on the edges while giving care, especially if one staff member is present. Findings include: Review of the Electronic Medical Record (EMR) Continuity of Care Document revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/04/2019, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #7's cognition was severely impaired and could not complete the interview. This quarterly MDS revealed Resident #7 required total assistance of one person for bed mobility. Review of the EMR Care Plan revealed Resident #7 had a care plan for falls prior to the incident on 06/13/20. At the time of the incident, the Falls care plan stated Resident #7 needed total assistance from staff for potential for fall/injury due to decreased cognitive function related to a [DIAGNOSES REDACTED].the resident requires total assistance by one staff with bed mobility . The ADL care plan was revised on 06/16/20 requiring assistance from two staff with bed mobility for Resident #7. A review of the facility investigation, dated 06/18/20, revealed Resident #7 had a fall with injuries on 06/13/20 at approximately 7:20 PM. The incident report indicated CNA #8 was providing personal care to the resident and turned Resident #7 on his/her side while lying in the bed. CNA #8 turned away from Resident #7 and Resident #7 slipped off the bed and fell to the floor. According to the incident report, Resident #7 hit his/her head and sustained a laceration above the left eyebrow. CNA #8 called for assistance and Resident #7 was assessed and provided immediate treatment for [REDACTED].#7, the resident was transferred to the local hospital emergency room for examination. The incident report further revealed Resident #7 received sutures for the laceration above the left eye and radiology results from the hospital indicated Resident #7 had a facial fracture as a result of the fall. The incident report stated Resident #7 returned to the facility on [DATE] at 12:00 AM. A review of hospital discharge records for Resident #7, dated 06/13/20, revealed Resident #7 was treated for [REDACTED]. In addition, Resident #7 received a CT scan of the head and neck and a chest x-ray. The radiological reports found in the hospital record indicated Resident #7 had a closed orbital [MEDICAL CONDITION] sinus (facial fracture) caused by a traumatic injury of the head. A review of a written statement by CNA #8 dated, 06/14/20, revealed CNA #8 stated he/she turned the resident on the side while providing perineal care. CNA #8 further stated he/she turned away from the resident and Resident #7 slipped off the bed. In addition, CNA #8 stated he/she tried to catch the resident. On 07/27/20 at 3:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated CNA #8 was providing perineal care to Resident #7 on 06/13/20 at the time of the resident's fall. The DON stated it was determined CNA #8 took his/her hand off the resident and turned away from Resident #7 while the resident was on his/her side in the bed. The DON further stated Resident #7 would not have fallen out of the bed and injured himself/herself if CNA #8 had maintained a hand on the resident during the care. On 07/27/20 at 4:30 PM, an interview was conducted with the Administrator and the Human Resource (HR) Director regarding the facility's investigation of Resident #7's fall. The Administrator stated the facility determined CNA #8 failed to provide adequate supervision to Resident #7 while providing perineal care. The HR Director stated CNA #8 was terminated for unsafe practice related to the incident with Resident #7 on 06/13/20. On 07/29/20 at 2:35 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator confirmed Resident #7 had been assessed as being total dependent for bed mobility and the resident required one person for assistance at the time of the fall. The MDS Coordinator further confirmed Resident #7's care plan was revised on 06/16/20, after the fall on 06/13/20, to require two persons for assistance. Observations conducted on 07/28/20 at 10:15 AM revealed Resident #7 was asleep in his/her room. Resident #7's bed was observed in a low position and had been placed against the bedroom wall.

Based on record review and interview, the facility failed to ensure an environment free from neglect for 1 of 6 sampled residents reviewed for abuse/neglect (Resident #14) as evidenced by failure to follow the Care Plan related to method of transfer resulting in injury to the resident. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/04/19 at approximately 9:01 AM revealed an Incident Report dated 11/25/19 at 10:42 AM which stated Licensed Practical Nurse (LPN) #1 was called to Resident #14's room by Certified Nursing Assistant (CNA) #2. LPN #1 found Resident #14 on the floor sitting up being supported by CNA #2. CNA #2 stated Resident #14 slipped during transfer and was lowered to the floor. Resident #14 denied any pain and vitals were taken after being assisted off of the floor. Further review revealed a Progress Note from the Social Worker stating that the Resident Representative (RR) asked that Resident #14 be transferred to the emergency room (ER). Resident #14 refused to be transferred to the ER. The RR was notified of the refusal. A Progress Note dated 11/25/19 at 7:46 PM by LPN #2 stated Resident #14 complained of pain in his/her left shoulder and upper arm. An x-ray obtained by a mobile provider revealed an acute impacted left humeral neck fracture. In an interview on 12/04/19 at approximately 1:50 PM, CNA #2 admitted to using the Sit to Stand lift on 11/25/19 to transfer Resident #14 out of bed. CNA #2 stated it was the first time s/he had attempted to get Resident #14 up alone. CNA #2 also stated that s/he was aware that a Full Body Lift (which requires 2 people) was the correct device to use for Resident #14 but there was not another CNA available to assist in using the Full Body Lift. In an interview on 12/04/19 at approximately 12:37 PM, the Director of Nursing (DON) confirmed that CNA #2 failed to follow policy and protocol by not using the correct device for the transfer of Resident #14 as per the Care Plan. In an interview on 12/04/19 at approximately 2:22 PM, the Medical Director stated the expectation for CNA #2 would be to follow the Care Plan which called for the use of the Full Body lift, which is a two-person transfer.

Based on record review and interview, the facility failed to ensure an environment free from accident hazards for 1 of 5 sampled residents reviewed for accidents (Resident #14) as evidenced by failure to follow the Care Plan related to method of transfer resulting in injury to the resident. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/04/19 at approximately 9:01 AM revealed an Incident Report dated 11/25/19 at 10:42 AM which stated Licensed Practical Nurse (LPN) #1 was called to Resident #14's room by Certified Nursing Assistant (CNA) #2. LPN #1 found Resident #14 on the floor sitting up being supported by CNA #2. CNA #2 stated Resident #14 slipped during transfer and was lowered to the floor. Resident #14 denied any pain and vitals were taken after being assisted off of the floor. Further review revealed a Progress Note from the Social Worker stating that the Resident Representative (RR) asked that Resident #14 be transferred to the emergency room (ER). Resident #14 refused to be transferred to the ER. The RR was notified of the refusal. A Progress Note dated 11/25/19 at 7:46 PM by LPN #2 stated Resident #14 complained of pain in his/her left shoulder and upper arm. An x-ray obtained by a mobile provider revealed an acute impacted left humeral neck fracture. Review of the Care Plan for Resident #14 revealed an approach/intervention with a start date of 11/17/16, last updated on 0[DATE], instructing to Provide appropriate assistance of staff members before attempting to transfer. Use Full Body Mechanical Lift as designated. In an interview on 12/04/19 at approximately 1:50 PM, CNA #2 admitted to using the Sit to Stand lift on 11/25/19 to transfer Resident #14 out of bed. CNA #2 stated it was the first time s/he had attempted to get Resident #14 up alone. CNA #2 also stated that s/he was aware that a Full Body Lift (which requires 2 people) was the correct device to use for Resident #14 but there was not another CNA available to assist in using the Full Body Lift. In an interview on 12/04/19 at approximately 12:37 PM, the Director of Nursing (DON) confirmed that CNA #2 failed to follow policy and protocol by not using the correct device for the transfer of Resident #14 as per the Care Plan. In an interview on 12/04/19 at approximately 2:22 PM, the Medical Director stated the expectation for CNA #2 would be to follow the Care Plan, which called for the use of the Full Body lift which is a two-person transfer.

