Every finding on record at LaGrange Trails of Journey LLC

Based on observations, staff interviews, and review of the facility policy titled, Glucometer Disinfection, the facility failed to ensure staff followed appropriate disinfection procedures for blood glucose monitoring devices. Specifically, staff failed to properly disinfect the glucometer between resident use during blood glucose monitoring observations for three of three sampled Residents (R) (R4, R2 and R3). This deficient practice placed residents at increased risk for infection transmission and cross-contamination. Findings Include:Observation on 05/12/2026 at 10:08 AM on Hall 300 (East Wing) with Licensed Practical Nurse (LPN) AA revealed R4 received a blood glucose check using a shared glucometer. Following use, the nurse cleaned only the strip insertion area of the glucometer with an alcohol swab rather than disinfecting the entire device according to facility policy.Observation on 05/12/2026 at 10:39 AM on Hall 300 (East Wing) with LPN AA revealed R2 received a blood glucose check using the same shared glucometer. Following use, the nurse cleaned only the strip insertion area with an alcohol swab rather than disinfecting the entire device.Observation on 05/12/2026 at 11:02 AM on Hall 300 (East Wing) with LPN AA revealed R3 received a blood glucose check using the same shared glucometer. Following use, the nurse cleaned only the strip insertion area with an alcohol swab rather than disinfecting the entire device according to facility policy.Interview on 05/12/2026 at 11:58 AM with LPN AA regarding glucometer use and infection control practices revealed there was one shared glucometer available for resident use. The nurse stated proper protocol required disinfecting the glucometer with approved sanitizing wipes between each resident use and allowing appropriate drying/contact time. LPN AA reported checking the medication room and medication carts but was unable to locate disinfecting wipes. She further stated she had not been informed that alcohol wipes could be used in place of approved disinfecting wipes.Interview on 05/13/2026 at 2:17 PM with the Director of Nursing (DON) revealed glucometers were expected to be disinfected between resident use with approved sanitizing wipes and allowed to air dry according to facility protocol. The DON stated alcohol wipes were not considered appropriate for glucometer disinfection and confirmed staff education had been initiated regarding proper disinfection technique. The DON further confirmed sanitizing wipes were available in the facility.Review of facility policy titled, Glucometer Disinfection revised February 1, 2024, revealed item 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (human immunodeficiency), Hepatitis C and Hepatitis B virus. Further review of item 4. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Medication Administration, Insulin Pen, and the package insert TRESIBA (insulin degludec) injection, for subcutaneous use, the facility failed to ensure the accurate administration of medications for four of 40 medication opportunities observed, resulting in a medication error rate of 10 percent for two residents(R) (R4 and R3) during medication administration. This deficient practice had the potential to negatively impact residents' clinical conditions and lead to complications in their current health statusFindings include:Observation on 05/12/2026 at 10:08 AM on Hall 300 (East Wing) with Licensed Practical Nurse (LPN) AA revealed R4 had a physician order for Calcium 600 (calcium carbonate), give 600 milligrams(mg) one time a day. During medication administration, the nurse administered Calcium 600 + D 10 micrograms(mcg), which did not match the physician's order. Observation on 05/12/2026 at 11:02 AM on Hall 300 (East Wing) with LPN AA revealed R3 had physician orders for Amlodipine Besylate 5 mg daily and Losartan Potassium 50 mg daily for hypertension. During medication administration, the nurse obtained the resident's blood pressure of 125/63 and heart rate of 101, then withheld both antihypertensive medications, stating the resident's blood pressure was too low for administration despite no physician-ordered hold parameters.During the same observation, R3 also had an order for Degludec (Tresiba) 100 unit/milliliters(ml) solution, inject 30 units subcutaneously daily for DM (diabetes mellitus). LPN AA dialed the ordered dose but failed to prime the insulin pen prior to administration. The insulin pen was removed approximately two seconds after the final click, and medication leakage was observed at the injection site, right upper arm. The nurse wiped the leakage with the resident's shirt sleeve.Interview on 05/12/2026 at 11:58 AM with LPN AA stated that she believed dialing the prescribed dose constituted priming the pen. When questioned regarding post-injection dwell time, the nurse provided inconsistent responses, 30 seconds to 15 seconds, regarding how long the pen remained in place following administration. Follow-up interview with LPN AA on 05/13/2026 at 1:44 PM revealed it was her understanding that R3's blood pressure was typically low at baseline. The nurse stated she withheld the antihypertensive medications based on nursing judgment rather than physician-ordered parameters due to the resident's diastolic blood pressure of 63. Interview on 05/13/2026 at 2:17 PM with the Director of Nursing (DON) revealed that nursing staff were expected to administer medications according to active physician orders, including following all ordered parameters for medications such as insulin and antihypertensives. The DON stated that nurses were expected to verify orders, obtain required vital signs and blood glucose readings, and clarify missing parameters with the provider prior to withholding medications. She also revealed that education may be needed when nurses were unclear when to administer medications such as antihypertensives when vitals were within normal limits. Medication discrepancies or errors are expected to be promptly addressed through provider notification, responsible party notification, and required facility documentation. The DON further stated that insulin administration should include proper insulin pen technique, including priming the pen with 2 units and holding the injection in place for three seconds after administration. She confirmed that all medications administered must match active physician orders.Review of the facility policy titled, Medication Administration revised February 14, 2024, revealed item 8. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Further review of item 11. Compare medication source (bubble pack, vial, etc.) with medication administration record(MAR) to verify resident name, medication name, form, dose, route, and time Item 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.Review of the facility policy titled, Insulin Pen implemented April 4, 2025, revealed item 11 . Procedure: h. Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Further review of item j. Fully depress the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin.Review of package insert titled, TRESIBA (insulin degludec) injection, for subcutaneous use revised July 2022 revealed under section Instruction for Use .step 7. Priming your TRESIBA FlexTouch Pen: Turn the dose selector to select 2 units, step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. Further review of step 13: Press and hold down the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. You may then hear or feel a click. Keep the needle in your skin after the dose counter has returned to 0 and slowly count to 6. When the dose counter returns to 0, you will not get your full dose until 6 seconds later. If the needle is removed before you count to 6, you may see a stream of insulin coming from the needle tip. If you see a stream of insulin coming from the needle tip you will not get your full dose. If this happens you should check your blood sugar levels more often because you may need more insulin.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Catheter Care, the facility failed to ensure privacy was maintained for two of six residents (R) (R94 and R54) with an indwelling urinary catheter. This deficient practice had the potential to place R94 and R54 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of the facility's policy titled Catheter Care, reviewed/revised 12/2/2024, revealed the Policy section stated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The Policy Explanation section included, . 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 3. Privacy bags will be changed out when soiled, with a catheter change or as needed. 1. Review of R94's electronic medical record (EMR) revealed diagnoses including, but not limited to, urinary tract infection and depression. Review of R94s Quarterly Minimum Data Set (MDS) assessment, dated 4/10/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 13 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident required assistance for all ADLs. Observation on 5/19/2025 at 2:41 pm revealed R94 in a wheelchair with a urinary catheter drainage bag attached to the bottom of the wheelchair with no privacy cover on it, allowing the resident's urine to be exposed for other residents, staff, and visitors to see. Observation on 5/21/2025 at 9:20 am revealed R94 coming from the dining room in a wheelchair with a urinary catheter drainage bag attached to the wheelchair with a privacy bag covering the urinary catheter drainage tubing, but not the drainage bag. In an interview on 5/21/2025 at 12:53 pm, Certified Nursing Assistant (CNA) RR stated that all residents with urinary catheter drainage bags should have a privacy cover on the bag. 2. Review of R54's EMR revealed diagnoses including, but not limited to, urinary tract infection and urethral stricture. Review of R54's Quarterly MDS assessment, dated 3/29/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 15 (indicating little to no cognitive impairment). Section H (Bladder and Bowel) documented the resident had an indwelling urinary catheter. Observation on 5/19/2025 at 3:25 pm revealed R54 lying in bed. Further observation revealed a urinary catheter drainage bag secured to the bed railing with no privacy cover on it. In an interview on 5/20/2025 at 3:45 pm, Licensed Practical Nurse (LPN) II revealed that every resident with an indwelling urinary catheter should have a privacy bag over their drainage bag. In an interview 5/21/2025 at 12:49 pm, Registered Nurse (RN) FF stated that resident R54 should always have a privacy bag on their urinary catheter drainage bag. She confirmed they put one on 5/20/2025 after it was observed that R54 did not have one. In an interview on 5/21/2025 at 12:58 pm, the Director of Nursing (DON) and the Corporate RN stated that all staff were instructed on placing all urinary catheter drainage bags in a privacy bag.

Based on observations, staff interviews, and review of the facility's policy titled Routine Bathroom Cleaning, the facility failed to ensure resident bathrooms were maintained in a clean and sanitary manner in three of seven resident restrooms. This deficient practice placed the residents residing in the rooms at risk of living in an unsanitary environment. Findings include: Review of the facility policy titled Routine Bathroom Cleaning, reviewed/revised 6/25/2024, revealed the Policy stated, It is the policy of this facility to establish policies, procedures, and guidelines to provide a clean and sanitary environment for residents, staff, and visitors in order to prevent cross contamination and transmission of healthcare associated infection (HAI). The Procedure section included, 1. a. Remove soiled linen from the floor, wipe up any spills, and remove waste. c. Clean wall attachments. g. Clean support railings, ledges, and shelves. i. Clean entire toilet including handle and underside of flush rim. Apply disinfectants and allow sufficient contact time according to manufacturer's recommendations. Observation on 5/19/2025 at 11:11 am in the bathroom for resident room [ROOM NUMBER] revealed a brown substance on the handrail beside the toilet. There was a wash basin on the floor with soiled pads in it. The bathroom had a strong odor of urine and feces. Photographic evidence obtained. Observation on 5/19/2025 at 12:01 pm in the bathroom for resident room [ROOM NUMBER] revealed the toilet seat had dried brown matter on the lid. The bathroom had a strong odor of urine and feces. Photographic evidence obtained. Observation on 5/19/2025 at 12:43 pm in the bathroom for resident room [ROOM NUMBER] revealed a strong odor of urine and feces. Observation revealed brown, dried matter visible on the handles of the over-toilet seat. Further observation revealed dried brown matter smeared on the toilet lid, with brown matter inside the toilet, and a washcloth with brown matter and an odor of feces was hanging on the bathroom handrail. Photographic evidence obtained. In an interview on 5/21/2025 at 2:35 pm, Housekeeper TT stated that the housekeeping staff spray the bathrooms, take out the trash, sweep and mop the floor, and scrub and wipe the toilets. Housekeeper TT further stated that the Certified Nursing Assistants (CNA) were responsible for cleaning up bodily fluids. In an interview on 5/22/2025 at 7:38 am, Housekeeper UU stated that the housekeeping staff clean the resident bathrooms by spraying them with a disinfectant and allowing it to sit to disinfect the surfaces. Housekeeper UU further stated that the housekeeping staff were not allowed to clean up bodily fluids, and the CNAs cleaned up bodily fluids. In an interview on 5/22/25 7:44 am, Environmental Supervisor VV stated housekeeping staff cleaned resident restrooms, and CNAs cleaned up bodily fluids. In an interview on 5/22/2025 7:55 am, the Administrator stated he expected resident rooms and bathrooms to be clean. The Administrator stated that nursing staff cleaned up bodily fluids, and housekeeping staff followed up to disinfect the area.

Based on staff interviews, record review, and review of the facility policy titled Bed Hold Notice, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for one of 43 sampled residents (R) (R82). This failure had the potential to contribute to possible denial of re-admission and loss of the residents' home following a hospitalization for residents transferred to the hospital. Findings include: Review of the facility policy titled Bed Hold Notice, dated February 5, 2025, revealed the Policy section stated, It is the policy of this facility to provide a written information to the resident and /or the resident representative regarding bed hold practices both well in advance, and at the time of a transfer for hospitalization or therapeutic leave. The Policy Explanation and Compliance Guidelines section included, 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or resident representative written information that specifies : A. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. 2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. Review of R82's Admission Record revealed the most recent admitted was 1/17/2025. Review of the R82's Discharge Minimum Data Set (MDS) assessment, dated 1/11/2025, revealed Section A (Identification Information) documented a discharge to a short-term general hospital with return anticipated. Review of R82's electronic medical record (EMR) revealed R82 was transferred to the hospital on 1/11/2025. Further review revealed no bed hold policy notice in the EMR or the paper chart. During an interview on 5/20/2025 at 11:45 am, Licensed Practical Nurse (LPN) II revealed that the facility did not complete bed hold policies before the week of 5/5/2025. She stated that the nurses were responsible for completing a bed hold policy when residents were sent to the hospital. She confirmed that a bed hold policy was not completed or provided for R82 at the time of discharge to the hospital on 1/11/2025. During an interview on 5/21/2025 at 11:15 am, the Director of Nursing (DON) confirmed that the bed hold policy was not completed for R82 when he was sent to the hospital on 1/11/2025. She stated that she had provided education to the nurses on the bed hold policy, and the nurses were for providing the written bed hold policy to the resident or resident representative at the time of transfers.

Based on observation, staff interviews, record review, and review of the facility policy titled Appropriate Use of Indwelling Catheters, the facility failed to transcribe a physician's order for an indwelling urinary catheter for one of six residents (R) (R94) with an indwelling urinary catheter. Findings include: Review of the facility's policy titled Appropriate Use of Indwelling Catheters, dated 12/2/2024, revealed the Policy section included, . An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. The Policy explanation and Compliance Guidelines section included, . 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable). Review of R94's electronic medical record (EMR) revealed admission on 12/13/2024 from an acute care hospital with diagnoses including, but not limited to, urinary tract infection and congestive heart failure. Review of R94s Quarterly Minimum Data Set (MDS) assessment, dated 4/10/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 13 (indicating little to no cognitive impairment). Section I (Bladder and Bowel) documented that the resident was incontinent of bladder and bowel. Review of R94's Order Summary Report revealed no order for an indwelling urinary catheter. Review of R94's Progress Notes revealed a Health Status entry dated 5/14/2025 of a verbal order for an indwelling urinary catheter, and the catheter was placed. Observation on 5/19/2025 at 11:54 am revealed R94 had an indwelling urinary catheter drainage bag visible with yellow colored liquid in it. Observation and interview on 5/20/2025 at 9:49 am revealed R94 had an indwelling urinary catheter drainage bag visible with yellow colored liquid in it. Interview with R94 revealed she had the catheter placed for measuring her urinary output due to fluid retention and heart failure. In an interview on 5/20/2025 at 3:54 pm, Licensed Practical Nurse (LPN) II confirmed there was no physician's order for R94 to have an indwelling urinary catheter. She confirmed she received a verbal order and did not transcribe it to the physician's orders. In an interview on 5/20/2025 at 4:08 pm, the Director of Nursing (DON) stated her expectation was for the nursing staff to document and transcribe physician orders directly to the proper place in the electronic health record system when received.

Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) therapy was administered according to the physician's order and respiratory equipment was maintained in a sanitary manner for one of 23 residents (R) (R6) receiving O2 therapy. The deficient practices had the potential to place R6 at risk of respiratory distress and a diminished quality of life. Findings include: Review of the facility policy titled Oxygen Administration, revised 4/9/2025, revealed the Policy explanation and Compliance Guidelines section included, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 5. d. If applicable change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. e. Keep delivery devices covered in plastic bag when not in use. Review of R6's Admission Record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, unspecified chronic bronchitis, and hypoxemia/dependence on supplemental oxygen. Review of R6's Annual Minimum Data Set (MDS) assessment, dated 4/9/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented the resident received O2. Review of R6's care plan revealed a Focus dated 3/9/2023 that the resident required the use of O2. Review of R6's Clinical Physician Order revealed an order dated 6/18/2024 for O2 at two liters per minute (LPM) via nasal cannula (NC) continuous. Further review revealed an order dated 12/23/2024 for ipratropium-albuterol inhalation solution 0.5-2.5 3 milligram (mg)/3 milliliter (ml), one vial orally via nebulizer (a medication used to treat lung conditions). Observation on 5/19/2025 at 11:27 am revealed R6 was receiving O2 via an NC via an O2 concentrator, and the flow rate was set between one and one and a half LPM. Further observation revealed a nebulizing mask hanging from a metal pole, dated 12/6/2024, unbagged and exposed to the environment. In an interview and observation on 5/21/2025 at 8:36 am, the Director of Nursing (DON) and Regional Nurse Consultant confirmed R6's O2 concentrator was incorrectly set at one and a half LPM and confirmed the nebulizer mask was dated 12/6/2024 and unbagged. In an interview on 5/20/2025 at 10:59 am, the DON stated O2 should be administered according to the physician's orders, nebulizer masks and tubing should be changed weekly, and nebulizer masks should be stored in a protective bag when not in use.

Based on staff interviews and record review, the facility failed to ensure that physician-ordered medications were obtained from the pharmacy to be administered at the designated time for three of 43 sampled residents (R) (R93, R64, and R24). This deficient practice had the potential to place R93, R64, and R24 at risk of unmet needs and medical complications. Findings Include: 1. Review of R93's Admission Record revealed R93 was admitted to the facility on [DATE] with diagnoses including, but not limited to, essential hypertension and hyperlipidemia. Review of R93's Physician Orders revealed an order dated 5/6/2025 for amlodipine besylate (a medication used to treat high blood pressure, chronic stable chest pain, and coronary artery disease) oral tablet 5 milligrams (mg), give one by mouth one time a day for blood pressure, hold if systolic blood pressure is less than 110. Further review revealed an order dated 5/6/2025 for atorvastatin calcium oral tablet 40 mg, give one by mouth one time a day for cholesterol. Review of R93's medication administration record (MAR) dated 5/2025 revealed the amlodipine besylate oral tablet 5 mg was documented as not administered on 5/6/2025, 5/10/2025, 5/12/2025, 5/16/2025, 5/18/2025, and 5/20/2025, and the atorvastatin calcium oral tablet 40 mg was documented as not administered on 5/6/2025, 5/16/2025, 5/17/2025, and 5/20/2025. The MAR documentation for all dates that the medications were not administered was marked with the number 9. Review of the Chart Codes located on the MAR indicated the number 9 indicated other/see nurse notes. Review of R93's clinical record revealed a Pharmacy Alert, alert effective date 5/16/2025, for amlodipine besylate oral tablet 5mg, documenting that the pharmacy indicated the order would not be filled due to rejection and to resubmit on or after 6/1/2025. In an interview on 5/20/2025 at 7:55 am, Certified Medication Technician (CMT) EE stated they informed the Licensed Practical Nurse (LPN) when medication was missing and they ordered from the pharmacy. CMT EE stated an order was placed with the pharmacy for R93's amlodipine besylate oral tablet 5mg on 5/6/2025. In an interview on 5/22/2025 at 10:31 am, Registered Nurse (RN) FF confirmed R93 was not administered the amlodipine besylate oral tablet 5mg six times in the last 20 days. She further confirmed that the only blood pressure documented in R93's clinical record was on 5/17/2025. 2. Review of R64's Admission Record revealed R64 was admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic diastolic heart failure, Parkinsonism, cardiomegaly, chronic obstructive pulmonary disease, type II diabetes mellitus, pulmonary hypertension, and atrial fibrillation. Review of R64's Physician's Orders revealed an order dated 12/25/2024 for Sinemet oral tablet (a medication used to treat Parkinson's disease) 25-100 mg, give two tablets by mouth three times a day. Further review revealed an order dated 12/25/2024 for amiodarone hydrochloride oral tablet (a medication used to treat heart rhythm problems) 200 mg, give one tablet by mouth one time a day, hold for pulse less than 62, and an order dated 4/11/2025 for apixaban oral tablet 5 mg (a medication used to prevent and treat blood clots), give one tablet twice a day. Review of R64's MAR, dated 5/2025, revealed the Sinemet oral tablet 25-100 mg was not documented as administered on 5/5/2025 12:00 pm, 5/8/2025 at 5:00 pm, and 5/11/2025 at 12:00 pm. There was no documentation on the MAR indicating a reason the medication was not documented as administered. Further review revealed the amiodarone hydrochloride oral tablet 200 mg was documented as not administered on 5/15/2025, 5/16/2025, and 5/17/2025. The MAR documentation for all dates that the medications were not administered was marked with the number 9. Further review revealed there was no documentation of the amiodarone hydrochloride oral tablet 200 mg being administered on 5/9/2025. Continued review revealed the apixaban oral tablet 5 mg was documented as not administered on 5/11/2025 at 9:00 am or 9:00 pm, 5/12/2025 at 9:00 am, and 5/15/2025 at 9:00 am. Review revealed no documentation in the 5/11/2025 9:00 am section, and the number 9 was coded on the dates of 5/11/2025 9:00 pm, 5/12/2025 9:00 am, and 5/15/2025 9:00 am. Review of the Chart Codes located on the MAR indicated the number 9 indicated other/see nurse notes. Review of R64's clinical record revealed a Pharmacy Alert, alert effective date 5/20/2025, for apixaban oral tablet 5mg and amiodarone hydrochloride oral tablet 200 mg, documenting that the pharmacy indicated the orders would not be filled due to rejection. In an interview on 5/20/2025 at 10:41 am, the Director of Nursing (DON) and the Corporate Nurse Consultant stated that nurses reorder medication through the MARs. They stated that if a medication was unavailable, it should be pulled from the emergency medication supply, and if it was not in stock in the emergency medication supply, the pharmacy should be called. 3. Review of R24's Admission record revealed R24 was admitted to the facility on [DATE] with diagnoses including, but not limited to, essential (primary) hypertension. Review of R24's Physician Orders revealed an order dated 4/22/2024 for Tiadylt extended release (ER) 24-hour oral 180 mg capsule (a medication used to treat high blood pressure or chronic stable chest pain), give one capsule daily by mouth. Review of R24's MAR, dated 5/2025, revealed Tiadylt ER 24-hour oral 180 mg capsule was not documented as administered on 5/2/2025, 5/11/2025, 5/12/2025, 5/13/2025, 5/15/2025, 5/17/2025, and 5/20/2025. Further review revealed 5/11/2025 and 5/20/2025 had no documentation, and all other identified dates were marked with the number 9. Review of the Chart Codes located on the MAR indicated the number 9 indicated other/see nurse notes. In an interview on 5/21/2025 at 9:13 am, Pharmacy Technician LL stated R24's Tiadylt ER 24-hour oral 180 mg capsule required a new order. Pharmacy Technician LL further stated a billing issue was holding the delivery up, but it was also not time for this medication to be filled. In an interview on 5/21/2025 at 9:15 am, Pharmacists MM stated R64 had been inactive in their system, had been reactivated, and any missing medications would be sent to the facility that night. Pharmacists MM stated they were unaware of why the resident had been inactive. In an interview on 5/21/2025 at 11:45 am, Nurse Practitioner OO stated the facility had been having problems with the pharmacy reordering process, and she had discussed the concern with the DON and Unit Managers. In an interview on 5/21/2025 at 1:24 pm, the DON and the Corporate Nurse Consultant confirmed that there had been a problem with communication with the pharmacy. They stated their expectation was for the nurse to notify the DON when a medication was not available. In an interview on 5/21/25 at 4:15 pm, LPN YY stated that it took a long time to receive medications from the pharmacy at times.

Based on observations, staff interviews, and record review, the facility failed to ensure a medication error rate of less than five percent. There were three errors of 30 opportunities for two of six residents (R) (R93 and R24) observed for a medication error rate of 10 percent. This deficient practice had the potential to result in medication not being given in accordance with the physician's orders and the potential to adversely affect R93 and R24's clinical conditions. Findings include: 1. Review of R93's Physician Orders revealed an order dated 5/6/2025 for amlodipine besylate (a medication used to treat high blood pressure, chronic stable chest pain, and coronary artery disease) oral tablet 5 milligrams (mg), give one by mouth one time a day for blood pressure, hold if systolic blood pressure is less than 110. Further review revealed an order dated 5/6/2025 for atorvastatin calcium oral tablet 40 mg (a medication used to lower cholesterol), give one by mouth one time a day for cholesterol. Review of R93's medication administration record (MAR), dated 5/2025, revealed the amlodipine besylate oral tablet 5 mg and atorvastatin calcium oral tablet 40 mg were scheduled to be administered at 9:00 am. Observation on 5/20/2025 at 7:53 am revealed Certified Medication Technician (CMT) EE administered R93's morning medications. Observation revealed that the amlodipine besylate oral tablet 5 mg and the atorvastatin calcium oral tablet 40 mg were unavailable to administer. In an interview on 5/20/2025 at 7:55 am, CMT EE revealed the Licensed Practical Nurse (LPN) was informed of missing medication, and they would find it for them, or would order from the pharmacy. CMT EE stated that R93's amlodipine was ordered on 5/6/2025. 2. Review of R24's Physician Orders revealed an order dated 4/22/2024 for Tiadylt extended release (ER) 24-hour oral 180 mg capsule (a medication used to treat high blood pressure or chronic stable chest pain), give one capsule daily by mouth. Review of R24's MAR, dated 5/2025, revealed the Tiadylt ER 24-hour oral 180 mg capsule was scheduled to be administered at 9:00 am. Observation on 5/20/2025 at 8:10 am revealed CMT EE administered R24's morning medications. Observation revealed that the Tiadylt ER 24-hour oral 180 mg capsule was unavailable to administer. In an interview on 5/20/2025 at 8:15 am, CMT EE stated R24's Tiadylt ER 24-hour oral 180 mg capsule was not available to administer and was not in the emergency medication stock. In an interview on 5/20/2025 at 10:41 am, the Director of Nursing (DON) and the Corporate Nurse stated that the nurses should obtain medications from the emergency medication supply if the medication was unavailable from the cart.