Based on observation, interview, record review, and policy review, the facility failed to report to the state survey agency and to the administrator incidents of potential abuse, thoroughly investigate incidents of resident to resident physical and sexual altercations/abuse perpetuated by resident (R) R215 and R369, and implement follow up interventions for 7 of 57 stage 2 sampled residents (R) (R37, R215, R405, R236, R400, R326, R406 and an unknown female resident). Additionally, a reported incident of staff to resident abuse towards R471 was not adequately investigated. Specifically: The facility failed to ensure aggressive behaviors of R215 towards other residents were thoroughly investigated by the facility, reported to the state survey agency and administrator, and sufficient interventions were implemented to keep the remaining 43 residents who resided on the secure unit safe from harm inflicted by R215. R215, who was cognitively impaired but at a higher cognitive level than the residents he targeted, exhibited aggressive physical behaviors towards residents on 3 occasions and sexually aggressive behaviors towards residents on 4 occasions between 8/7/16 and 4/19/17. The residents assaulted by R215 were R405, R236, R400, R326, R406 and an unknown female resident. Investigations into the incidents and protective measures to prevent recurrence were lacking creating an unsafe environment in the secure unit which perpetuating future incidents of abuse. The facility's failure to report, investigate, and implement interventions to prevent abuse was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified to have existed on 8/7/16 at 6:23 p.m. when R215 was first sexually aggressive towards R405. The administrator and director of nursing (DON) were informed of the Immediate Jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17 and the immediate jeopardy was removed on 4/21/17 at 6:20 p.m. The scope and severity was lowered to a E, a pattern with potential for more than minimal harm, once the immediate jeopardy was removed. Findings include: 1. Abuse Policies and Procedures a. Per the facility policy and procedure Facility Wide Abuse/Neglect/Misappropriation, dated 2/2004, under Prevention Bullet D, .the facility will thoroughly investigate any suspected abuse, neglect and/or misappropriation of resident property and take appropriate action to prevent recurrence . Under Investigation bullet A .all suspicious incidents will be thoroughly investigated in a timely fashion, documented via an Alleged Abuse/Incident of Unknown Origin packet and forwarded to the required state agencies as outlined in policy 02-22, Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Responsibilities . b. The facility's 5/27/16 policy addressing Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Complaint (sic) Responsibilities documented: (The state licensing body) shall be notified within 24 hours of a serious accident/incident .A written report will be sent within five (5) days of the serious accident or incident .A serious incident shall be considered as, but not limited to . 7. Confirmed or suspected cases or resident abuse, neglect, or exploitation .There is no requirement to report resident-to-resident abuse where the incident fails to meet other reporting criteria. Though the above policy specifically referred to reportable occurrences as determined by the state licensing entity, the facility failed to address resident-to-resident abuse as a facility system. The facility interpreted the above policy as meaning an incident report, investigation into the root cause and nature of the incident, as well as interventions to keep residents safe from further abuse did not need to be completed for resident-to-resident incidents. Thus, the facility did not have a system to determine whether a resident-to-resident incident constituted confirmed or suspected cases of resident abuse . and would have therefore been considered reportable to the state licensing entity. c. The facility's 2/5/04 Abuse/Neglect/Misappropriation policy documented, (Name of facility) is committed to the prohibition of any mistreatment, neglect, and abuse of residents or the misappropriation of resident property. The policy went on to address screening and training of employees, prevention of abuse through staff training and supervision, and policies on suspending an employee pending investigation of staff to resident abuse. Resident-to-resident abuse was not addressed in the policy. d. The facility's 3/15/00 Resident (to) Resident Abuse policy documented procedures to assess a potential for abusive behavior and develop interventions to prevent aggression toward other residents. The policy did not address reporting and investigating these incidents. 2. Review of R215's Annual Minimum Data Set assessment (MDS) (a resident assessment tool), dated 1/20/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the MDS assessment dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score, measuring cognition, was 10 out of 15. A score of 10 indicated moderate cognitive impairment. The MDS, Section E, Behavior, indicated R215 exhibited physical and sexual, behavioral symptoms toward others. The MDS, Section G, Functional Status, indicated R215 could move about on the unit (locomotion) with limited assistance once he was in his wheelchair Observation of R215 on 4/19/17, 4/20/17 and 4/21/17 at various times of the day, revealed he could independently maneuver his wheelchair throughout the secure unit. He was talkative with staff; however, at times became argumentative when he was not allowed to exit the unit. R215 had a non-releasing seat belt and pommel cushion while in his wheelchair. Review of R215's behavior care plan revealed his physical, verbal and sexually aggressive behaviors were not addressed. a. Seven incidents of physical or sexual abuse, in which R215 was the aggressor, occurred between 8/7/16 and 4/19/17. Cross -reference F323. R215 was physically or sexually aggressive towards R405, R236, R400, R326, R406 and an unknown female resident: 1) 8/7/16 Incident Between R215 and R405 Review of nursing progress notes on 4/21/17 revealed on 8/7/16 at 6:23 pm .Resident observed attempting to kiss R405. When stopped by this nurse R215 briefly became argumentative and made one attempt to repeat behavior. Residents were physically separated by this nurse . A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 2) 8/21/16 Incident Between R215 and R236 Review of nursing progress notes on 4/21/17 revealed on 8/21/16 at 9:41 a.m. .resident observed with his left hand under the gown of R236. R215 was informed this was not acceptable behavior and to the nurse's station. R215 gave no verbal or physical reply and was not resistive . The quarterly MDS dated [DATE] revealed R236 was severely, cognitively impaired. 3) 8/21/16 Incident Between R215 and R400 Review of nursing progress notes on 4/21/17 revealed on 8/21/16 at 7:10 p.m. .resident observed rubbing buttocks of R400. R400 was not receptive to behavior. Informed R215 touching of this nature was not appropriate, resident became agitated loudly stating 'Why don't you keep your hands to yourself' and 'You go on.' Residents separated by staff . The MDS dated [DATE] revealed R400 was severely, cognitively impaired. 4) 10/25/16 Incident Between R215 and R326 Review of nursing progress notes on 4/21/17 revealed on 10/25/16 at 5:15 p.m. .Resident seen by CNA striking (R326). Strike an open-handed swipe . The quarterly MDS dated [DATE] revealed R326 was severely, cognitively impaired. 5) 11/17/16 Incident Between R215 and R405 Review of nursing progress notes on 4/21/17 revealed on 11/17/16 at 7:07 p.m. .Resident inappropriately touching R405. This resident (R215) had his right hand reaching up resident's shirt and was attempting to kiss other (sic) resident. When confronted about this behavior resident (R215) laughed, stated 'She wants it.' Informed resident this was not acceptable behavior, separated residents . This was second resident-to-resident sexual altercation between R215 and R405. A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 6) 2/14/17 Incident Between R215 and Unknown Female Resident Review of nursing progress notes on 4/21/17 revealed on 2/14/17 at 10:43 pm .Resident (215) swung at another resident (female) with closed fist because she touched his friend. Only touched her arm out of [MEDICATION NAME] but (R215) swung at resident with open fist . The facility was unable to determine who the female resident was. 7) 4/19/17 Incident Between R215 and R406 Review of nursing progress notes on 4/21/17 revealed on 4/19/17 at 8:54 p.m. .Resident (215) in altercation with Resident (R406). Resident 215 punched R406 in the face because he said resident (R406) was talking to his 'girlfriend.' Redirection was given to Resident 215. Altercation broken up by staff. Closed fist altercation . The quarterly MDS dated [DATE] revealed R406 was severely, cognitively impaired. No evidence was found or provided to demonstrate any of the incidents were reported to the state agency. Furthermore, there was a lack of evidence staff reported the incidents to the administrator. None of the incidents were investigated. b. Staff interviews During an interview with the DON on 4/21/17 at 10:30 a.m., she stated I am not aware of the specifics of R215's resident-to-resident altercations, but more on the fringe of things. During an interview with the DON and (nursing manager) NM1 on 4/21/17 at 11:50 a.m., the DON confirmed the facility did not complete incident reports, or conduct any type of investigation when resident-to-resident altercations occurred. She stated We (the facility) just never have. The DON also stated, according to their abuse policy, We are not required to report resident-to-resident abuse to the state. Additionally, neither the DON nor NM1 could say how they tracked or monitored resident-to-resident altercations, and how they determined correct interventions had been implemented. During the same interview with the DON and NM1 on 4/21/17 at 11:50 a.m., they were asked what interventions were implemented to prevent further resident-to-resident altercations. The DON stated They were separated at the time of the incident. Neither the DON or NM1 could state what, if any, additional interventions were put into place following each altercation, other than what was already charted in R215's clinical record. On 4/21/17 at 6:31 p.m., the administrator stated resident-to-resident abuse, physical aggression, or sexually inappropriate behavior had not been brought to his attention. He stated, We don't know about it. With (R215), it appears the nurse made a note and did not tell anybody. My expectation is an incident report be completed. (An incident report) should have been done for every instance. The administrator also stated, I would agree there is a problem with the investigation process. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. 