Based on staff interview, record review, and review of the facility policy titled, Antipsychotic Medication Use, the facility failed to ensure that behavior monitoring was documented for one of four residents (R) (R17). The deficient practice had the potential to inhibit nursing staff from monitoring side affects and or adverse reactions for R17 while consuming antipsychotic medications and reporting the findings to the physician. Finding include: Review of the facility policy titled, Antipsychotic Medication Use, with revised date of December 2016 revealed under Policy Interpretation and Implementation: 16. The staff will observe, document and report to the Attending Physician information regarding the effectiveness of any intervention, including antipsychotic medication. 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic Medication to the attending physician. Record review for R17 revealed resident was admitted to the facility with diagnoses that included but not limited to bipolar disorder, and schizophrenia. Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R17 had a Brief Interview for Mental Status (BIMS) of 13 indicating the resident had intact cognition. Further review revealed R17 had no behaviors exhibited but required assistance due to impairment on one side. R17 uses a wheelchair for ambulation. Review of R17 physician orders revealed the following medications not all inclusive of Lexapro oral tablet 10 milligrams (mg) (medication used to treat depression and anxiety), Quetiapine Fumarate oral tablet 100 mg (medication used to treat schizophrenia), and trazadone oral tablet 100 mg (medication used to treat depression) Review of the Electron Medical Records (EMR) revealed there was no evidence of behaviors and/or side effects being monitored for R17 prescribed medications. Interview on 11/14/2023 at 3:10 pm with Certified Medical Assistant (CMA) AA, regarding the information related to how residents are monitored for behaviors when given a medication. CMA AA states, I know my residents so if a change of behavior is shown I document it and tell the Unit manager on schedule. Surveyor asked if there was an order to include behavior monitoring when giving psychotropic drugs. CMA revealed there should be but not always. Interview on 11/14/2023 at 3:00 pm with Unit Manager, CC revealed she revealed an order of behavior monitoring should always be in place to assist with monitoring behaviors and adverse side effects. Interview on 11/14/2023 at 3:05 pm with Unit Manger DD verified there were no orders for R17 behavior monitoring. She expresses all residents receiving psychotropic medications should always have an order to assist with monitoring behaviors. Interview on 11/16/2023 at 3:00 pm with the Directive of Nursing (DON) revealed her expectation is for all residents that receive antipsychotic medications to have an order for behavior monitoring. She states any behaviors, side effects, or adverse reactions should be documented.

Based on observations, staff interviews, record reviews, and review of the facility policies titled, Obtaining a Fingerstick Glucose Level and Hand Hygiene Policy and Procedures, the facility failed to ensure infection control procedures were followed during Glucose finger stick monitoring for three of five Residents (R) (R57, R49, and R12). The deficient practice had the potential to increase the probability of the spread of infection between residents R57, R49, and R12 while monitoring their blood glucose levels. Findings include. Review of the facility policy titled, Obtaining a Fingerstick Glucose Level, Revised October 2010, under Steps in the Procedure: 1. Place the equipment on the bedside stand or table. Arrange the supplies so they can be easily reached. 4. Wear clean gloves. 17. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 18. Remove gloves and discard into designated container. 19. Wash hands. Review of the facility policy titled, Hand Hygiene Policy and Procedures reviewed 3/26/2020, under Policy: All team members (employees) providing direct or indirect care or service will wash their hands/perform hand hygiene in the facility prior to contact with the residents also but not limited team members will wash their hands after gloves are removed after taking care of a Resident who is infected, when hands are visibly soiled, and before leaving the Resident's room. Record review for R57 revealed medical diagnosis included but not limited to Type 2 Diabetes Mellitus. Review of the Care Plan indicated R57 has Diabetes Mellitus and is at risk for hyper/hypoglycemia; physician orders include Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML, NovoLog Flex Pen Solution Pen-injector 100 UNIT/ML (milliliters) Insulin, Levemir FlexTouch Solution Pen-injector 100 UNIT/ML Insulin, and Accu checks before meals and at bedtime. Observation on 11/14/2023 at 9:15 am of fingerstick testing (monitoring of blood sugar level in the blood) for R57 revealed Medication Technician (Med Tech) Certified Nurse Aide (CNA) BB after fingerstick testing was completed did not wash or sanitize her hands after cleaning Glucometer (machine used to monitor blood sugars) and removing dirty gloves. Record review for R49 revealed the medical diagnosis include but not limited to Type 2 Diabetes Mellitus with hyperglycemia, Long term use of Insulin. Physician Orders included: NovoLog Injection Solution (Insulin Aspart), fingerstick glucose before meals, Tresiba Solution 100 UNIT/ML (Insulin Degludec); Care Plan review revealed, the Resident is at risk for hypo/hyperglycemia related to Diabetes Mellitus. Observation on 11/14/2023 at 11:45 am of fingerstick testing for R49 with Med Tech/CNA EE; revealed after fingerstick testing was complete Med Tech/CNA EE took the gloves off and picked up the glucometer and did not immediately sanitize her hands after the procedure; she proceeded to look for the Resident's insulin by opening drawers on the medication cart; she put the glucometer on the cart with no barrier. Interview on 11/14/2023 at 11:55 am with Med Tech/CNA EE she confirmed she did not sanitize her hands immediately after performing the fingerstick test and she did not use a barrier for the meter. Record review for R12; revealed a medical diagnosis included but not limited to Type 2 Diabetes Mellitus with Neuropathy; physicians orders include fingerstick glucose every morning and at bedtime. Observation on 11/15/2023 at 11:30 am of fingerstick testing with Licensed Practical Nurse (LPN) FF for R12 revealed during the procedure the LPN FF put the glucometer on the bedside table without a barrier; after the glucometer was used it was put on top of the cart with no barrier; then put in the drawer on the medication cart without being cleaned. Interview on 11/15/2023 with LPN FF confirmed she did not use a barrier under the glucometer after use and was put in the drawer without being cleaned. She stated she was distracted because a Resident down the hall fell . Interview on 11/16/2023 at 10:50 am with the Infection Preventionist (IP) LPN DD revealed that hand hygiene should be completed before and after care. There is hand sanitizer available in the hall. The process for fingerstick testing includes, sanitizing the machine, get barrier, washing hands prior to the testing procedure, put on gloves, have a barrier in the room to lay on bedside table after finger, take gloves off and sanitize hand, clean glucometer, and lay on barrier. Interview on 11/16/2023 at 5:30 pm with the Administrator it was revealed there have been multiple classes for the staff on infection control including hand hygiene and the use of barriers with glucometers. Further interview also revealed that the staff should have used a barrier before placing glucometer on the residents' table or on the medication cart.

Based on observation, interviews, and review of Storage of Medications Policy the facility failed to ensure that the medication storage room was locked for one of two storage rooms. Findings include: Observation on 1/4/2023 at 9:05 a.m. revealed the East Wing nurses' station was not attended. It was observed that the medication storage room was unlocked and the refrigerator containing medication was also unlocked. Further observation on 1/5/2023 at 9:00 a.m. revealed the medication storage room on the East Wing was still unlocked. However, the refrigerator containing medication was locked at this time. An interview with Licensed Practical Nurse (LPN) AA, on 1/5/2023 at 9:05 a.m. revealed that the door is supposed to be locked. She stated, oh well, and then locked it. Interview on 1/5/2023 11:45 a.m. with Registered Nurse (RN) CC revealed the storge room door is propped open, only while she was at the nurse's station. When the nurse's station is unattended the door is to be closed and locked. Review of the policy titled Storage of Medications, that was revised in November 2020, revealed that compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not to be left unattended. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.

Based on observation, staff interview, and review of the policy, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measure, the facility failed to ensure effective infection control practices were maintained for two residents (R) (#58 and #179) with the diagnosis of COVID-19; there was no supply of personal protective equipment (PPE) outside or immediately within the room for staff, inconsistent use of respirator masks and gloves and no observation of the use of gowns. The census was 83. Findings include: Review of facility policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures (review date unknown) documented the facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Addendum: Vaccinated/Unvaccinated Residents for COVID-19: If a vaccinated or unvaccinated resident test positive for COVID and there are no signs and symptoms present. They must quarantine 3-5 days on Covid Unit, resident may self-quarantine in room if no roommate is present. All residents testing positive displaying symptoms: shortness of breath, febrile, loss of taste/smell, and nausea and vomiting ect. must be moved to the Covid Unit for isolation 3-5 days until signs/symptoms subside. Residents with suspected or confirmed SARS-CoV-2 infection are placed in a single-person room. The door will be kept closed (if safe to do so). Staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection will adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. 1. Review of the clinical record revealed R#58 with diagnoses including Anxiety, Essential Hypertension, Post-Traumatic Stress Disorder, Shortness of Breath, Morbid (severe) obesity, and Obstructive Sleep Apnea. Review of Progress Note dated 1/1/2023 revealed R#58 continues with non-productive cough at times, rapid covid test done with positive results noted, resident is afebrile at this time, administrator made aware, will continue to assist as needed. During an observation on 1/3/2023 at 10:45 a.m., R#58 room was lying in bed with mask on and coughing. R#58 stated she was doing ok. Roommate was in her bed with no complaints. During an observation on 1/4/2023 at 10:00 a.m. R#58 was lying in bed with door open coughing at intervals. During an interview 1/5/2022 at 09:00 a.m. with Medical Tech II revealed they went through Infection Control training during orientation and has been working at this facility for three weeks. Observed Medical Tech II go into R#58's room with no gloves or gown. 2. Review of the clinical record revealed R#179 with diagnoses including Ischemic Cardiomyopathy, Morbid (Severe) Obesity, Mood Disorder, Personal History of Nicotine Dependence, Wheezing, Mild Intermittent Asthma, and Other Nonspecific Abnormal Finding of Lung Field. Review of the Progress Note dated 1/1/2023 revealed R#179 continues with non-productive cough at times, rapid covid test done with positive results noted, resident is afebrile and has had covid vaccine, administrator made aware, will continue to assist as needed. During an observation and interview on 1/3/2023 at 11:00 a.m., R#179 was asked how she was doing and she said, I have COVID. There was no Transmission Based Precaution supplies outside of room and no sign on the door indicating any kind of precaution. During an interview with Licensed Practical Nurse (LPN) AA, confirmed R#179 tested positive for COVID a few days ago. She is in a room by herself, but she does go out to smoke but sits away from other residents. LPN AA asked about classes on infection control and stated she has not had any classes lately. During an interview on 1/4/2023 at 11:20 a.m. with the Nursing Supervisor revealed the two residents who are COVID positive are asymptomatic and that is why they were not moved to the COVID unit and one of the residents has a roommate who is still residing in the room. During an interview on 1/4/2023 at 12:30 p.m. with Certified Nursing Assistant (CNA) EE revealed there are three COVID patients on the East hall. Special precautions used for residents with COVID include: donning and separation, monitor temperature, resident stays in the room, no precautions with feeding the residents with COVID who can feed themselves. The linen service is the same. During an observation on 1/4/2023 at 1:00 p.m. revealed CNA FF passing lunch trays and entered R#179's room. CNA FF did not have on any gloves. She had on a surgical mask. She did not sanitize hands and did not wear a gown. Interview at this time with CNA FF revealed that with COVID residents, staff should sanitize and wash hands. During an observation on 1/4/2023 at 1:05 p.m. of CNA GG, passing lunch trays, wore no gloves, but did have on a surgical mask. CNA GG did sanitize hands after going into room. During interview at this time, CNA GG stated most of the time she's goes in with a face shield and mask, but today she forgot her face shield. During an interview on 1/4/2023 at 1:10 p.m. with CNA HH revealed that when taking care of residents with COVID, staff should wear proper PPE, N95 mask, and gloves. Staff should wash hands after patient contact. During an interview on 1/4/2023 at 3:00 p.m. with the Administrator revealed there are two residents on the East Hall with COVID; R#58 does not want to move, and her roommate does not want to move; both have BIMS of 13 or 14. R#179 is asymptomatic. Residents with COVID would follow normal protocol, they should have on a mask which would be N95 or surgical mask, and staff should wash their hands. Staff should wear gloves and follow contact precautions. Staff have been educated. If there are visitors they will be screened, wear mask, and the facility should protect from COVID.

Based on observations, staff interviews, record review and review of policies titled Self-Administration of Medications and Administering Medications, the facility failed to ensure one of 22 sampled residents (R) (#134) was assessed to self-administer medications. Findings include: Review of the electronic medical record for R#134 revealed diagnoses including COPD (chronic obstructive pulmonary disease) and dementia. During the initial interview and observation on 1/3/2023 at 11:50 a.m., with R#134 revealed a Trelegy inhaler was observed on the over bed table of the resident. R#134 revealed that she takes that for her breathing. Review of resident's electronic medical record revealed that Trelegy Ellipta Aerosol Powder Inhaler was last documented as given on 1/4/2023. Progress Note dated 1/1/2023 revealed that medication not available in med cart. On 1/4/2023 at 11:24 a.m., it was observed that Trelegy inhaler was still on the over bed table of R#134. On 1/5/2023 at 10:09 a.m., it was observed that Trelegy inhaler and Fluticasone propionate nasal spray were on the over bed table of R#134. It was verified by Certified Medication Aide (CMA) BB and she stated that she leaves it on the table because the resident always states that she is never ready for it at the time she bring sit in. Further review of the clinical record revealed no assessments for R#134 related to self-administering medication. Review of the policy titled Self-Administration of Medications dated February 2021, revealed that residents have the right to self- administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. It also revealed that self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Review of the policy titled Administering Medications dated April 2010, revealed that residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision - making capacity to do so safely.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, homelike environment related to dusty air intake vents, missing tiles, and disrepair of sinks on one of six halls (100 hall). Findings include: On 1/3/2023 at 9:49 a.m., an initial observation and interviews had begun, and the following were noted: 1. At 9:52 a.m., room [ROOM NUMBER] was noted with dusty air intake vent. 2. At 9:59 a.m., room [ROOM NUMBER] was noted with dusty air intake vent. 3. At 10:06 a.m., room [ROOM NUMBER] was observed with dusty air intake vent. The shared bathroom was noted to have a dripping faucet with rust-colored stains around the knobs and there was a missing tile on the bathroom wall. 4. At 10:29 a.m., room [ROOM NUMBER] was observed with dusty air intake vent. 5. At 10:41 a.m., room [ROOM NUMBER] was observed with dusty air intake vent. 6. At 11:03 a.m., room [ROOM NUMBER] was observed with dusty air intake vent. 7. At 11:27 a.m., room [ROOM NUMBER] was observed with dusty air intake vent. Rust colored stain noted around knobs at bathroom sink. 8. At 11:35 a.m., room [ROOM NUMBER] was observed with dusty air intake vent. 9. At 11:50 a.m., room [ROOM NUMBER] was observed with dusty air intake vent. 10. At 12:00 p.m., room [ROOM NUMBER] was observed with trash bag missing in bathroom can and dusty air intake vent. On 1/4/2023 at 9:08 a.m., it was observed that the sink in the medication storage room, behind the east hall nurses' station had standing water in it. On 1/5/2023 at 3:24 p.m. the same environmental concerns above were observed on a second walk around with the Maintenance Director. During an interview at this time, the concerns were verified with him. He stated that the sink in the medication room was an ongoing problem. Due to all the rain, that has occurred, he stated that the drainage pipes were old, but he was working on the problem. He also stated that the administrator had budgeted for the facility to start switching the bathroom sinks to new ones. He stated that he receives a few sinks at a time. It was also revealed by him, that house keeping staff are assigned to specific halls usually and some of staff were new, and that he, himself, had only been at the facility for four months, would educate the staff on the importance of cleaning air intake vents.

Based on observations, record review, and review of policy titled Oxygen Administration, the facility failed to obtain a physician's order to administer oxygen to one resident (R) (#41) of ten residents receiving oxygen therapy. Findings include: On 1/3/2023 at 12:15 p.m., R#41 was observed in her bed. She was receiving oxygen via nasal cannula at 2.5 liters. She was also observed eating her lunch meal. She was pleasantly confused and stated that she uses oxygen all the time for her breathing. The humidification bottle was dated for 12/24/2022. There were no signs of distress noted. On 1/4/2023 at 3:23pm, R#41 was observed in her bed. The humidification bottle was dated 1/3/2023, and the resident was on 2.5 liters of oxygen via nasal cannula. Review of the electronic medical record for R#41 revealed that resident had diagnoses including Chronic Diastolic Heart Failure, Chronic Respiratory Failure, Shortness of Breath, Dependence on supplemental oxygen, and Chronic Obstructive Pulmonary Disease. Review of physician orders for January 2023 for R#41 revealed that there was no order for oxygen to be administered. Review of care plan dated 2/8/2022 for R#41, revealed R #41 required the use of oxygen and had the following interventions. 1. Change O2 (oxygen) tubing weekly. 2. Change humidifier water weekly and as needed. 3. Clean O2 concentrator weekly and as needed. 4. Check O2 saturation as ordered and as needed. 5. Observe for signs of respiratory distress, and report any changes to MD (medical doctor). Review of policy titled Oxygen Administration, revised October 2010, revealed the following: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.

Based on observation, record review, resident and staff interview and policy review titled Hemodialysis Access Care, the facility failed to ensure the dialysis access site was monitored for one resident (R) (#59) receiving dialysis. Findings include: Review of the clinical record revealed R#56 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia and end stage renal disease (ESRD) with dialysis. The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14. Section O revealed resident was receiving dialysis. An interview with R#59 on 1/3/2023 at 12:08 p.m. revealed that she receives dialysis. She stated the facility does not always look at her dialysis site. She also revealed that she has never had problems with the site. Review of care plan for R#56, dated 4/9/2021, revealed resident needs dialysis related to diagnosis of ESRD. Interventions to care included to assess dialysis site per Physician Order/facility policy. Review of Nurses Notes from 12/26/2022 through 1/5/2023 revealed no evidence that R#56's dialysis access site was checked post dialysis. An interview with the Licensed Practical Nurse (LPN) AA on 1/5/2023 at 10:09 a.m. revealed that she has worked at the facility for nine years. She stated that she does not check dialysis site, stating that the resident will tell her if it bleeds. She revealed that there is a communication form that is sent with the resident to dialysis and is to return with the resident that has vital signs and details of the dialysis session on it. She stated that vital signs are checked before and after returning. Review of the policy titled Hemodialysis Access Care dated September 2010, revealed that the general medical nurse should document in the resident's medical record every shift as follows: 1. Location of the catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis.

Based on observations, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance for four resident rooms (102A, 102B, 106A and 106B) on one of six halls (100 hall). Findings include: Observations on 1/3/2023 at 10:15 a.m., during initial tour of resident rooms revealed the following: 1. On the 100 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 2. On the 100 Hall, room [ROOM NUMBER] bed B, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 3. On the 100 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 4. On the 100 Hall, room [ROOM NUMBER] bed B, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. Environmental rounds on 1/5/2023 at 3:34 p.m., with Maintenance Director, verified rooms 102A, 102B, 106A and 106B had non-functioning call lights. Interview on 1/3/2023 at 9:52 a.m., R#36 stated that his call light has not worked for a while. He stated that he does everything for himself and didn't need it. Resident was sitting in a chair. An interview with Maintenance Director on 1/5/2023, at 3:44 p.m. revealed that it is the responsibility of the Certified Nursing Assistants (CNAs) to report non-functioning call devices to maintenance by completing a work order. He stated that he was unaware of the non-functioning call devices at this time. No adverse outcomes were identified related to non-functioning call lights.

Based on observations, interviews, record review, and facility policy review, the facility failed to providing bathing assistance for four residents of 20 residents (Resident (R) 5, R6, R8, and R10) reviewed for Activities of Daily Living (ADL) care. This failure had the potential to affect the residents' comfort, body image, increased the risk for skin breakdown, and increased the risk for infections. Findings include: Review of the facility's policy titled, ''Activities of Daily Living (ADLs), Supporting,'' revised 03/2018, stated ''Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: . hygiene (bathing, dressing, grooming, and oral care) .'' 1. Review of R6's ''Face Sheet'' provided by the facility indicated she was originally admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's ''Care Plan'' dated 07/19/22 and provided by the facility included bath/showers to be given on Tuesday, Thursday, and Saturday allowing resident to do as much of her ADL's as possible, set up equipment within easy reach, assist with care as needed. Review of R6's quarterly ''Minimum Data Set [MDS]'' with an assessment reference date (ARD) of 07/19/22 indicated she required supervision with showering/bathing and had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident had moderate cognitive impairment. Review of the ''Bath Days Schedule,'' provided by the facility, for the East Wing revealed R6 was to be bathed on Tuesday, Thursday, and Saturday. Review of the facility's grievance log revealed no complaints had been filed on behalf of the resident or her responsible party regarding any concerns. However, the grievance log included complaints from three residents regarding inadequate bathing/showering since August 2022. Review of the Resident Council Meeting Minutes document provided by the facility indicated in August 2022 meeting included complaints from residents that they were not receiving showers as scheduled. After this meeting the facility implemented Quality Assurance Plan of Improvement for showers. Review of R6's bath/shower documentation by Certified Nurses Assistants (CNA) revealed the resident missed 22 showers between 07/01/22 and 10/08/22. During an interview on 10/06/22 at 1:02 PM, R6 stated she had not been given the opportunity to bathe/shower throughout the last year like she should have. Additionally, R6 stated her showers were supposed to be on Tuesday/Thursday/Saturday and that did not always happen. During an interview on 10/07/22 at 1:15 PM, Registered Nurse (RN) 2 stated R6 and many other residents were not receiving three baths/showers per week per facility policy due to lack of staffing over the past two years. 2. Review of R5's undated ''Face Sheet'' provided by the facility indicated R5 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's undated care plan provided by the facility indicated bed baths were to be given Mondays, Wednesdays, and Fridays. Review of R5's quarterly ''MDS'' with an ARD of 06/07/22 indicated R5 had a BIMS score of 15 out of 15 indicating R5 was cognitively intact. The ''MDS'' indicated R5 was assessed as totally dependent to requiring extensive assistance in ADL's with the exception of eating which required R5 to be set up with the ability to feed self. Review of the ''Bath Days Schedule'' for West wing revealed R5 was to be bathed on Mondays, Wednesdays, and Fridays. Review of R5's bath documentation by CNAs, provided by the facility, between July 2022 through September 2022 revealed R5 had 34 opportunities for a bath with 25 days not given or offered. During an interview on 10/06/22 at 12:00 PM, R5 indicated he has not had his hair shampooed in approximately five weeks. R5 stated he had told the CNAs he wanted a shampoo and was informed the facility no longer has the shampoo caps that are utilized to wash the hair of bedbound residents. Observation of R5's hair on 10/06/22 at 12:00 PM, noted hair to be brushed and greasy with scattered dandruff throughout his head. During an interview on 10/08/22 at 12:49 PM, the Administrator indicated the facility did have shower caps for bedbound residents that were unable to go to the shower and she encouraged residents to go to the shower because there were many residents that were physically able to go to the shower, not physically bedbound so she encourages them to get up. The Administrator stated she was not aware that R5 was not getting his hair washed and would have it done immediately. 3. Review of R10's ''Face Sheet'' provided by the facility indicated R10 was originally admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's undated Care Plan provided by the facility indicated bed baths were to be given on Mondays, Wednesdays, and Fridays. Review of R10's quarterly MDS with an ARD of 06/22/22 indicated R10 had a BIMS of 11 out of 15 indicating R10 has mild cognitive impairment. Functional Status indicated he required supervision with toileting and ADL's. Review of the ''Bath Days Schedule'' for West wing revealed R10 was to be bathed on Mondays, Wednesdays, and Fridays. Review of R10's bath documentation by Certified Nursing Assistants (CNA), provided by the facility, between July 2022 through September 2022 revealed R10 had 33 opportunities for a bath with 15 bathes/showers not given or offered. During an interview on 10/06/22 at 12:00 PM, R10 indicated his baths were not always given as scheduled. R10 also stated, he often calls for his brief to be changed and has waited over one hour before being cleaned. While speaking, R10 pulled his brief to the side to revealed redness on his bilateral groin folds. During an interview, on 10/08/22 at 3:18 PM, the Administrator indicated she was not aware showers were not being given per facility policy after they were in the Quality Assurance Plan until she began getting the grievances recently. 4. Review of R8's ''Face Sheet'' provided by the facility indicated she was originally admitted on [DATE] and discharged home on 09/21/21 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R8's ''Care Plan'' was not available for review. Review of R8's quarterly MDS provided by the facility indicated she required total assist with baths. Review of the ''Bath Days Schedule'' for the East Wing revealed R6 was to be bathed on Monday, Wednesday, and Friday. Review of R8's bath/shower documentation by CNAs, provided by the facility, revealed the resident missed 13 showers between 08/23/21-09/21/21. Review of R8's nursing progress notes, provided by the facility, dated 08/21/21 through 09/21/21 indicated the resident did not refuse any showers/baths. The current Director of Nursing (DON) was not available for interview during the survey from 10/06/22 through 10/08/22. During an interview on 10/07/22 at 10:10 PM, the Administrator indicated that for every bath/shower that was provided for a resident the CNAs were to fill out the ''CNA Skin Assessment Check List.'' Additionally, based on the Quality Assurance Plan of Improvement (QAPI), the new Director of Nursing (DON) was to ensure shower logs were verified against the bath/shower schedule. The current plan was not being followed because the previous DON did not notify her that showers were not being done, and the new DON had been out of work on multiple occasions so that ''there is no system . there has not been any follow-through on anything . the wound care nurse should be looking at the skin sheets and had not been.'' The administrator stated the facility policy included showering/bathing three times per week unless the resident refused; if the resident refused, then this should be documented, the charge nurse needs to follow-up with the resident, the family should be notified, and the refused shower documented in their chart and on the skin assessment sheet.

Based on family/staff interviews, record review, and review of the facility policy titled, Abuse Prevention Program, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA) within the required time frame for one resident (R A) of five sampled residents. Findings include: Review of the undated face sheet in the Electronic Health Record (EHR) revealed R A was admitted to the facility on [DATE] and was discharged on [DATE] with return to the facility anticipated. The resident had [DIAGNOSES REDACTED]. Review of a Progress Note dated 2/26/2020 at 3:08 p.m. revealed R#1 went to [MEDICAL TREATMENT] that morning and the [MEDICAL TREATMENT] center called the facility to advise them R#1 was sent to the Emergency Department (ED) from the [MEDICAL TREATMENT] center for critical labs and low blood pressure. During a telephone interview on 3/5/2020 at 2:00 p.m., Family of R A stated he was the resident's Responsible Party (RP) and Power of Attorney (POA). Family of R A was informed by the hospital that the resident had a broken right hip that must have happened at the nursing home. Family of R A informed the facility of the findings and filed a complaint on 2/29/2020. Review of an acute hospital x-ray report, dated 2/28/2020, revealed R A had an acute, angulated [MEDICAL CONDITION] distal femoral shaft (thigh bone near the knee). Further investigation revealed R A did have a fall on 2/13/2020. However, there was no evidence in the clinical record indicating injury or pain. Through additional record review and interviews, there was also no evidence that the resident experienced abuse in the facility. During an interview on 3/5/2020 at 9:15 a.m. the Administrator stated he was the Abuse Coordinator for the facility. The Administrator recalled talking to the Director of Nursing (DON) about a complaint for R A, but they did not think it needed to be reported to the state. During an interview on 3/5/2020 at 1:30 p.m., the DON stated she was made aware of the fracture for R A on 2/29/2020. She reviewed documentation of the transfer to the hospital and spoke with the nurse involved. The DON did not report the injury of unknown origin to the state because R A was discharged from the facility. There was no evidence of a broken bone when the resident went to [MEDICAL TREATMENT] on 2/26/2020. The DON stated there would be no record of a facility-reported incident to the SSA because she never filed one. Review of the undated facility policy titled, Abuse Prevention Program revealed that injuries of unknown origin such as bruises, fractures, contusions, abrasions, etc. and other resident injuries for which the injury is unknown must be reported to state regulatory agencies just as known or suspected abuse/ mistreatment, etc. G. Reporting/Response: The facility is aware it must report all alleged violations and substantiated incidents to the state agency promptly per state regulations and to all other agencies as required by state and federal law

Based on interviews, record review and review of the facility policy titled, Abuse Prohibition the facility failed to ensure that one resident (R#1) was free from sexual abuse; and, one resident (R#8, the roommate of R#1), who witnessed the abuse, was free from psychosocial harm from a sample of eight residents. Findings include: The facility had an Abuse Prohibition policy. The policy included a definition of sexual abuse as non-consensual sexual contact of any type with a resident. The policy includes a definition of mental abuse as includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Identification of Abuse: Neglect, and Exploitation-6. The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: a) resident, staff or family report of abuse; f) physical abuse (sexual abuse) of a resident observed; and g) Psychological abuse of a resident observed. 1. Resident #1(R#1) was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].); and hypertension. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating the resident is severely impaired. Review of the care plan with a start date of 8/22/13 for R#1 revealed a problem area related to assistance required with Activities of daily living (ADL) due to [MEDICAL CONDITIONS], incontinence and impaired mobility and Impaired thought processes related to [MEDICAL CONDITION], that the resident is non-verbal but can answer yes/no by nodding his head. Record review of the facility investigation, dated 8/29/19, revealed an allegation that Certified Nursing Assistant (CNA) AA had sexually assaulted R#1 on 8/26/19. 2. Resident #8 (R#8) was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed a BIMS score of 3, indicating the resident has severe cognitive impairment. Review of R#8's care plan with a start date of 12/30/16 revealed the resident has difficulty communicating needs related to a history [MEDICAL CONDITIONS]. The resident is also care planned for potential mood/behavior due to impaired communication and depression. The resident will refuse medications at times, will cry at times and ask for his family member to be called. The care plan was reviewed and updated on 8/1/19. Review of the written statement from CNA NN, dated 8/27/19, revealed that during patient care for R#8 (roommate of R#1) he was attempting to tell staff something regarding R#1. R#8 was then asked if it was a nurse or a CNA, man or a woman, and when the staff said a man, R#8 responded yeah. When staff asked R#8 what had happened, he pointed to his private area. R#8 was asked if the man did something to R#1's private area and R#8 nodded his head yes. R#8 was asked why he had not turned on his call light and he pointed to the wall where the call light was out of reach. R#8 was very upset and crying. Record review of a written statement by CNA YY, dated 8/27/19, revealed that she had come into help her co-worker with R#8 who was trying to explain something about his roommate, R#1. The statement stated that R#8 was clearly upset. The CNA then asked R#1 if something had happened and if he knew what had happened and R#1 nodded yes. They asked if a CNA had done something to R#1's private area and he nodded yes. When asked why R#1 had not turned on his call light, he pointed to the overbed light, where the call light was out of reach. Record review of a written statement by CNA XX, dated 8/28/19, revealed that she had entered the room of R#1 and R#8 to see if her co-workers needed help. She further revealed that R#8 was trying to explain that something had happened to his roommate (R#1). She further revealed that R#1 was asked if he knew what had happened and he nodded his head yes. R#1 was then asked why he didn't turn on his call light and he pointed to his overbed light on the wall, where the call light was located, out of reach. She stated that R#8 was upset and crying and that the CNA assured the resident that she would get help. Review of a written statement by Licensed Practical Nurse (LPN) FF, dated 8/27/19, revealed that at approximately 4:20 p.m. she was called to the room of R#1, by staff, stating that she was needed to help the resident. The staff believed that something had happened to R#1, sexually, by CNA AA, on the night before. LPN FF interviewed R#1 asking did something happen to him the night before with CNA A[NAME] R#1 bowed his head up and down, indicating yes. LPN FF then asked what had happened, and R#1 pointed to his groin area. LPN FF asked R#1 if CNA AA had touched him and the resident moved his head right to left indicating no. When asked again what had happened, R#1 held his hand in a fist and opened his mouth, making an up and down motion. LPN FF then checked the resident's skin, with permission, which indicated no skin issues. LPN FF then stated that she notified the Administrator, Director of Nursing (DON), family, Physician and the police. A review of the police report dated 8/27/19 at 17:28 (5:28 p.m.) revealed that Police Officer ZZ was notified by LPN FF, that R#1 is non-verbal but can communicate using gestures and can answer yes/no questions. Police Officer ZZ then notified a Detective who then came to the facility and interviewed the R#1 who's family member was now present. Further review revealed that CNA AA was arrested on 8/28/19 and was charged with sodomy, sexual assault and reckless conduct. A review of facility investigation summary which is not dated, revealed that CNA AA was suspended on 8/27/19 when the facility became aware of the allegation of abuse. Review of the facility Separation Notice, dated 8/28/19, revealed that CNA AA was terminated from employment. Review of the personnel file for CNA AA indicated a start date of (MONTH) 2019. Review of the Background check (Georgia Crime Information Center-GCIC) for CNA AA, dated 7/11/19, was performed after the CNA had begun working at the facility, revealed that no adverse records were found. Record review for R#1 revealed Physician Orders, dated 8/29/19, for [MEDICAL CONDITION] panel laboratory test. An interview on 8/29/19 at 1:56 p.m. with R#1, revealed through nodding his head and using hand gestures, that the sexual assault occurred at night and that he knew who did it. The resident gestured with his left hand (the resident is unable to move his right hand) that oral sex (pointed to genital area and his mouth) had occurred. The resident answered no, when asked if he had asked CNA AA for oral sex. When asked if sexual acts were performed in his mouth or rectal area the resident indicated no by moving his head from side to side. When asked if the resident he had witnessed CNA AA abusing other residents the resident moved his head from side to side indicating no. The resident was asked how many times the sexual act occurred, he held up five fingers, indicating it had occurred five times. The resident further indicated that the sexual assault occurred in his bed by pointing at the bed and the privacy curtain. The resident further indicated that he had told a nurse but indicated that the nurse did not understand him. An interview with LPN FF on 8/29/19 at 2:30 p.m. revealed that on 8/27/19 at about 4:30 p.m. that a CNA reported to her that R#1 needed help. The CNA revealed that she went to the resident's room and he communicated, with motion, that oral sex had occurred. An interview on 8/29/19 at 3:40 p.m. with R#8 (R#1's roommate) revealed by pointing behind the curtains, that he saw CNA AA through the curtains. He further revealed that the sexual assault had occurred four times by holding up four fingers. R#8 revealed pointing to his call light and saying no that he pressed the call light, and no one came. An interview with the DON on 8/29/19 at 3:30 p.m. revealed that the sexual assault was reported that afternoon and an investigation was started immediately. She revealed that she did not know how many times the assault had occurred. She revealed that R#1 only reported one occasion; and, had never reported anything to the facility. She revealed that CNA AA never worked again when the allegation was discovered. The DON further revealed that the facility terminated CNA AA on 8/28/19. The DON further revealed that the facility had been notified, by the police, that CNA AA had confessed to sexually assaulting R#1. A follow up interview with R#8 (R#1's roommate) on 10/8/19 at 2:00 p.m. revealed that the sexual act towards his roommate still bothers him. R#8 repeats I saw, I saw and points and pulls the curtain. He further revealed that no one ever came to answer the call light by pointing to the call light and saying No. A post survey telephone interview with the Administrator on 10/24/19 at 2:10 p.m. confirmed that the background check for CNA AA was completed after the start date. The Administrator revealed that background checks were identified during the Recertification Survey of 8/8/19 and was cited as deficient practice. He revealed that all background checks have been completed on existing employees and are completed prior to staff beginning work. A post survey telephone interview with the Detective on 10/28/19 at 9:50 a.m. revealed that during a video investigation interview with CNA AA, that the CNA confessed to sexually assaulting R#1. The Detective further revealed, that during the same video interview, CNA AA confessed to having a chronic [MEDICAL CONDITION]. This confession resulted in an additional charge of reckless conduct. The Detective further revealed that CNA AA remains in jail without bond. A post survey telephone interview with the DON on 11/4/19 at 12:52 p.m. revealed that the Social Worker (SW) had conducted interviews with all male resident's in the building on 8/29/19 related to if they had been abused or had witnessed abused while in the care of the facility, and if they knew how to report abuse if they were a victim or witnessed abuse. The sign-in sheet revealed that 14 male residents were interviewed, and none reported any abuse. A post survey telephone interview on 11/4/19 at 1:17 p.m. with LPN FF revealed that she was notified by the Detective that CNA AA had confessed to sexually assault on CNA AA during the investigation interview. Additionally, the Detective informed LPN FF that CNA AA had also confessed to having a chronic [MEDICAL CONDITION], although he had no laboratory proof. LPN FF further revealed that she had notified the Physician for R#1 who order laboratory test for [MEDICAL CONDITION]. A post survey telephone interview with the Physician for R#1 on 11/4/19 at 1:37 p.m. revealed that she and her Nurse Practitioner are seeing this resident. The laboratory tests were ordered as a precaution and all were negative. She further revealed that the laboratory test will be repeated to ensure the that R#1 remains free of infection.