3. An incident of physical abuse was observed during the survey in which R369 hit R37. On 4/18/17 at 12:50 p.m., when R37 commented to R369 regarding her missing shoe, R369 exclaimed, Mind your own damn business! She then hit R37 in the left arm. Three staff members witnessed the altercation; one redirected R369 back to the dining room. R37 wheeled toward his room down the hall; staff were not observed to assess R37 for injury. a. Background Information R369 According to the undated Resident Face Sheet, R369 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/17/17 quarterly MDS assessment documented R369 had severely impaired cognition (section C1000). She had unclear speech (section B0600) and was rarely/never able to understand others (section B0800). R369 exhibited physical and verbal behavioral symptoms directed toward others (section E0200). R369's Care Plan, revised 3/28/17, documented poor safety awareness and impaired decision-making ability due to her dementia and was anxious at times. The approaches included: continuously remind resident of boundaries, .frequently monitor for safety issues and address as needed, .re-direct if wandering and/or any other behaviors are effecting (sic) safety and/or health, .(and) identify environmental factors that may increase anxiety b. Background Information R37 According to the undated Resident Face Sheet, R37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/7/17 quarterly MDS assessment documented R37 had moderately impaired cognition (section C1000). He was rarely/never able to make himself understood or understand others (sections B0700 and B0800). R37's 5/1/14 Care Plan, revised 4/11/17, documented he had cognitive loss (related to) ETOH (alcoholic) dementia with impaired decision making ability and decreased safety awareness with potential for injury and/or elopement. The approaches included, frequently monitor for safety issues and address as needed .continuously remind resident of boundaries .decrease external stimuli and provide a safe environment .(and) identify environmental factors that may increase anxiety. R369's 4/18/17 Progress Note documented, (R37) yelled at this resident, 'Where are your shoes' - This resident made verbal response and slapped (R37) on the left arm - No injuries occurred and staff intervention was successful. Cross-reference F323: the facility failed to identify R369's physical and verbal behavioral symptoms directed toward others in the care plan and include approaches to ensure the safety of the residents on the secure unit for additional aggressive behaviors. Additionally, the facility failed to address the incident in R37's record and there was no evidence the staff assessed R37 to ensure he was not injured by the incident and was not afraid of R369. c. Facility Investigation - 4/18/17 Incident On 4/20/17 at 10:42 a.m., an incident report of the 4/18/17 resident-to-resident altercation was requested from the assistant director of nursing (ADON). The ADON responded that there was no incident report or investigation, as the facility did not complete incident reports for resident-to-resident altercations (cross-reference F226: failure to develop policies to address resident-to-resident altercations and/or abuse). The ADON added the facility did not internally report these incidents or document them on incident reports because the state licensing body did not require them to be reported. On 4/20/17 at 3:45 p.m., the director of nursing (DON) provided the policy addressing resident-to-resident altercations and confirmed these incidents were not reported and no incident reports or other investigations were completed for resident-to-resident altercations. On 4/20/17 at 6:35 p.m., the DON was alerted to the observed resident-to-resident altercation that occurred on 4/18/17 and follow up information was requested. On 4/21/17 at 4:21 p.m., NM 1 stated a progress note for R37 regarding the incident was written on 4/20/17, but should have been done at the time of the incident on 4/18/17. She stated the staff verbally reported the incident to her, but there was no incident report/investigation because these were not completed for any resident-to-resident altercations. However, she stated she would have expected the staff to assess R37 for injury and address the incident in R369's care plan at the time the incident occurred. On 4/21/17 at 5:08 p.m., the medical director stated, with resident-to-resident incidents, they did not complete incident reports or report to the state licensing authority unless the incident was criminal in nature. He stated he would have preferred the facility investigate and implement approaches to prevent recurrence at the time of the incident rather than several days later. 4. R471 The undated Resident Face Sheet documented R471 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R471's closed record was reviewed. The 2/27/17 admission MDS assessment documented R471 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. She exhibited physical behavioral symptoms directed toward others and behavioral symptoms not directed toward others (section E0200) and several mood symptoms of depression (section D0200). R471's 3/15/17, 2:15 p.m. Progress Note documented, Resident went to cardiac appointment with son .and daughter-in- law .While there she voiced concerns to son. Daughter-in-law spoke with Nurse Manager. The ambulance company called and asked what to do as the son had said to take the resident to his home. Nurse Manager spoke with son who stated he was not bringing his mother back that she was going home . A 3/15/17 investigation report documented this statement, written by the director of nursing (DON): At 2:14 p.m., I received a call from Nurse Manager (NM) 3), (who) spoke with (R471's) daughter-in-law who stated that the resident was saying she was mistreated last night. (R471) was going to the bathroom and the (certified nursing assistant (CNA)) began cursing and hit the wall. She was unable to say who the person was but knew that it was not CNA15 or CNA14; that it was someone at night who had worked with (R471) but she couldn't (sic) say who. During this time, (NM3) received a call from the ambulance company transporting (R471) stating the son was telling them not to go back to the facility but take her to his home. (NM3) and I discussed this issue. (NM3) called the son .to speak to him about a discharge against medical advice. (NM3) tried to talk with the son but he kept interrupting her. At one point, she hands me the phone. (R471's) son states he is taking his mother home, that the night (CNA) had verbally abused her and hit the wall with her fist. At one point he uses the word accosted his mother At 3:28 p.m. I received a phone call from (the insurance company representative) .He had been told by (R471's son) that a night shift (CNA) had verbally abused his mother, hit the wall with her fist, and punched a hole in the wall. The representative was calling to inform us that he was filing a quality of care grievance. He asked what we were doing. I told him it had been reported and we would be investigating. He stated it wasn't right that staff should be cussing out people and beating on walls. I again stated this was being investigated.R471is alert and oriented with confusion at times. Her BIMS score is 14 out of 15. She is a very anxious person who had told therapy staff she wanted to go home. During this investigation, the evening CNA .was here. She explained that evening, she was taking (R471) to the bathroom to get ready for bed. She was very anxious, didn't (sic) want to stand up, when the CNA got the sit to stand lift, she became even more anxious. She got assistance and they were able to assist (R471) and get her into bed, a statement to be obtained. Review of the incident investigation, conducted by the facility on 3/15/17 to 3/17/17, revealed it included interviews with 5 staff members as well as observation of R471's bathroom wall, which did not have a hole in it. However, the investigation did not include interviews with other residents who would have had the same caregiver as R471 to rule out similar incidence of abuse. On 4/21/17 at 8:55 a.m., the assistant director of nursing (ADON), whom the facility had designated as their abuse coordinator, stated she had not done any interviews with other residents who lived near R471. She stated, We don't (sic) normally do that. If there was a resident in the room, we would interview them, but we usually don't (sic) interview other residents. On 4/21/17 at 9:53 a.m., the DON stated, it depends on what the complaint is whether we do resident interviews. In the past, we have interviewed the other residents in the same group to see if there are similar complaints. We could not speak with (R471) as she had been discharged from the facility before making the allegation, but we did speak with her CNAs. The story changed as it went along. The family said there was a hole punched in the (bathroom) wall, but we went to look and there was no hole. The DON confirmed there were no interviews conducted with residents as part of this investigation and agreed interviews with residents who might have had the same care givers would be an integral part of an abuse investigation. Although the facility 2/5/04 Abuse/Neglect/Misappropriation policy documented, All suspicious incidents will be thoroughly investigated in a timely fashion The policy did not address all necessary components of the investigation. Except for the resident involved in the incident, the policy did not address the need to obtain witness statements and/or interviews from additional residents. Cross-reference F226 for the failure to develop a comprehensive abuse policy in the area of investigation. Immediate Jeopardy (IJ) was identified in the areas of 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration at F490 and F501, and 42 CFR 483.75 Quality Assurance & Performance Improvement at F520, all cited at a Scope and Severity of a K. Substandard Quality of Care was identified at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation and Quality of Care. Immediate Jeopardy was identified on 4/21/17 and determined to exist starting on 8/7/16 when R215's first sexually aggressive incident occurred towards R405. The facility Administrator was informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17. The State Survey Agency validated the IJ was removed on 4/21/17 at 6:20 p.m. The AOC included: Removal plan for Resident #215 for Psychological Evaluation Until Resident #215 can be discharged from the facility, he will be supervised by staff one-on-one. Transport is being arranged for Resident #215 to be discharged immediately to (name of) emergency room for evaluation. He will be evaluated for return following appropriate evaluations and treatment as required . Immediate Plan to Prevent Future Occurrence Residents on the secure unit with known potential for aggressive behaviors will have their care plan reviewed and updated as required. All other residents on the secure unit will have their care plans reviewed and updated as required. All staff currently on duty on the secure unit will be in-serviced during immediately on how to recognize abuse, intervention techniques, and proper reporting. All other staff reporting for future shifts on the secure unit will be in-serviced as above prior to beginning their shift. This will continue until all staff on the secure unit have been in-serviced. All staff will be in-serviced on how to recognize abuse, intervention techniques. All residents in the facility will be assessed for resident-to-resident abuse potential and actions taken as necessary (to include discharge from the facility) to alleviate any concerns. The resident-to-resident abuse policy will be reviewed and amended to include tracking, monitoring, and reporting of any incidents. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. The Scope and Severity was lowered to a E at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration, at F490; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes.