Based on review of the facility policy titled Facility Abuse Policy, most recently revised on 11/24/16, record review, resident and staff interviews, and observations, the facility failed to ensure four Residents (R) #62, R#105, R#110, and R#170) were free from abuse to include resident to resident abuse and staff abuse of a resident. The sample size was 42 residents. On 6/30/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at §483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. §483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: The Facility Abuse Policy, most recently revised on 11/24/16 read, in pertinent part, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. 1. R#105 was admitted to the facility, per the Face Sheet, on 7/29/15 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an annual comprehensive assessment of overall health status dated 6/1/17 indicated R#105 was cognitively intact (Score 15/15 on the Brief Interview for Mental Status, (BIM)), and required limited to extensive assistance from staff to compete all of his Activities of Daily Living (ADLs). R#105's Interdisciplinary Notes were reviewed in their entirety from June 2016 through June 2017 and indicated that there was not any evidence that the resident had any behaviors. Record review revealed a Departmental Note for R#105, dated 7/9/16, documented by RN BB documented in pertinent part, Resident (R#105) reported that (R#14) was sexually harassing him. Resident stated she hit him in his private, but I was standing in office door and she was noted touching the collar of his shirt in the hall. Upon questioning him he said the incident when he was hit in his private was last week and that he reported it to the lady in the front and would follow up with her on Monday. I (meaning RN BB) spoke with the DON (Director of Nursing) and Administrator. Record review revealed a Departmental Note for R#105, dated 1/19/17 that documents, in pertinent part, Resident (R#105) reported that (R#14) came into his room without permission while he was finishing breakfast. He stated he asked her to get out; however, (R#14) proceeded to roll forward. Once she was within reach of the resident she touched/grabbed him in his private area. (R#105) reported incident to writer (LPN DDD). During an interview with R#105 on 6/29/17 at 6:10 p.m., he was asked if he had any concerns with any other resident in the facility and he stated, I have concerns with (R#14). She put me in the hospital. She can't keep her hands off no man or woman in here. She came up beside me and hit me and bruised my right testicle. My testicle is swollen up big now, and I have to go back to the doctor again. I have a bad bruise and I may have to have surgery. I went to the doctor's office (urologist) after the doctor here got me an appointment. She (R#14) was just over here (near R#105's room) a few minutes ago and she comes in my room. If you are asleep she'll run her hand down your britches and play with you. It happens during the day. She'll fondle me in my (wheel) chair. I went to Administrator the other day (R#105 showed a notebook where he had documented the referred to the meeting with the Administrator on 5/25/17), and talked to her and told her I want to keep (R#14) away from me and that she keeps coming in my room. The Administrator told me she was going to move me to another home. I don't feel safe in my own home .and they want throw me out of here. I like it here. My family is close by and my girlfriend is here. R#105 verbalized that he had reported R#14's behaviors towards him multiple times, however he was unable to recall specific names and dates of the reports. R#105 was observed to be upset during the interview, and indicated that he was distressed due to the lack of follow up regarding his complaints of sexual abuse. Record review revealed Ultrasound Results, dated 9/6/16 documents, in pertinent part, Impression: 6 x 3 x 6 cm (centimeter) fluid collection in the right hemi scrotum. Differential consideration includes a hematoma and complicated epidydimal cyst. Record review revealed an Ultrasound Results report dated 12/26/16 documents, in pertinent part, Impression: 6.4 x 4.6 x 3.6 cm echogenic fluid collection superior to the right testes, probably a hematoma, slightly smaller than the prior. A complicated epidydimal cyst is less likely. Abscess is less likely. Record review revealed a Follow-Up Urology Consult Notes, dated 1/10/17 documents, in pertinent part, The patient seen today to go over recent ultrasound to evaluate scrotal mass. It was initially thought to possibly be hydrocele, however the current reading mentions a possible hematoma. It is getting smaller with time. The patient now seems to remember having trauma to the scrotum at the time of initial growth of the fluid collection. Record review, for R#14 the alleged abuser, revealed that the resident was admitted to the facility on [DATE], according to the Face Sheet printed on 6/29/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) for R#14 was a quarterly assessment of overall health status dated 5/3/17 indicated R#14 was cognitively impaired per Brief Interview for Mental Status (BIMS score 5/15). During an interview, conducted with Licensed Practical Nurse (LPN) AAA on 6/29/17 at 5:55 p.m., she was asked if she was aware of any concerns related to resident abuse or behavior. She stated, I am aware that R#14 touches peoples' privates, and that R#105 has a big issue with her. He has reported this to the Administrator several times. She (R#14) comes in his room at night and she'll touch his privates. He told me directly that he reported it to the Administrator. There have been multiple incidents. The last incident I am aware of is within the last two weeks. R#14 will walk up to R#105 and hit him in the head, hit his leg, grab him in the privates. He has made it clear to everyone that he doesn't like it. He has threatened to leave and everything. During an interview with LPN CCC on 6/29/17 at 6:00 p.m., she stated, she was R#14's nurse for a little while. She likes to touch you in private places. She'll rub your butt when you walk by. I just know that she will take and rub my butt when she passes by. I'm not aware of any complaints from residents about her doing that, just staff. During an interview with Registered Nurse (RN) DD on 6/29/17 at 6:40 p.m., she stated that R#14 wanders over here, the unit R#105 lives, sometimes. R#105 hasn't told me that R#14 touches him inappropriately, but I do know that R#14 touches people like that. She will go by and touch me on the butt. During an interview with Certified Nursing Assistant (CNA) ZZ on 6/30/17 at 9:05 a.m., she stated, R#14 rolls over here on this side where R#105 lives and then she goes in other people's rooms, and some residents might turn the light on to get her out. I hear them (staff and residents) say she rubs on people or pets on them. During an interview with CNA TT on 6/30/17 at 9:10 a.m., she stated, R#14 likes to touch you. If I'm taking care of her she might reach at my breast or pat my hand. Sometimes she will touch other residents like she does us. Its male or female, she doesn't have a preference. I've reported this to the Weekend Supervisor (LPN SS) and the Unit Manager (UM UU). During an interview with the UM LPN UU on 6/30/17 at 8:50 a.m., she stated, I know that R#14 likes to rub on us while we are giving her care. She'll rub on our arms, pat our hand, and kiss our hand. UM LPN UU stated she had not received any reports from staff that R#14 had been inappropriate with other residents. She stated, She has patted me on the butt and kept going. I didn't take it as sexual. I took it as she was hitting me and moving on. During an interview with the former Director of Nursing (DON) on 6/30/17 at 1:15 p.m., she stated she was present during a conversation between R#105 and a male physician. During this conversation R#105 told the physician that he had been hit in his scrotum/testicles by R#14. She stated an appointment was made after that for R#105 to see an Urologist. The former DON stated she did not make out an incident report or do an investigation of R#105's allegation of being hit in the testicles due to the fact that she thought R#105 and his physician were having a Man to Man talk. She stated, (R#14) is touchy feely and likes to be affectionate with everyone. During an interview with R#105's physician on 6/30/17 at 2:05 p.m., he stated, I sent him (R#105) to see the Urologist because he had hydroceles. I don't remember having a conversation with (R#105) him about being hit. The physician stated he had never received the urology or ultrasound reports from the Urologist indicating R#105's injury to his testicles was a hematoma likely caused by trauma. He stated he would follow up with R#105 as soon as possible. During an interview with the Administrator on 6/29/17 at 6:45 p.m., she stated, R#14 is elderly and pleasantly confused. Here recently, in the last two to three months, she has rebounded from a bed bound position and wanders about the facility. She taps on people. It has been reported that she wanders into resident's rooms. It has been reported that she touches people on the leg or arm. (R#105) complained about her several weeks ago, about coming down the hallway and opening the door to his room. He took his foot to the door and closed her out with his foot. The Administrator stated she had no knowledge of R#14 hitting R#105 in his testicle and had no reports of R#14 groping other residents inappropriately. She stated no investigations had been done and nothing had been reported to the state. She stated, I was aware of tapping .but nothing sexual. Observations were made by the surveyor and the Director of Nursing (DON) of R#105's genitalia with his permission on 6/30/17 at 11:20 a.m. The resident's right testicle was observed to be considerably larger than the left testicle. R#105 stated the area remained painful when he moved. He stated the pain was resolved with Tylenol. During an interview with RN BB on 7/1/17 at 10:25 a.m., she stated, I remember reporting to the DON and Administrator regarding the incident reported by (R#105). It was the current Administrator and the former DON. At that time, the former DON said she was aware of the situation and that it had been reported to the resident's physician, and that he (R#105, was being referred to the Urologist. They were going to have an ultrasound for R#105. (R#105) reported it to me (RN BB) and I reported it to Administration like I was supposed to. Incident reports and an investigation regarding R#14 to R#105 were requested, and the facility was unable to locate any documentation related to the alleged incidents. Post survey interview on 7/12/17 at 3:15 p.m. with LPN MDS revealed that during the interview LPN MDS reviewed the resident's medical chart and upon reviewing the residents chart read the following documentation: A. Patient at Risk (PAR) noted dated 5/5/17, in pertinent part, Resident has inappropriate behavior touching male and female residents. B. Social Services Quarterly Note dated 2/17/17 that documented that resident was observed kissing the hands of other residents and wandering down other hall in facility. C. Nurses note dated 8/9/16, in pertinent part, Resident is alert, she has demonstrated sexual behavior toward staff to get in bed with her, resident lowered her top and asked staff to get in bed with her. Continued interview with LPN MDS, at this same time, revealed that she is a new employee and has been the LPN MDS for about one month and that she had not observed R#14 exhibit any inappropriate behaviors, but that she was aware that the resident was severely cognitively impaired and that she had socially inappropriate behavior, such as touching inappropriately, and that she had heard that R#14 had groped a resident. 2. R#110 was admitted the facility on 8/7/15, according to the Face Sheet printed on 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/18/17 indicate R#110 was cognitively intact (BIMS score 15/15), and required supervision to limited assistance from staff to compete all of his Activities of Daily Living (ADLs). R#110's Interdisciplinary Notes were reviewed in their entirety from June 2016 through June 2017 and revealed that there was not any evidence of any documentation that the resident had any behaviors. During an interview, conducted with R#110 on 6/29/17 at 6:20 p.m., she was asked if she had ever had any concerns with another resident in the facility and she stated, Yah, I do. R#114 was my roommate when they first moved me over here from 5 (the rehabilitation area). One day she (R#14) was out of the room and I laid down like I usually do. She (R#14) come in and it was about this time of the evening (around 6:30 p.m.), and I was laying on my left side facing the wall, and I began to feel someone coming on up my side, and up my side, and then I turned to look at her and she kissed me on the mouth. I about came up out of my bed and I told her not to do that to me. I called my daughter and I was crying and I was upset. I told her I was leaving and I would sleep on the bridge if I had to. I was afraid to sleep. I was afraid. I said I was leaving. My daughter was really upset and she said (to the staff) you will move her .and they did. That happened after I left the 5 hall. It's been several months ago. I don't want to be harassed like that. R#110 stated she reported the incident to her daughter and to a nurse (she could not recall which nurse). An interview was conducted on 6/30/17 at 1:48 p.m. with R#110's daughter and revealed that there had been an incident in November 2015. She stated that the resident woke her (R#110) up rubbing her legs and when she turned her head the resident kissed her. She stated this made her mother very uncomfortable. The incident was reported to the previous Social Worker. Record review revealed that there was not any documentation of the alleged incident that could be found in the medical records for either R#110 or R#14. Incident reports and an investigation regarding R#14 to R#110 were requested, and the facility was unable to locate any documentation related to the alleged incident. During an interview with the Administrator on 6/29/17 at 6:45 p.m. she stated she did not recall R#110's daughter reporting an incident of sexual abuse by R#14. She stated no investigation had been completed and no reports had been made to the appropriate entities. 3. R#170 was admitted the facility on 4/26/17, per the Face Sheet dated 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/3/17 indicate R#170 was cognitively intact (BIMS score 14/15), and required extensive assistance from staff to compete all her Activities of Daily Living (ADLs). R#170's Interdisciplinary Notes were reviewed in their entirety for April 2017, May 2017, and June 2017 and indicated that there was not any evidence of any documentation that the resident had any behaviors. During an interview with CNA PP on 6/28/17 at 3:20 p.m., she stated about three weeks prior to this interview, R#170 was in the lobby by the hallway. R#46 was backing up in her wheelchair and that her roommate was in her way, so the roommate tapped on her to let her know she was backing up and R#46 grabbed her arm (R#170) and twisted it (arm). CNA PP stated, I didn't see it myself, but I was right there and heard it. She stated R#170 was very upset by the incident. CNA PP indicated the survey team should speak with CNA DDD, as she was also present at the time of the incident. During an interview with CNA DDD on 6/29/17 at 1:30 p.m., she stated, she thought R#46 was going in her room one day when R#170 touched her shoulder then someone was hollering. R#170 said she (R#46) twisted her arm. CNA DDD asked R#46,Why did you twist her arm? and (R#46) said because she (R#170) pulled my ear. I didn't see R#170 touch R#46. R#170 is hardly ever in the room with R#46 and I think it's probably because R#170 feels like she's not allowed in there. CNA DDD stated she didn't know if R#170 was afraid of R46, but she stated, I do know that since (R#170) has been in that room (R#46) feels like she can run that room. When R#46 comes around R#170 makes her Oh I hate to see her come face. She have (sic) called R#46 the Devil. CNA DDD stated the Administrator was standing near in the hallway when the incident occurred, so she did not report the incident. She stated, When it (the incident) was going on the Administrator was in the hall. I thought she had seen it. She was standing right there when all of the commotion was going on. Right there at the top of the hallway. Because she was there I didn't tell anyone else. I should have, but I was thinking the Administrator would have charted it. During an interview with R#170 on 6/28/17 at 1:00 p.m., she stated, I don't have nothing to do with her. When asked if she was afraid of R#46, R/#170 nodded her head in the affirmative and stated, She acts all stupid. She don't act right. I don't know why she act like that but she do. Record review for R#46, the alleged abuser, revealed that the resident was admitted the facility, per the Face Sheet printed on 6/29/17, on 5/12/11 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an annual comprehensive assessment of overall health status dated 5/18/17 indicate R#46 was cognitively intact (BIMS score 15/15). The resident's PHQ-9 (an assessment to identify depression) score was 9, indicating R#46 was moderately depressed, and the assessment indicated R#46 was not displaying any current behaviors. During an interview with the Administrator on 6/28/17 at 3:45 p.m., she stated she could not recall the incident between R#46 and R#170. She stated no incident had been reported to her. During an interview with the Nurse Consultant on 6/28/17 at 3:50 p.m., she stated R#170 was being moved to another room on a different unit away from R#46. 4. Review of the record of the most recent Quarterly Minimum Data Set (MDS), for R#62, dated 4/6/17 indicated R#62 was admitted on [DATE] and has an active [DIAGNOSES REDACTED]. R#62 was assessed as cognitively intact per a Brief Interview of Mental Status (BIMS score 14/15), and required moderate to extensive assistance from staff to complete all his Activities of Daily Living (ADLs). Section G of the MDS indicated R#62 is totally dependent for bathing. An interview was conducted on 6/26/17 at 3:20 p.m. with Resident (R) #62 and revealed that when asked if he had ever been abused, either physically, verbally, or sexually, the resident responded yes. The Surveyor asked R#62 to describe the abuse, R#62 stated a girl on second shift was giving him a shower, pushed him against the wall and hit his head. The Surveyor asked how long ago did this happen? R#62 revealed that it happened three or four weeks ago. When the Surveyor asked R#62 what the name of the girl was he stated her name is - and named the CNA which was identified to be CNA HH. Further interview of R#62 on 6/26/17 at 3:20 p.m. indicated Some staff yell at you and push you around and are sarcastic. R#62 stated this happened a couple days ago, usually on the 3rd shift and that he told the nurse. The resident was not able to identify the nurse or the CNA by name. R#62 stated that yesterday, 6/25/17, that he was not moving fast enough yesterday, and that the CNA was pushing and tugging him about 10:00 a.m. on the way to the shower but he did not tell the nurse. An interview was conducted on 6/26/17 at 4:40 p.m. with LPN AAA revealed that R#62 had complained of staff being rude but has not made any statement of being hit before. A review of the Incident log ran on 6/26/17 at 4:47 p.m. for the dates 3/26/17 to 6/26/17 revealed that there were not any evidence of any documentation that any incidents had been logged R#62. No matching records found. A review of the Departmental Notes dated 6/14/17 at 1:18 p.m. revealed a care plan meeting entry by social services that documented, in pertinent part, R#62 indicated as well that the CNA's are a little rough and would like them to be more gentle while in the sit and stand Hoyer lift. In addition, a hand-written note, dated 6/14/17 at 10:35 a.m., by LPN HH regarding an incident which occurred on 6/13/17 at approximately 10:00 a.m. for R#62. The note documented that LPN HH was invited to attend a care plan meeting for R#62, and that R#62 stated that one time in the shower his head was bumped against the wall of shower. An interview on 6/26/17 at 4:50 p.m. with the Psychiatric Advanced Practice Registered Nurse (APRN) for R#62. The APRN revealed that the resident's mental status is a 26/30, per the Mini Mental Status Exam. A maximum score is 30 points. A score of 26 indicates that the resident is cognitively intact. An interview on 6/26/17 at 5:10 p.m. with the Social Services Director (SSD) revealed that R#62 reported today, 6/26/17, that he has been having issues with three CNA's handling him roughly in the shower. He has requested one CNA not be in the room when he is in the shower. He said the nursing staff is doing a good job, but that CNA HH is rough with him, CNA OOO just stands there and watches and CNA KKK is very pushy when she picks him up and is always in a hurry and never takes her time. He stated he was scared. He named CNA KKK, CNA OOO, CNA HH and a heavy-set African American woman who picks up residents and looks like she could throw the resident in the bed or chair. Further interview with the SSD, at this time, regarding the care plan meeting note, for R#62, documented in the Departmental Notes on 6/14/17, concerning staff handling him roughly, she stated she did recall that meeting and that she wrote a grievance and turned it over to the Director of Nursing (DON). The SSD did not identify the date that she had given to the DON nor could she produce a document to verify the incident was reported. The SSD proceeded to leave her office to find the grievance, when she returned she was accompanied by the Administrator and stated that the Administrator did not complete a grievance or report because she didn't see it as an incident. She felt it was resolved because he stated to her they had roughly washed his hair. The Administrator instructed the SSD to enter a grievance for R#62's care plan meeting complaint as a late entry and another one for today's complaint. The facility did not follow their Abuse Prevention Program Policy with regards to keeping residents free from the alleged physical abuse.

Based on review of the facility policy entitled Facility Abuse Policy most recently revised on 11/24/16, record review and resident and staff interviews, the facility failed to investigate and report allegations of abuse for four Residents (R) (R#62, R#105, R#110, and R#170). The sample size was 42 residents. On 6/30/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at §483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. §483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: The Facility Abuse Policy, most recently revised on 11/24/16 read, in pertinent part, When an alleged incident of abuse, neglect, or misappropriation of resident's personal property is reported, the Administrator will appoint a representative to investigate the incident; and The facility is aware that it must report all alleged violations and substantiated incidents to the state agency promptly per state regulation and to all other agencies as required by state and federal law and this it must take all necessary corrective actions depending on the result of the investigation. 1. Record review revealed that R#105 was admitted the facility, according to the Face Sheet, on 7/29/15 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an annual comprehensive assessment of overall health status dated 6/1/17 indicate R#105 was cognitively intact (BIMS (brief interview of mental status) score 15/15), and required limited to extensive assistance from staff to compete all of his Activities of Daily Living (ADLs). Record review revealed a Departmental Note, written by RN BB for R#105 dated 7/9/16, was reviewed and read, in pertinent part, Resident reported that (R#14) was sexually harassing him. States she hit him in his private, but I was standing in office door and she was noted touching the collar of his shirt in the hall. Upon questioning him he said the incident where he was hit in his private was last week and he reported it to the lady in the front and would follow up with her on Monday. I (RN BB) spoke with DON (Director of Nursing) and Administrator. Record review revealed a Departmental Note for R#105, dated 1/19/17 documents, in pertinent part, Resident reported that (R#14) came into his room without permission while he was finishing breakfast. He stated he asked her to get out; however, R#14 proceeded to roll forward in her wheelchair. Once she was within reach of resident she touched/grabbed him in his private area. R#105 reported incident to writer, LPN DDD. Record review for R#14, the alleged abuser, revealed the resident was admitted the facility on 9/25/15, according to the Face Sheet dated 6/29/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) for R#14 was a quarterly assessment of overall health status dated 5/3/17 indicate R#14 was cognitively impaired per Brief Interview for Mental Status (BIMS score 5/15), and required supervision from staff for mobility throughout the facility in her wheelchair. Incident reports and an investigation regarding R#14 to R#105 were requested, and the facility was unable to locate any documentation related to the alleged incidents. During an interview with the Director of Nursing (DON) on 6/29/17 at 2:35 p.m., he stated The only thing that is being tracked as an incident at this point is falls .and maybe skin tears. He stated, There is room to grow regarding the recognition, reporting, and investigation of abuse. During an interview with the Administrator on 6/29/17 at 6:45 p.m., she stated she had no knowledge of R#14 hitting R#105 in his testicle. She stated no investigations had been done and nothing had been reported to the State. Cross refer to F223 for specifics related to R#105's allegations of sexual abuse by R#14. 2. R#110 was admitted to the facility on [DATE], according to the Face Sheet dated 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/18/17 indicated R#110 was cognitively intact (BIMS score 15/15), and required supervision to limited assistance from staff to compete all of his Activities of Daily Living (ADLs). No documentation of the alleged incident could be found in either R#110 or R#14's medical records. Incident reports and an investigation regarding R#110's allegation of sexual abuse by R#14 were requested, and the facility was unable to locate any documentation related to the alleged incident. During an interview with the Administrator on 6/29/17 at 6:45 p.m. she stated she did not recall R#110's daughter reporting an incident of sexual abuse by R#14. She stated no investigation had been done and that no reports had been made to the appropriate entities. Cross refer to F223 for specifics related to R#110's reported allegation of sexual abuse by R#14. 3. R#170 was admitted the facility on 4/26/17, according to the Face Sheet dated 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/3/17 indicated that R#170 was cognitively intact (BIMS score 14/15), and required extensive assistance from staff to compete all of her Activities of Daily Living (ADLs). Cross refer to F223 for specifics related to R#170's reported allegation of physical/verbal abuse by R#46. During an interview with the Administrator on 6/28/17 at 3:45 p.m., she stated she could not recall the incident between R#46 and R#170. She stated no incident was reported to her. She stated no investigation into the alleged incident had been done and nothing had been reported to the State Agency. She further stated, Off the top of my head I believe we should instantly start investigation (after an allegation of abuse). She stated, We have a two-hour reporting period whether with or without seriously bodily injury. Cross refer to F223 for specifics related to R#170 4. R#62 was admitted to the facility on [DATE], according to the most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] with an active [DIAGNOSES REDACTED]. The resident was assessed as cognitively intact per a brief interview of mental status (BIMS score 14/15), and required moderate to extensive assistance from staff to complete all of his Activities of Daily Living (ADLs). An interview was conducted on 6/26/17 at 3:20 p.m. with Resident (R) #62. When R#62 was asked if he had ever been abused, either physically, verbally, or sexually, the resident responded yes. The Surveyor asked R#62 to describe the abuse, R#62 stated a girl on second shift was giving him a shower, pushed him against the wall and hit his head. The Surveyor asked how long ago did this happen? R#62 responded it happened three or four weeks ago, when the Surveyor asked R#62 what the name of the girl was he stated her name is - (identified by Surveyor as Certified Nurse's Aide (CNA) HH). Cross refer to F223 A review of the Incident log ran on 6/26/17 at 4:47 p.m. for the dates 3/26/17 to 6/26/17 for R#62 revealed no matching records found. During the interview, the SSD was asked about R#62's Departmental Notes on 6/14/17, concerning staff handling him roughly, she stated that . the Administrator stated she did not complete a grievance or report because she didn't see it as an incident. She felt it was resolved because he stated to her they had roughly washed his hair. During an interview conducted on 6/26/17 at 5:10 p.m. the Social Services Director (SSD) stated R#62 reported today that he has been having issues with three CNAs handling him roughly in the shower. He has requested one CNA not be in the room when he is in the shower . CNA HH is rough with him, CNA OOO just stands there and watches and CNA KKK is very pushy when she picks him up and is always in a hurry and never takes her time. He stated he was scared. He named CNA KKK, CNA OOO, CNA HH and a heavy-set African American woman who picks up residents and looks like she could throw the resident in the bed or chair. Post survey interview on 7/7/17 at 10:27 a.m. with the Administrator revealed that she was made aware of the grievances for R#62 dated 6/13/17 and 6/26/17 on 6/26/17. The Administrator stated upon review of the grievances that she considered that when the grievance documented that the resident's head was bumped, or that the resident verbalized that the CNA was pushy, and that he was scared of the CNA that she considered those grievances to be potential abuse and that the grievances had been investigated, but they had not been reported to the State Survey Agency (SSA). Further interview revealed that the Administrator stated that the grievances had not been reported to the SSA because they were late entries and then in further interview the Administrator stated the grievances had not been reported because these grievances had been placed in a file and that it (the grievance being reported) had just been missed. Further interview with the Administrator revealed that as of 6/29/17, the Director of Nursing (DON) had been named the Abuse Coordinator. The Administrator revealed that the DON is the third Abuse Coordinator since September 2016, and that a previous Social Services Director had been the Abuse Coordinator from 9/21/16 through 3/31/17, and that the next Social Services Director had been the Abuse Coordinator from 3/28/17 through 6/29/17, but that per their facility policy that the Administrator, DON, or designee is the appointed Abuse Coordinator. Post survey interview on 7/7/17 at 11:03 a.m. with the DON revealed that his first day working in the facility was 6/12/17 and that he had been named the Abuse Coordinator on 6/29/17. The DON revealed that he became aware of the grievances for R#62 on 6/26/17 and that he had investigated the grievances and had removed the CNA's, that were named in the grievance, from working on the same unit as R#62, interviewed the resident, notified the physician, notified the responsible party, immediately educated the staff on abuse, but that he had not reported the grievance to the SSA. Post survey interview on 7/7/17 at 11:14 a.m. with the Staff Development Coordinator revealed that prior to the survey the last time she had educated the staff on abuse was 2/23/17 and that at that time she had educated the staff on abuse including the different types of abuse, definitions of abuse, and that abuse should be reported to the Abuse Coordinator. Further interview revealed, that prior to this survey that, per facility policy, she had educated the staff that the Administrator was the Abuse Coordinator and that staff should report all allegations of abuse to the Abuse Coordinator (the Administrator). The facility failed to investigate the alleged physical abuse, failed to file a report with the state agency of the alleged abuse.