Based on observation, record review, policy review and interview, the facility failed to ensure the abuse policy and procedure was adequate, providing sufficient detail and direction to staff in the areas of reporting, investigating, and follow up in response to incidents of resident to resident abuse. The facility's current policies and procedures were insufficient in these areas. Staff failed to report and investigate 7 instances of resident to resident sexually or physically aggressive behaviors by resident (R) R215 towards 6 residents (R400, R406, R405, R236, R326, and one unknown female resident) and 1 incident of resident to resident physically aggressive behavior by R369 towards R37. All 8 instances took place in the secure unit where a total of 44 residents resided. In none of these 8 instances, was a report made to the state agency, a thorough investigation completed or sufficient interventions implemented to prevent recurrence. Additionally, R471 reported an allegation of abuse; a thorough investigation was not conducted. The facility's failure to ensure the abuse policy was adequate to prevent the occurrence of resident to resident abuse was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus, immediate jeopardy was identified on 4/21/17 at 2:42 p.m. All 43 residents who resided on the secure unit with R215 were at risk of abuse from R215 as well as other residents with allegations of abuse that might not be thoroughly investigated. The immediate jeopardy was determined to first exist on 8/7/16 at 6:23 p.m., when R215 was first sexually aggressive towards another resident on the secure unit. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received, and approved, by the state survey agency on 4/21/17 at 6:20 p.m. Following removal of the immediate jeopardy, the deficient practice remained at an E scope and severity, indicating a pattern of potential for more than minimal harm. Findings include: 1. Abuse Policies and Procedures a. The facility's 3/15/00 policy on Resident (to) Resident Abuse documented, Each resident has the right to be free from mistreatment, neglect, and misappropriation of property by anyone. Although the policy identified residents having the right to be free from mistreatment, neglect and misappropriation of property, the policy failed to identify the right of residents to be free from abuse. b. The Abuse/Neglect/Misappropriation Standard Policy/Procedure dated 2/5/14 documented, the facility was committed to the prohibition of any mistreatment, neglect, and abuse of residents or the misappropriation of resident property. The terms Neglect and Misappropriation of resident property were defined; however, the definition of abuse was not defined or addressed. c. The facility's 5/27/16 policy addressing Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Complaint (sic) Responsibilities documented: All alleged abuse, neglect, exploitation of an adult, incidents of unknown origin with suspicious circumstances, and accident or serious injury such as fractures, severe burns, severe lacerations, severe hematoma; will be investigated, documented and reported to the appropriate state agency as further described in this policy .DHEC (state agency) Licensure shall be notified within 24 hours of a serious accident/incident by phone, email or fax .A serious incident shall be considered as, but not limited to: .7. Confirmed or suspected cases of resident abuse, neglect, or exploitation .DHEC Certification and the facility Administrator shall be notified immediately but not to exceed 24 hours after discovery of all alleged violations involving abuse (physical, verbal, sexual or mental) .There is no requirement to report resident-to-resident abuse where the incident fails to meet other reporting criteria. Although the policy directed staff to report and investigate allegations of abuse, the policy was not clear to direct staff to report and investigate alleged abuse allegations if they were resident to resident incidents. Staff interpreted the policy to mean resident to resident incidents did not need to be reported or investigated without an injury or a crime being obvious or present (see staff interviews below). d. The facility's 5/27/16 policy addressing Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Complaint (sic) Responsibilities documented: Documentation to include but not limited to: 1. All information and forms included in abuse packet 2. Face sheet from resident's chart 3. Pertinent lab or x-ray results 4. Nurse's notes pertinent to the incident 5. Event documentation 6. Physician's Progress Notes pertinent to the incident if available 7. Care Plan pertinent to the incident 8. Copies of all information sent back with the resident if they were seen in the emergency room for treatment or if they were admitted to the hospital and released back (to the facility) 9. Statements from staff that may have been involved in or who have knowledge of the incident 10. Statement from the resident involved if they are alert, oriented, and interviewable 11. All statements must be signed and dated by the writer and witnessed by two individuals. This policy did not address the need to obtain witness statements and interviews from other residents. Cross-reference F225 for the failure to thoroughly investigate allegations of abuse. e. The facility's 2/5/04 Abuse/Neglect/Misappropriation policy documented, All suspicious incidents will be thoroughly investigated in a timely fashion The policy did not address necessary components of the investigation to ensure the investigation was thorough. 2. Review of R215's Annual Minimum Data Set assessment (MDS) (a resident assessment tool), dated 1/20/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the MDS assessment dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score, measuring cognition, was 10 out of 15. A score of 10 indicated moderate cognitive impairment. The MDS, Section E, Behavior, indicated R215 exhibited physical and sexual, behavioral symptoms toward others. The MDS, Section G, Functional Status, indicated R215 could move about on the unit (locomotion) with limited assistance once he was in his wheelchair. Observation of R215 on 4/19/17, 4/20/17 and 4/21/17 at various times of the day, revealed he could independently maneuver his wheelchair throughout the secure unit. He was talkative with staff; however, at times became argumentative with staff when he was not allowed to exit the unit. R215 had a non-releasing seat belt and pommel cushion while in his wheelchair. Review of R215's behavior care plan revealed his physical, verbal and sexually aggressive behaviors were not addressed. Seven incidents of physical or sexual abuse, in which R215 was the aggressor, occurred between 8/7/16 and 4/19/17. R215 was physically or sexually aggressive towards R405, R236, R400, R326, R406 and an unknown female resident. Cross-reference F323 for specific information regarding the incidents. During an interview with the DON on 4/21/17 at 11:50 a.m. she confirmed the facility did not complete incident reports, or conduct any type of investigation when resident-to-resident altercations occurred. She stated .we (the facility) just never have . The DON also stated, according to their abuse policy, .we are not required to report resident-to-resident abuse to the state . Additionally, neither the DON or Nurse Manager (NM)1 could state how they track, or monitor, resident-to-resident altercations, in which to determine correct interventions have been implemented. 3. An incident of physical abuse was observed during the survey in which R369 hit R37. On 4/18/17 at 12:50 p.m., when R37 commented to R369 regarding her missing shoe, R369 exclaimed, Mind your own damn business! She then hit R37 in the left arm. Three staff members witnessed the altercation; one redirected R369 back to the dining room. R37 wheeled toward his room down the hall; staff were not observed to assess R37 for injury. Cross-reference F323: the facility failed to identify R369's physical and verbal behavioral symptoms directed toward others in the care plan and did not include approaches designed to ensure the safety of the residents on the secure unit for additional aggressive behaviors. Additionally, the facility failed to address the incident in R37's record and there was no evidence the staff had assessed R37 to ensure he was not injured by the incident and was not afraid of R369. On 4/20/17 at 10:42 a.m., an incident report of the 4/18/17 resident to resident altercation was requested from the assistant director of nursing (ADON). The ADON responded that there was no incident report, as the facility did not complete incident reports for resident to resident altercations. The ADON stated the facility did not internally report these incidents or document them on incident reports because the state licensing body did not require them to be reported. On 4/20/17 at 3:45 p.m., the director of nursing (DON) provided the policy addressing resident to resident altercations and confirmed that these incidents were not reported and no incident report or investigation was completed for resident to resident altercations. On 4/20/17 at 6:35 p.m., the DON was alerted to the observed resident to resident altercation on 4/18/17 and follow up information was requested. On 4/21/17 at 4:21 p.m., nurse manager (NM) 1 stated a progress note for R37 regarding the incident was written on 4/20/17, but should have been done at the time of the incident on 4/18/17. She stated the staff verbally reported the incident to her, but there was no incident report done as these were not completed for any resident to resident altercations. She stated she would have expected the staff to assess R37 for injury and address the incident in R369's care plan at the time the incident occurred. On 4/21/17 at 5:08 p.m., the medical director stated with resident-to-resident incidents, the facility would typically notify the family. They did not complete incident reports or report to the state licensing authority unless the incident was criminal in nature. The medical director stated he had not been alerted to many of the resident to resident incidents that occurred in the facility. He stated he would have preferred the facility investigate and implement approaches to prevent recurrence at the time of the incident. 4. The undated Resident Face Sheet documented R471 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 2/27/17 admission MDS assessment documented R471 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. R471's 3/15/17, 2:15 p.m. Progress Note documented, Resident went to cardiac appointment with son .and daughter-in- law .While there she voiced concerns to son. Daughter-in-law spoke with Nurse Manager. The ambulance company called and asked what to do as the son had said to take the resident to his home. Nurse Manager spoke with son who stated he was not bringing his mother back that she was going home . A 3/15/17 investigation report, written by the director of nursing (DON), indicated she received a report from R471's family members that R471 was mistreated at night while going to the bathroom. A family member reported to the DON the certified nurse aide (CNA) verbally abused and accosted the resident as well as hitting the wall with her fist. Cross-reference F225 for details regarding the incident. Review of the incident investigation, conducted by the facility on 3/15/17 to 3/17/17, revealed it included interviews with 5 staff members. However, the investigation did not include interviews with other residents who would have had the same caregiver as R471 to rule out similar incidence of abuse. On 4/21/17 at 9:53 a.m., the DON stated, it depends on what the complaint is whether we do resident interviews. In the past, we have interviewed the other residents in the same group to see if there are similar complaints. We could not speak with (R471) as she had been discharged from the facility before making the allegation. The DON confirmed there were no interviews conducted with residents as part of this investigation and agreed interviews with residents who might have had the same care givers would be an integral part of an abuse investigation. Apart from interviewing the resident who was the potential recipient of an abuse incident, the facility policy (see above) did not direct staff to conduct interviews with additional residents. No residents were interviewed during this investigation. Immediate Jeopardy (IJ) was identified in the areas of 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration at F490 and F501, and 42 CFR 483.75 Quality Assurance & Performance Improvement at F520, all cited at a Scope and Severity of a K. Substandard Quality of Care was identified at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation and Quality of Care. Immediate Jeopardy was identified on 4/21/17 and determined to exist starting on 8/7/16 when R215's first sexually aggressive incident occurred towards R405. The facility Administrator was informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17. The State Survey Agency validated the IJ was removed on 4/21/17 at 6:20 p.m. The AOC included: Removal plan for Resident #215 for Psychological Evaluation Until Resident #215 can be discharged from the facility, he will be supervised by staff one-on-one. Transport is being arranged for Resident #215 to be discharged immediately to (name of) emergency room for evaluation. He will be evaluated for return following appropriate evaluations and treatment as required . Immediate Plan to Prevent Future Occurrence Residents on the secure unit with known potential for aggressive behaviors will have their care plan reviewed and updated as required. All other residents on the secure unit will have their care plans reviewed and updated as required. All staff currently on duty on the secure unit will be in-serviced during immediately on how to recognize abuse, intervention techniques, and proper reporting. All other staff reporting for future shifts on the secure unit will be in-serviced as above prior to beginning their shift. This will continue until all staff on the secure unit have been in-serviced. All staff will be in-serviced on how to recognize abuse, intervention techniques. All residents in the facility will be assessed for resident-to-resident abuse potential and actions taken as necessary (to include discharge from the facility) to alleviate any concerns. The resident-to-resident abuse policy will be reviewed and amended to include tracking, monitoring, and reporting of any incidents. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. The Scope and Severity was lowered to a E at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration, at F490, while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes.

Based on observation, interview, record review, and policy review, the facility failed to provide adequate supervision and implement interventions to prevent resident to resident altercations and/or a fall for 8 of 57 stage 2 sampled residents (R) (R37, R72, R215, R405, R236, R400, R326, R406), an unknown female resident, and 43 residents residing on the secure unit with R215. Specifically, -The facility failed to ensure aggressive behaviors of R215 towards other residents were addressed and sufficient interventions were implemented to keep the remaining 43 residents who resided on the secure unit safe from harm inflicted by R215. R215, who was cognitively impaired yet at a higher cognitive level than his victims, exhibited aggressive physical behaviors towards residents on 3 occasions and sexually aggressive behaviors towards residents on 4 occasions between 8/7/16 and 4/19/17. The residents assaulted by R215 were R405, R236, R400, R326, R406 and an unknown female resident. The facility failed to notify R215's physician of the physically and sexually aggressive incidents; subsequently, there was a lack of physician response to the incidents. Investigations into the incidents and protective measures to prevent recurrence were lacking creating an unsafe environment in the secure unit. The facility's failure to provide supervision to keep residents safe from R215 was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified to have existed on 8/7/16 at 6:23 p.m. when R215 was first sexually aggressive towards R405. The administrator and director of nursing (DON) were informed of the Immediate Jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17 and the immediate jeopardy was removed on 4/21/17 at 6:20 p.m. The scope and severity was lowered to a E, pattern at potential for more than minimal harm, once the immediate jeopardy was removed. -The facility failed to respond appropriately to an incident of resident-to-resident aggression between R369 and R37 to address potential injury and develop interventions to prevent recurrence. -The facility failed to investigate, address potential injury and develop interventions to prevent recurrence for a self-reported incident for R72 which met the criteria for a fall. Findings include: 1. Review of R215's Annual Minimum Data Set assessment (MDS) (a resident assessment tool), dated 1/20/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score, measuring cognition, was 10 out of 15. A score of 10 indicated moderate cognitive impairment. Section E, Behavior of the MDS indicated R215 exhibited physical and sexual, behavioral symptoms toward others. Under Section G, Functional Status, R215's locomotion on the unit was coded as limited assistance once he was in his wheelchair. Observation of R215 on 4/19/17, 4/20/17 and 4/21/17 at various times of the day, revealed he was able to independently maneuver his wheelchair throughout the secure unit. He was talkative with staff; however, at times became argumentative with them when he was not allowed to exit the unit. R215 had a non-releasing seat belt and pommel cushion in place while in the wheelchair. Although R215 had a care plan addressing behaviors, his physical, verbal and sexually aggressive behaviors were not identified or addressed. a. Seven incidents of physical or sexual abuse, in which R215 was the aggressor, occurred between 8/7/16 and 4/19/17. R215 was physically or sexually aggressive towards R405, R236, R400, R326, R406 and an unknown female resident: 1) 8/7/16 Incident Between R215 and R405 Review of R215's nursing progress notes on 4/21/17 revealed on 8/7/16 at 6:23 pm .Resident observed attempting to kiss R405. When stopped by this nurse R215 briefly became argumentative and made one attempt to repeat behavior. Residents were physically separated by this nurse . This was the first resident-to-resident sexual altercation between R215 and R405. Review of R405's nursing progress notes on 4/21/17 R405 revealed . Resident observed holding hands with R215. R215 was attempting to kiss resident. R405 was neutral towards behavior with no attempt to withdrawal (sic) or return kiss, and talking in confused speech. Resident's currently separated by this nurse. R405 making no attempt to return to R215. Will continue to monitor . A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 2) 8/21/16 Incident Between R215 and R236 Review of R215's nursing progress notes on 4/21/17 revealed on 8/21/16 at 9:41 a.m. .resident observed with his left hand under the gown of R236. R215 was informed this was not acceptable behavior and to the nurse's station. R215 gave no verbal or physical reply and was not resistive . Review of R236's clinical record revealed no documentation of the observed sexually aggressive incident of R215 towards R236. The quarterly MDS dated [DATE] revealed R236 was severely, cognitively impaired. 3) 8/21/16 Incident Between R215 and R400 Review of R215's nursing progress notes on 4/21/17 revealed on 8/21/16 at 7:10 p.m. .resident observed rubbing buttocks of R400. R400 was not receptive to behavior. Informed R215 touching of this nature was not appropriate, resident became agitated loudly stating 'Why don't you keep your hands to yourself' and 'You go on.' Residents separated by staff . Review of R400's clinical record revealed no documentation of the observed sexually aggressive incident of R215 towards R400. The MDS dated [DATE] revealed R400 was severely, cognitively impaired. 