Based on record review, resident and staff interviews the facility failed to follow the Behavior Care Plan interventions to assess the need for a psych consult for mood, behavior, or psychosocial wellbeing changes; Social Services involvement if needed; inform physician of behavior for possible medication changes for one resident (R#14). Additionally, the facility failed to follow the care plan titled, [MEDICAL TREATMENT] Access Care related to checking for a thrill and bruit for one of one [MEDICAL TREATMENT] residents (R) (#116). A thrill and bruit need to be assessed after each [MEDICAL TREATMENT] session, listening to the bruit and feeling the thrill help determine if the access site is functional. The sample size was 42 residents. On 6/30/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at §483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. §483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: 1. Record review revealed that R#14 was admitted the facility on 9/25/15, according to the Face Sheet printed on 6/29/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) for R#14 was a quarterly assessment of overall health status dated 5/3/17 indicated R#14 was cognitively impaired per Brief Interview for Mental Status (BIMS score 5/15), and required supervision from staff for mobility throughout the facility in her wheelchair. She had the ability to wheel herself about the facility to where she wanted to go MDS section G Functional Status quarterly dated 2/2/17: section F: Locomotion: resident #14 identified as a level 2 defined as limited assist under self performance locomotion off the unit, self-sufficient once in wheelchair. MDS section G Functional Status quarterly assessment dated [DATE] under Locomotion: assessed at level 1 indicating supervision/oversight only required, self-sufficient once in wheelchair. Review of the Behavior Care Plan, for R#14, dated 9/7/16 and most recently revised on 5/3/17 documented, in pertinent part, I have the potential for mood/behavior and/or psycho-social decline related to dementia and depression. She will wander in and out of other residents' rooms socializing with residents and families. She will at times kiss people on the hand and [MEDICAL CONDITION] at times. She is usually easily directed. Approaches included, in pertinent part: Assess the need for psych consult if mood, behavior, or psycho-social well-being changes; Social Services involvement if needed; Inform physician of behavior for possible medication changes . Record review revealed that The Behavior Care Plan, for R#14, did not include information related to R#14's sexually abusive behavior toward other residents although there was evidence that staff were aware of her behaviors and were aware of R#105's allegations of sexual abuse. There was not any evidence that the staff consulted psych services or that the social worker had reviewed and discussed additional interventions needed to prevent the resident from further sexually inappropriate behavior. The facility policy regarding resident care planning was requested by the survey team on 6/30/17 at approximately 6:30 p.m., however, the Director of Nursing (DON) stated the facility had no specific policy related to care planning. During an interview with the Administrator on 6/29/17 at 6:45 p.m., she indicated that she was not aware that R#14 was behaving in a sexually abusive manner. The DON confirmed on 6/30/17 at 6:39 p.m. the facility had no policy to require completion of a care plan. Post survey interview on 7/12/17 at 3:15 p.m. with LPN MDS revealed that she is a new employee and has been the LPN MDS for about one month and that she had not observed R#14 exhibit any inappropriate behaviors, but that she was aware that the resident was severely cognitively impaired and that she had socially inappropriate behavior such as touching inappropriately and that she had heard that R#14 had groped a resident. LPN MDS revealed that the interventions that have been in place for R#14 have been to redirect the resident. Further interview with LPN MDS revealed that when assessing a resident to determine if the resident needs a psychiatric evaluation you determine if the resident need any medical interventions first such as collecting a urinalysis to determine if a resident had a urinary tract infection, first. LPN MDS reviewed the medical record for R#14 and revealed that prior to this survey that the resident had a urinary tract infection in August 2016. Continued interview with LPN MDS, at this same time, revealed that MDS normally updates and revises residents care plans for behaviors and that they discuss behaviors during their morning meeting and that the DON brings in a list of incidents that have occurred the day before and that the incidents are discussed and it is decided if a resident's care plan should be updated, revised, or if a new care plan needs to be developed, and that prior to the survey R#14's behaviors had not been discussed, in the morning meeting, since she had been the LPN MDS a little over a month ago. 2. Interview and observation of R#116 on 6/27/17 at 4:15 p.m. revealed he was up in a power scooter at bedside. He stated he went to [MEDICAL TREATMENT] three times a week. He stated when he returned from [MEDICAL TREATMENT] the nurse only looked at the bandage over his [MEDICAL TREATMENT]. He stated the nurses never listened for a bruit or felt the access site for a thrill. A care plan for [MEDICAL TREATMENT] was dated 5/4/17 and indicated the onset of [MEDICAL TREATMENT] was 11/21/14. One approach on the care plan was to check the bruit and thrill in R#116's left forearm. The electronic treatment administration record (E-TAR) only called for checking his left forearm for bleeding on post [MEDICAL TREATMENT] days. Review of the Physician Orders for January 2017, February 2017 , March 2017 , April 2017, May 2017 and June 2017, revealed that there was not an order to check for bruit and thrill. Review of the chart and electronic Medication Administration Record [REDACTED]. During an interview with the West Wing Unit Manager on 6/29/17 at 2:52 p.m. she stated When I'm on the floor I check for it (bruit and thrill) and document. She was unaware the order on the E-MAR was to check for bleeding at the [MEDICAL TREATMENT] site and she was unable to show where she had documented the bruit and thrill in his medical record. During an interview with the Director of Nursing (DON) on 6/29/17 at 2:25 p.m. that he expected the nurses to check the bruit and thrill of a [MEDICAL TREATMENT] resident and document it in the chart. He also stated that there should be orders on the chart for checking for a bruit and thrill for any resident on [MEDICAL TREATMENT]. Review of the facility policy titled [MEDICAL TREATMENT] Access Care with a revision date of September 2010 revealed Care of AVFs (arteriovenous fistula artificial created pathway for [MEDICAL TREATMENT]) and AVGs (arteriovenous graft) item H. indicated Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access.

Based on review of the facility Administrator Job Description signed by the Administrator and dated 2/23/16, observation, record reviews and interviews, the facility's Administration failed to implement its resources effectively and efficiently to prevent instances of sexual and physical abuse and failed to investigate and report allegations of sexual and physical abuse to protect Residents (R) #62, R#105, R#110 and R#170. This failure placed residents at further risk for ongoing sexual, physical and verbal abuse. The sample size was 42 residents. On 6/30/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at §483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. §483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: Observations, clinical records review, and staff interviews revealed that the facility was not in substantial compliance during the standard/extended survey of 6/26/17 through 7/1/17. Refer to the following deficiencies for specific details of noncompliance: Cross reference to F223: The facility failed to ensure four Residents (R) #62, R#105, R#110, and R#170) were free from abuse to include resident to resident abuse and staff abuse of a resident. Cross reference to F225: The facility failed to investigate and report allegations of abuse for four Residents (R) (R#62, R#105, R#110, and R#170). Cross reference to F282: the facility failed to follow the Behavior Care Plan interventions to assess the need for a psych consult for mood, behavior, or psychosocial wellbeing changes; Social Services involvement if needed; inform physician of behavior for possible medication changes for one resident (R#14). Cross reference to F490: The facility's Administration failed to implement its resources effectively and efficiently to prevent instances of sexual and physical abuse and failed to investigate and report allegations of sexual and physical abuse to protect Residents (R) #62, R#105, R#110 and R#170. This failure placed residents at further risk for ongoing sexual, physical and verbal abuse. Cross reference to F520: The facility failed to maintain an effective Quality Assurance (QA) program which systematically reviewed, developed, and implemented plans to correct quality deficiencies for all 110 residents living in the facility as of 6/26/17. The facility's QA program failed to: Identify and respond to a pattern of failures regarding the identification, protection, investigation, and timely reporting of allegations of sexual and physical abuse. The Administrator Job Description, signed by the Administrator and dated 2/23/16 read, in pertinent part, Summary: Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives by performing the following duties personally or through subordinate supervisors; and Essential Job Functions: Implements and communicates policies and procedures for various departments; Conducts regular rounds to monitor residents needs are being addressed; Maintains a working knowledge and ensure compliance with all governmental regulations; Maintains (Company's) Quality Assurance Standards; Understands, complies with and promotes all rules regarding Residents' Rights; and Report all accidents and incidents. During an interview with R#105 on 6/29/17 at 6:10 p.m., revealed that R#14 came up beside him and hit me and bruised my right testicle. My testicle is swollen up big now, and I have to go back to the doctor again. I have a bad bruise and I may have to have surgery. I went to the doctor's office (urologist) after the doctor here got me an appointment. And that he went to Administrator on 5/25/17, and talked to her and told her I want to keep R#14 away from me and that she keeps coming in my room. The Administrator told R#105 that she was going to move him to another home. R#105 verbalized that he had reported R#14's behaviors towards him multiple times, however he was unable to recall specific names and dates of the reports. Record review revealed a Departmental Note for R#105, dated 7/9/16, documented by RN BB documented in pertinent part, Resident (R#105) reported that R#14 was sexually harassing him and further revealed he reported it to the lady in the front and Departmental Note documented by RN BB revealed that she had spoken with the DON (Director of Nursing) and the Administrator. Record review revealed a Departmental Note for R#105, dated 1/19/17 that documents, in pertinent part, Resident (R#105) reported that (R#14) came into his room without permission while he was finishing breakfast. During an interview, conducted with Licensed Practical Nurse (LPN) AAA on 6/29/17 at 5:55 p.m., revealed that LPN AAA was aware that R#14 touches peoples' privates, and that R#105 has a big issue with her. He has reported this to the Administrator several times. She (R#14) comes in his room at night and she'll touch his privates. He told me directly that he reported it to the Administrator. During an interview with RN BB on 7/1/17 at 10:25 a.m., she stated, I remember reporting to the DON and Administrator regarding the incident reported by (R#105). It was the current Administrator and the former DON. At that time, the former DON said she was aware of the situation. An interview on 6/26/17 at 5:10 p.m. with the Social Services Director (SSD) revealed that R#62 reported today, 6/26/17, further interview revealed that the Administrator stated that she did not complete a grievance or report because she didn't see it as an incident. She felt it was resolved because he stated to her they had roughly washed his hair. Post survey interview on 7/7/17 at 10:27 a.m. with the Administrator revealed that she considered that when the grievance documented that the resident's head was bumped, or that the resident verbalized that the CNA was pushy, and that he was scared of the CNA that she considered those grievances to be potential abuse and that the grievances had been investigated, but they had not been reported to the State Survey Agency (SSA). Further interview revealed that the Administrator stated that the grievances had not been reported to the SSA because they were late entries and then in further interview the Administrator stated the grievances had not been reported because these grievances had been placed in a file and that it (the grievance being reported) had just been missed. Review of deficient practices identified putting residents of the facility in immediate jeopardy: F223, F225, F282, F490, and F520 identified the facility Administrator failed to perform the duties per the job description to meet resident's needs, meet government regulation and implement or develop facility policies to protect residents from abuse, investigate abuse and report abuse as required.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance (QA) program which systematically reviewed, developed, and implemented plans to correct quality deficiencies for all 110 residents living in the facility as of 6/26/17. The facility's QA program failed to: Identify and respond to a pattern of failures regarding the identification, protection, investigation, and timely reporting of allegations of sexual and physical abuse. On 6/30/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at §483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. §483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: Interview with the Director of Nursing (DON) and Administrator on 7/1/17 at 11:10 a.m. revealed that both had shared responsibility for the facility's Quality Assurance and Performance Improvement (QAPI) program, however, the DON had only been employed at the facility for approximately three weeks prior to the survey and had not attended a QA meeting as of the time of the interview. Deficient areas that were identified through observations, interviews, and record review during the Recertification and extended survey are examples of how the facility's QAPI program failed to function. Refer to the following deficiencies for specific details of the noncompliance that was not addressed by the facility Quality Assurance Committee, including: F223: Residents Rights to be free from Abuse F225: Failed to Investigate reports of Abuse F282: Services by Qualified Persons F490: Effective Administration/Resident Well Being F520: Quality Assurance & Performance Improvement During the interview which began on 7/1/16 at 11:10 a.m., the DON and Administrator were asked if the QA committee had identified the failure to identify, immediately report, thoroughly investigate, and take immediate actions to protect residents from potential abuse. The Administrator stated, Any allegation of abuse should be brought into QA. We have what we call an incident Log. We should be using the incident log it MUST be completed and then all supporting documentation should be attached to the incident log. We should then summarize the allegations. This has not been happening up to now. They (staff) have just been reporting off on grievances, and this has included verbal reports of missing laundry and things like that. The incident log itself has not been brought into the (QA) meeting. No allegations of abuse have been reviewed in QA up to this point. Further interview with the DON and Administrator revealed that the QA committee had not identified any systemic problems with its abuse/neglect prevention program prior to the survey team bringing the allegations of abuse to their attention during the survey of 6/26/17 through 7/1/17. A request was made for the facility policy for guidance of the QA committee on 7/1/17. The facility did not have a policy for the QA committee to follow.