4) 10/25/16 Incident Between R215 and R326 Review of R215's nursing progress notes on 4/21/17 revealed on 10/25/16 at 5:15 p.m. .Resident seen by CNA striking (R326). Strike an open-handed swipe. Resident (R215) stated 'I didn't mean to, I was trying to hit her hand' and 'She was trying to take my hat.' Informed resident (R215) to notify staff if residents attempt to take his belongings, that striking other residents was not acceptable behavior. Resident apologized, did not repeat incident through shift . Review of R326's nursing progress notes on 4/21/17 R326 revealed .resident seen by CNA being struck open-handed by R215. Resident was reported as attempting to take R215's hat. Resident free from injury, non-distressed, talking in confused babbling speech, reaching for other residents and staff per baseline. Resident (R326) witnessed returning to R215 once to take that resident's hat. Resident (R326) redirect herself away from R215 after being unable to reach hat. Will continue to monitor . The quarterly MDS dated [DATE] revealed R326 was severely, cognitively impaired. 5) 11/17/16 Incident Between R215 and R405 Review of R215's nursing progress notes on 4/21/17 revealed on 11/17/16 at 7:07 p.m. .Resident inappropriately touching R405. This resident (R215) had his right hand reaching up resident's shirt and was attempting to kiss other (sic) resident. When confronted about this behavior resident (R215) laughed, stated 'She wants it.' Informed resident this was not acceptable behavior, separated residents . This was second resident-to-resident sexual altercation between R215 and R405. Review of R405's nursing progress notes on 4/21/17 of R405 revealed .resident observed by this nurse being inappropriately touched by R215. This resident (R405) was passive during this episode, was seen talking but was not able to be heard by this nurse. Separated residents. When asked if she (R405) is ok resident states 'I'm fine.' Will continue to monitor . A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 6) 2/14/17 Incident Between R215 and Unknown Female Resident Review of R215's nursing progress notes on 4/21/17 revealed on 2/14/17 at 10:43 pm .Resident (215) swung at another resident (female) with closed fist because she touched his friend. Only touched her arm out of compassion but (R215) swung at resident with open fist . The facility was unable to determine who the female resident was. 7) 4/19/17 Incident Between R215 and R406 Review of nursing progress notes on 4/21/17 revealed on 4/19/17 at 8:54 p.m. .Resident (215) in altercation with Resident (R406). Resident (215) punched resident (R406) in the face because he said resident (R406) was talking to his 'girlfriend.' Redirection was given to Resident 215. Altercation broken up by staff. Closed fist altercation . Review of R215's nursing progress notes on 4/21/17 revealed .on 4/21/17 at 8:40 am was able to reach RP (responsible party) this morning and discuss altercation between his father and resident (R406). RP stated, 'I thought he was doing better on the Zoloft.' RP informed that the resident has shown an improvement with aggressive behaviors since his increase in Zoloft back in February, but due to his lasted (sic) altercation, it may benefit the resident to have a psychiatric consult. The RP agreed . Review of nursing progress notes on 4/21/17 of R406 revealed R406 had .No apparent injuries noted . The quarterly MDS dated [DATE] revealed R406 was severely, cognitively impaired. b. The facility failed to implement adequate interventions directed at R215 to prevent resident to resident altercations and to keep residents on the secure unit safe from R215. Interventions consisted of medication changes and separating residents at the time the incident occurred. Interventions implemented were as follows: According to the pharmacist progress note dated 3/24/16, R215 was started on Seroquel (an antipsychotic) 25 mg daily on 3/3/16. The Seroquel was increased to 25 mg twice a day on 3/9/16. Pharmacy recommendation stated .resident displaying aggressive behaviors . The social work quarterly progress note dated 7/27/16, revealed R215 .was recently transferred to the secure unit and is alert with a BIMS of 13/15. It was noted that he can be aggressive and has an order for [REDACTED]. The nursing progress notes dated 8/22/16 at 10:49 p.m., revealed R215 was started on Zoloft (an antidepressant) 25 mg daily .related to resident's inappropriate behavior towards female residents. Message left on answering machine for RP to call facility . No additional documentation could be found which indicated the RP was aware of the new order for Zoloft. Cross reference F157. On 2/14/17 the medication was increased to 50 mg daily. According to the social work progress note dated 8/22/16 at 4:59 p.m., .social work (SW) spoke with R215 regarding his inappropriate sexual behaviors. R215 reported that he needed others to behave as well. SW explained that he did not need to touch anyone that did not want to be touched and that some of the females that may allow it did not understand all that was going on when/if he touched them in a sexual manner. SW not sure of all that was understood, but SW reiterated that he need (sic) to behave himself and he stated that he would 'try.' SW will continue to provide support and assistance as needed . The pharmacist progress note dated 10/11/16, revealed .Tolerating medications well. Recommend physician consider GDR (gradual dose reduction) of Seroquel . The physician progress notes [REDACTED].history of aggressive behaviors, ok today. Stable and continue current treatment . Nursing progress notes dated 10/24/16 at 2:24 p.m., revealed .bath certified nursing assistant (CNA) reported that resident was combative-hitting-during his shower . Further review of the nursing progress notes dated 10/25/16 at 2:20 p.m., revealed .new order noted to decreased (sic) Seroquel to 25 mg at night . The social work quarterly progress note dated 10/24/16, revealed R215 .was alert with a BIMS of 9/15, but does have some confusion at times. He has been adjusting to his current unit and has taken to some of the female residents on the unit. It was noted he can be aggressive at times. He is not followed by psych; however, it will be available to him if needed . The pharmacist progress note dated 1/13/17, revealed .12/13/16 Depo-Provera 150 mg IM (intramuscular) every 3 months. Recommend physician add [DIAGNOSES REDACTED]. No documentation could be located for the Depo-Provera as of 4/21/17 and R215 was still receiving the medication. During an interview with Nurse Manager (NM)1on 4/21/17 at 11:50 a.m., she stated the RP was not notified prior to starting the medication. Cross-reference F157. The social work annual progress note dated 1/25/17, revealed R215 .was alert with a BIMS of 10/15. During this assessment, he exhibited physical aggression towards others. R215 is known for engaging with the females in which sometimes he has to be redirected for inappropriate touching and/or comments. He is not followed by psych . A Physician order [REDACTED].increase Seroquel to 25 mg twice a day . As of 4/21/17 R215 was still receiving the medication at this dose. Review of the physician progress notes [REDACTED]. Furthermore, there was a lack of documentation in R215's medical record to show the physician was notified of the resident to resident altercations initiated by R215 towards other residents. Cross reference F157 for specific findings. No individualized interventions for R215 were developed or implemented in response to resident-to resident altercations. The only intervention, in addition to medication management, was the immediate separation of R215 and R400, R406, R405, R236 and R326. Since R215's admission to the facility on [DATE], and subsequent transfer to the facility secure unit on 7/27/16, no referral for psychiatric consult or any other professional service to address the resident's mood and behaviors was obtained. c. Staff Interviews On 4/21/17, multiple requests to administration to interview the social worker for the secure unit were made; however, an interview did not occur. During an interview with the DON and nurse manager (NM)1 on 4/21/17 at 11:50 a.m., they were asked what interventions were implemented to prevent further resident-to-resident altercations. The DON stated They were separated at the time of the incident. Neither the DON or NM1 could state what, if any, additional interventions were put into place following each altercation, other than what was already charted in R215's clinical record. When NM1 was asked about obtaining a psychiatric consult, she stated .The son (RP) refused . NM1 was also asked if R215's RP was aware of the number of resident-to-resident altercations and she stated he was. NM1 further stated R215's RP stated to her That's dad. Dad will be dad. During the same interview with the DON on 4/21/17 at 11:50 a.m. she confirmed the facility did not complete incident reports, or any other investigation when resident-to-resident altercations occurred. She stated We (the facility) just never have. On 4/21/17 at 6:31 p.m., the administrator stated resident-to-resident abuse, physical aggression, or sexually inappropriate behavior had not been brought to his attention, or to the attention of the QA committee, for root cause analysis, tracking and trending of incidents, or development of a plan to prevent additional occurrences. He stated, We don't know about it. With (R215), it appears the nurse made a note and did not tell anybody. My expectation is an incident report be completed. (An incident report) should have been done for every instance. d. Policy and Procedure According to the facility policy and procedure Resident-Resident Abuse, dated 3/00, Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis. According to the facility policy and procedure Facility Wide Abuse/Neglect/Misappropriation, dated 2/04, under Prevention - bullet D .the facility will thoroughly investigate any suspected abuse, neglect and/or misappropriation of resident property and take appropriate action to prevent recurrence . 2. According to the undated Resident Face Sheet, R369 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/17/17 quarterly MDS assessment documented R369 had severely impaired cognition (section C1000). She had unclear speech (section B0600) and was rarely/never able to understand others (section B0800). R369 exhibited physical and verbal behavioral symptoms directed toward others (section E0200). R369's Care Plan, revised 3/28/17, documented R369 had poor safety awareness and impaired decision-making ability due to her dementia and was anxious at times. The approaches included: continuously remind resident of boundaries, .frequently monitor for safety issues and address as needed, .re-direct if wandering and/or any other behaviors are effecting (sic) safety and/or health, .(and) identify environmental factors that may increase anxiety R369's Care Plan did not address physical or verbal behaviors toward others. On 4/18/17 at 12:50 p.m., R369 was observed in an altercation with R37. When R37 commented to R369 regarding her missing shoe, R369 exclaimed, Mind your own damn business! She (R369) then hit R37 in the left arm and he raised his fist in a threatening gesture. Three staff members witnessed the altercation, and one redirected R369 back to the dining room. R37 wheeled himself toward his room down the hall; staff were not observed to assess R37 for injury or ask about how he was doing. According to the undated Resident Face Sheet, R37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/7/17 quarterly MDS assessment documented R37 had moderately impaired cognition (section C1000). He was rarely/never able to make himself understood or understand others (sections B0700 and B0800). R37's 5/1/14 Care Plan, revised 4/11/17, documented he had cognitive loss (related to) ETOH (alcoholic) dementia with impaired decision making ability and decreased safety awareness with potential for injury and/or elopement. The approaches included, frequently monitor for safety issues and address as needed .continuously remind resident of boundaries, .decrease external stimuli and provide a safe environment, .(and) identify environmental factors that may increase anxiety. R369's 4/18/17 Progress Note documented, (R37) yelled at this resident, 'Where are your shoes' - This resident made verbal response and slapped (R37) on the left arm - No injuries occurred and staff intervention was successful. Review of R369's Care Plan on 4/20/17 revealed it had not been updated to reflect her physical and verbal behavioral symptoms directed toward others and did not include approaches designed to ensure the safety of the residents on the secure unit for additional aggressive behaviors. Review of R37's Progress Notes on 4/19/17 revealed there was no documentation addressing the incident described in R369's notes above. There was no evidence the staff had assessed R37 to ensure he was not injured by the incident and was not afraid of R369. On 4/20/17 at 10:42 a.m., an incident report of the 4/18/17 resident-to-resident altercation was requested from the assistant director of nursing (ADON). The ADON responded that there was no incident report, as the facility did not complete incident reports for resident-to-resident altercations (cross-reference F225: failure to report and investigate resident-to-resident altercations and F226: failure to develop policies to address resident-to-resident altercations and/or abuse). On 4/20/17 at 3:45 p.m., the director of nursing (DON) provided the policy addressing resident-to-resident altercations and confirmed that these incidents were not reported and no incident reports were completed for resident-to-resident altercations. On 4/20/17 at 6:35 p.m., the DON was alerted to the observed resident-to-resident altercation on 4/18/17 and follow up information was requested. On 4/21/17 at 4:21 p.m., NM1 stated a progress note for R37 regarding the incident was written on 4/20/17, but should have been done at the time of the incident on 4/18/17. She stated the staff verbally reported the incident to her, but there was no incident report done as these were not completed for any resident-to-resident altercation. She stated she would have expected the staff to assess R37 for injury and address the incident in R369's care plan at the time the incident occurred. On 4/21/17 at 5:08 p.m., the medical director stated with resident-to-resident incidents, the facility would typically notify the family. They did not complete incident reports or report to the state licensing authority unless the incident was criminal in nature. The medical director stated he was not alerted to many of the resident-to-resident incidents in the facility. He stated he would have preferred the facility investigate and implement approaches to prevent recurrence at the time of the incident. 3. Review of R72's undated Resident Face Sheet, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of R72's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 2/13/17, documented R72 with a BIMS score of 15/15 indicating no cognitive impairment. R72 required extensive assistance of one staff for bed mobility, dressing, and toilet use and limited assistance of one staff for transfers (section G0110). She was frequently incontinent of bladder and occasionally incontinent of bowel (section H0300 and H0400). R72 also received daily diuretic and antianxiety medications (section N0410). Review of R72's Care Plan, edited on 3/1/17 documented, Potential for falls/injury due to unsteady gait, decreased safety awareness, and HX (history) of fall. The goal was to be free of complications related to falls through next review. The pertinent interventions included: Document any falls/injuries and circumstances of incident, intervene as needed. Encourage to use call light for assistance, keep within reach and answer call light promptly. Instruct to call for assistance prior to attempting to ambulate/transfer. Keep environment free of obstacles that may cause falls/injuries . Observe for unsafe actions and intervene. Observe frequently when out of bed to monitor safety needs. On 4/18/17 at 2:43 p.m. R72 was interviewed and stated she fell approximately a week ago in the bathroom and hurt her left shoulder. R72 attempted to move her arm but grimaced and was unable to lift it more than 10 degrees off the bed. She was lying in bed with the head of the bed raised approximately 25 degrees. Several minutes later, at 2:45 p.m. R72 was noted without her call light in reach. Upon further review the call light was found on the floor towards the head of R72's bed. Review of the Resident Progress Note, dated 4/11/17 at 7:53 a.m. revealed, Resident stated she fell in bathroom earlier today. No report given of a fall. No report given to CNA. Resident in bed all shift. Review of the Resident Progress Note dated 4/20/17 at 1:30 a.m. indicated LPN10, Went in to draw blood and member (R72) c/o (complained of) pain in the left arm and appeared to guard arm. When asked what happened, resident stated that she fell but she could not remember when. Pain medicine offered and resident refused and stated, 'It don't help anyway.' Will report to supervisor. Review of the Resident Progress Notes dated 4/20/17 at 6:50 a.m. indicated R72 complained of left arm and side pain. LPN10 reported it to her supervisor and was advised to fill out a doctor concern form, which she placed in R72's chart. Review of the Resident Progress Notes dated 4/20/17 at 10:40 a.m. indicated the resident complained of left shoulder pain to LPN11. The resident requested Tramadol for pain. R72 remained in bed reading the newspaper. An order was obtained for x-rays to the left humerus (bone in the arm), the forearm and a chest x-ray, two views. LPN11 notified and spoke to resident's responsible party. Review of the x-ray taken on 4/20/17 revealed that there were no fractures, bony lesions, or calcifications. However, the resident was noted to have degenerative changes in both shoulders. On 4/20/17 at approximately 11:00 a.m., the Director of Nursing (DON) was asked for the fall investigation/incident report for R72's report of falling in the bathroom on 4/11/17. On 4/20/17 at 4:55 p.m. The DON provided a copy of a typed one page report, two Investigative Report Statement Form(s) and the PRN Medication Administration History 4/1/17-4/21/17. The DON stated the fall had not been investigated. The DON acknowledged, that although the resident reported she did not fall, the definition of a fall was any change in plane and because no one witnessed the incident, it should have been investigated as a fall when it was reported on 4/11/17. On 4/20/17 at 5:00 p.m. during an interview with R72 and the Director of Nursing (DON), R72 reported that she almost fell a week ago on either 4/10/17 or 4/11/17. R72 stated that she got herself out of bed on her own and went to the bathroom. She stated, When going to get up my head got all funny and I went forward but used my left arm to hold myself up. I was there awhile but reached my wheelchair with my right hand and then managed to get into my chair by myself. Ever since then my shoulder has been hurting me. She discussed that there were two CNAs that came in and put her back to bed, but she could not remember their names. She was asked why she did not pull the emergency cord and she stated, I had my arm in the bar and could not pull the string, I was dangling forward and holding myself up with my left arm. Review of the report titled Follow up report on (resident's name) reported fall in the bathroom by on 4/10/17, provided on 4/20/17 at 4:55 p.m. by the DON revealed, the resident was being re-positioned in bed and was observed to have both arms overhead, using trapeze (a bar used to assist residents with re-positioning) to assist certified nursing assistant (CNA) with positioning in the bed. The report documented that both R72's arms were fully extended, and no favoring of either side, resident observed moving from side to side for positioning devices to be placed. Per the report, R72 gave the following statement, I was in my bed coloring after lunch. I had to go to the bathroom, so I got myself up. Once I was in the bathroom, my head got weird, and I thought I was going to fall. l grabbed the bar with my arm, and hung until I felt better. I did not want to hit my face. After my head cleared, I used my other arm to reach out for my wheelchair. I got it over to me, and got myself in it. When I got back over by my bed, 2 aides came in and asked what I was doing. I told them I had gone to the bathroom, and they helped me back into bed. The nurse conducting the interview documented the following, When asked if she knew when this happened, she said after lunch, probably 2:00 or 2:30 p.m. When asked what day, she stated 'last Monday.' She reported that while she hung on to the bar in the bathroom, all her weight was on her left shoulder, and that is why it now hurt. When asked when it started hurting, she stated 'that day' and says she reported the pain to the nurse that day. When this writer referred to a 'fall' she corrected me and stated she never fell . She reported she used the bar and her arm to hold herself up so she would not fall and hit her face. When asked if she went to the bathroom alone normally, she stated it depended. On days she felt good, she could go to the bathroom independently. Staff reported she sporadically went to the bathroom without help, but was encouraged to ask for assistance. When asked if she knew to use the call light for assistance, in both the bathroom and her bed, she stated she did. On 4/21/17 at 9:33 a.m. LPN11 was interviewed and stated if a resident said they fell , an investigation should be initiated and would include assessing for pain, looking for bruising (head-to-toe assessment), and offering pain medication. LPN11 stated the policy directed staff to notify the family, check with other staff members who worked with resident to see if anything happened, and to notify the nurse supervisor. On 4/21/17 at 9:39 a.m. CNA1 was interviewed and stated on Tuesday R72 had told her that she had gone to the bathroom by herself on Monday night and complained that her left shoulder had been hurting. CNA1 stated there were no bruises on the resident's upper arm or shoulder and she had reported this to the nurse, but could not remember which nurse. CNA1 stated R72 has a history of getting herself up and going to the bathroom on her own. On 4/21/17 at 9:48 a.m. NM3 was interviewed and stated if a resident fell , an incident report must be completed and reported. She stated the form went to the nurse manager, there were standing orders for vital signs and depending on if head contact occurred, standing orders for that. She stated per the protocol, the nurse should have reported it on 4/11/17 and should have initiated the fall protocol with a follow up progress note, notification of the doctor and responsible party and updated the care plan. Review of the facility's Standard Policy/Procedure, NO. 12-07 Subject: Fall Prevention Program, dated 2/26/16, indicated in pertinent part .Reporting and Documenting 1. All resident falls are reported on a Falls Incident Report. 2. Nurses shall document a fall as an event in the electronic health record. Documentation includes the assessment of the resident every shift for 24 hours unless there has been head contact, it will then be for 48 hours. The Nurse manager or designee will close the event once all assessments are completed and will include an evaluation or summary of the fall in the event before closing. 3. The Falls Incident Reports are routed to the Nurse Manager, Director of Nursing and Staff Development Assistant . Evaluating 1. Initial evaluation of the fall is made by the nurse following the fall. The Supervisor or a Registered Nurse will be notified to assess the resident and contact the physician if orders are needed. The nurse shall contact the responsible party. 2. The Falls Incident Report is completed by the nurse on the unit the fall occurred. It is important to collect the facts surrounding the fall at the time they occur. This nurse will initiate the Falls Event in the electronic health record. 3. An Acute Care Plan for falls will be initiated unless a care plan for falls is already in place. The current care plan would then be updated to reflect the fall. Immediate Jeopardy (IJ) was identifi

Based on observations, interviews, record review, and policy review, the facility failed to ensure it was administered in a manner to ensure effective use of its resources to prevent abuse, investigate abuse, and promote a culture and environment free of abuse for 42 residents who lived on the secure unit (all residents on the secure unit except for resident (R) R369 and R215) and for 1 resident (R471) with a reported allegation of abuse. Specifically: The facility failed to ensure aggressive behaviors of R215 towards other residents were reported, investigated, and sufficient interventions were implemented to keep the additional 43 residents who resided on the secure unit safe from potential harm. R215 was found to have exhibited aggressive physical behaviors on 3 different occasions and sexual behaviors on 4 different occasions toward residents R400, R406, R405, R236, R326 and an unknown female resident. The facility's failure to be administered in an effective manner to keep residents safe from R215 was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified to have existed on 8/7/16 at 6:23 p.m. when R215 was first sexually aggressive towards R405. The facility's administrator and director of nursing (DON) were informed of the Immediate Jeopardy on 4/21/17 at 2:42 p.m. Findings include: 1. Job Descriptions According to the administrator's job description, dated 5/2014, under Miscellaneous it read .assure that all residents receive care in a manner and in an environment, that maintains or enhances their quality of life without abridging the safety and rights of other residents . According to the Director of Nursing's (DON) job description, dated 7/02, it stated under Major Duties and Responsibilities - Administrative Functions bullet 1. .plan, develop, organize, implement, evaluate and direct the Nursing Services Department, as well as its programs and activities in accordance with current rules, regulations and guidelines that govern the long-term care facility . 2. Six citations were cited at immediate jeopardy during the recertification survey ending on 4/21/17: Cross-reference F323: Accidents and Supervision - The facility failed to respond appropriately to incidents of resident-to-resident aggression and/or sexually inappropriate behaviors and address any potential injury or psychological harm to the victims as well as develop interventions to prevent recurrence. Cross-reference F225: Abuse Investigation - The facility failed to ensure incidents of potential resident-to-resident physical and sexual abuse were reported, investigated and sufficient measures were implemented afterward to ensure the safety of the victims and prevent recurrence. Cross-reference F226: Abuse Policies and Procedures - The facility's current policies and procedures did not address the reporting, investigating, or monitoring of resident-to-resident abuse adequately and thus, facility staff did not report or investigate any of these incidents, and did not develop interventions to prevent recurrence. Cross-reference F501: Responsibilities of the Medical Director - The facility failed to ensure the medical director was involved in the development and implementation of an adequate and appropriate policy to address resident-to-resident abuse. Cross-reference F520: Quality Assurance (QA) - The facility failed to systematically report, monitor, and address incidents of resident-to-resident abuse. The facility's administration failed to ensure incidents of resident-to-resident abuse were reported, tracked and monitored for trends, or appropriately addressed to ensure new interventions after continued abusive behaviors to ensure the residents on the secure unit were protected from additional occurrences. The facility's administration also failed to promote a safe, homelike milieu for the residents in the secure unit free from abuse, which negatively affected the residents' quality of life and overall well-being. 3. On 4/21/17 at 6:31 p.m., the administrator was interviewed and stated resident-to-resident abuse, physical aggression, or sexually inappropriate behavior had not been brought to his attention, or to the attention of the QA committee, for root cause analysis, tracking and trending of incidents, or development of a plan to prevent additional occurrences. He stated, We don't know about it. With (R215), it appears the nurse made a note and did not tell anybody. My expectation is an incident report be completed. (An incident report) should have been done for every instance. The administrator also stated, I would agree there is a problem with the investigation process. Immediate Jeopardy (IJ) was identified in the areas of 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration at F490 and F501, and 42 CFR 483.75 Quality Assurance & Performance Improvement at F520, all cited at a Scope and Severity of a K. Substandard Quality of Care was identified at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation and Quality of Care. Immediate Jeopardy was identified on 4/21/17 and determined to exist starting on 8/7/16 when R215's first sexually aggressive incident occurred towards R405. The facility Administrator was informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17. The State Survey Agency validated the IJ was removed on 4/21/17 at 6:20 p.m. The AOC included: Removal plan for Resident #215 for Psychological Evaluation Until Resident #215 can be discharged from the facility, he will be supervised by staff one-on-one. Transport is being arranged for Resident #215 to be discharged immediately to (name of) emergency room for evaluation. He will be evaluated for return following appropriate evaluations and treatment as required . Immediate Plan to Prevent Future Occurrence Residents on the secure unit with known potential for aggressive behaviors will have their care plan reviewed and updated as required. All other residents on the secure unit will have their care plans reviewed and updated as required. All staff currently on duty on the secure unit will be in-serviced during immediately on how to recognize abuse, intervention techniques, and proper reporting. All other staff reporting for future shifts on the secure unit will be in-serviced as above prior to beginning their shift. This will continue until all staff on the secure unit have been in-serviced. All staff will be in-serviced on how to recognize abuse, intervention techniques. All residents in the facility will be assessed for resident-to-resident abuse potential and actions taken as necessary (to include discharge from the facility) to alleviate any concerns. The resident-to-resident abuse policy will be reviewed and amended to include tracking, monitoring, and reporting of any incidents. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. The Scope and Severity was lowered to a E at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration, at F490, while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes.