Every finding on record at Lake Park Nursing and Rehabilitation Center

Based on record review, and staff, resident, and Physician interviews, the facility failed to ensure advance directive information was consistent throughout the medical record for 1 of 4 residents reviewed for advance directives (Resident #84). The findings included: Resident # 84 was readmitted to the facility on [DATE]. Review of the Advance Directives binder located at the nursing station revealed a yellow Do Not Resuscitate (DNR) sticker on the outside Resident #84's binder (Binders with yellow stickers were used by nursing staff to identify Residents who have elected DNR status). Further review of the binder revealed Resident #84 had a Medical Orders for Scope of Treatment (MOST) form dated 03/09/2022 that was signed by the resident and the physician. The MOST form instructed to Attempt to Resuscitate (Full Code). Review of Resident #84's electronic health record (EHR) revealed an active Physician order dated 3/20/24 signed by the Physician that stated Do Not Resuscitate (DNR). Review of Resident #84's EHR revealed the Advance Directive was documented under the Demographics tab and under Physician Orders. The code status entered in the EHR was DNR. Resident #84's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was cognitively intact. Resident #84's advance directive care plan dated 12/16/2025 revealed the Resident's code status to be DNR. An interview with Resident #84 on 01/21/2026 at 11:14 AM revealed that Resident #84 remembered a staff member speaking with him at a previous time regarding his code status. Resident #84 was unable to recall the time frame or name of the staff member. The resident stated he made his wishes known to be Full Code. Resident #84 stated he did not inform anyone that he wished to be a DNR and did not recall signing paperwork for his code status. Interview with the MDS Nurse on 01/21/2026 at 12:16 PM revealed that upon admission, an admission Nurse was responsible for documenting the Resident's code status. The MDS Nurse explained that if a resident wished to change their code status, nursing staff would notify the physician to obtain a new order, and the change would be discussed during the daily morning clinical meeting. The MDS Nurse stated Resident #84 was a DNR per physician order. The MDS Nurse stated she was responsible for updating the care plan. She further stated she was unable to identify why Resident #84's code status had not been updated. The MDS Nurse also stated the Social Worker discussed code status during care plan meetings. Interview with Social Worker on 01/21/2026 at 2:54 PM revealed that code status was verified upon admission and discussed during baseline care plan meetings. The Social Worker reported that a code status audit had been conducted four months prior due to inconsistencies identified about a year earlier involving a resident's code status. The Social Worker stated the most recent care plan meeting for Resident #84 was held on 10/01/2025 and reported that code status was discussed during that meeting and Resident #84 remained a DNR. Attendees at the care plan meeting included the Social Worker, nursing staff, and Resident #84. When asked about the current discrepancy in Resident #84's code status, the Social Worker stated the Resident may not have fully understood the meaning of code status. The Social Worker further stated Resident #84 was cognitively able to express his wishes regarding code status. The Social Worker stated the MOST form had not been updated to reflect Resident #84's expressed wishes and acknowledged it was an error, stating she was unsure how the discrepancy in the Resident's code status was missed given her recent audit of all Residents. The Social Worker indicated that the Physician was responsible for correcting and signing the MOST form and acknowledged that the MOST form was not updated because it was overlooked by the Physician and Nursing staff. Review of progress notes and care plan meeting notes dated 10/01/2025 revealed no documentation that code status was discussed during the care plan meeting. In an interview conducted with the Physician on 01/21/2026 at 3:13 PM. The Physician stated he was responsible for writing advance directive orders for the facility. The Physician reported staff were required to notify him of any changes related to a Resident's code status. When asked about the discrepancy in Resident #84's documented code status, the Physician stated that in 2024 the resident was hospitalized and returned to the facility documented as Do Not Resuscitate (DNR). The Physician stated Resident #84 was cognitively intact and capable of making his own medical decisions. The Physician acknowledged the discrepancy had been overlooked and indicated that Resident #84 code status was not accurate in the EHR, Resident #84's code status binder, or Physicians DNR orders. On 01/22/2026 at 3:13 PM, the Physician stated he met with Resident #84 on 01/21/2026 to discuss the resident's code status. The Physician provided evidence of an updated advance directive in the EHR and in the facility's code status binder, which reflected Resident #84 code status as Full Code. In an interview conducted with the Director of Nursing (DON) on 01/22/2026 at 12:25 PM, the DON stated that upon admission, a resident's code status was established, entered into the electronic medical record under physician orders, placed in the Advance Directives binder if the Resident was designated as DNR, and incorporated into the comprehensive care plan. The DON reported that if a resident elected hospice services or was sent to the hospital, the code status should be reviewed to ensure it remained accurate and up to date. The DON stated that if a resident wished to change their code status at any time, the resident could notify nursing staff or the Social Worker. Regarding the inaccurate code status for Resident #84, the DON stated she did not know how the discrepancy occurred. The DON further stated the discrepancy may have occurred prior to her employment at the facility. The DON indicated she was part of the audit conducted by the Social Worker regarding Residents' code statuses. The DON provided no information regarding the recent audit of Residents' code statuses. The DON further stated that Resident #83's code status should have been consistently and accurately documented in the Advance Directives binder, the EHR, and in physician orders. In an interview conducted with the Administrator on 01/22/2026 at 3:43 PM, the Administrator reported that Resident #84 returned to the facility from the hospital with documentation reflecting DNR status. When asked about the discrepancy between the MOST form, which indicated Full Code and the facility's Physician's orders reflecting DNR status, the Administrator stated he was not aware of the inconsistency.

Based on record review, observations, and staff and Nurse Practitioner interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 2 residents reviewed for respiratory care (Resident #60). The findings included: Resident #60 was readmitted on [DATE]. Her diagnoses included atrial fibrillation, congestive heart failure, and shortness of breath. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 was moderately cognitively impaired and received oxygen therapy. Resident #60 had a physician order dated 11/19/24 indicated the administration of oxygen via nasal cannula at 2 liters per minute continuously to keep oxygen saturation levels above 90%. The order had no expiration date and was ordered as indefinite. Resident #60's current care plan dated 11/25/25 indicated Resident #60 was at risk for ineffective breathing pattern related to congestive heart failure and shortness of breath. Interventions included administering oxygen via nasal cannula as ordered. The Medication Administration Record (MAR) included an order for oxygen at 2 liters via nasal cannula to keep oxygen saturation levels above 90% every day and night shift for shortness of breath. The order start date was 11/19/2024. The MAR schedule included Oxygen at 2 liters via nasal cannula to keep oxygen above 90% every day and night shift for shortness of breath. There were two 12-hour blocks for each day of the month for staff to confirm the flow rate every twelve hours. One block was marked 12H which represented Day shift, and the second block was marked 12HR which represented Night shift. A review of January 2026 MAR revealed staff documented the flow rate at 2 liters per minute twice each day on 1/20/26, 1/21/26, and 1/22/26. The MAR review for 1/20/26 and 1/21/26 revealed Nurse #3 documented that the oxygen was set at 2 liters per minute for the Day shift both days. The MAR review for 1/22/26 revealed Nurse #1 documented that the oxygen was set at 2 liters per minute for Day shift. During observation on 1/20/26 at 10:52 AM Resident #60 was observed with the oxygen nasal cannula in place. Resident #60's oxygen regulator on the concentrator was set at 3 liters per minute when viewed horizontally at eye level. During observation on 1/21/26 at 9:00 AM Resident #60 was observed with the oxygen nasal cannula in place. Resident #60's oxygen regulator on the concentrator was set at 3 liters per minute when viewed horizontally at eye level. An interview was conducted with Nurse #3 on 01/21/26 at 9:31 AM. Nurse #3 did not answer questions specific to oxygen orders of Resident #60 but stated she would review the MAR for any medications or treatments. Nurse #3 indicated she followed what was listed on the MAR. Nurse #3 excused herself to complete her medication pass. Nurse #3 was not available for a follow-up interview during the survey. During observation on 1/22/26 at 10:07 AM Resident #60 was observed with the oxygen nasal cannula in place. Resident #60's oxygen regulator on the concentrator was set at 3 liters per minute when viewed horizontally at eye level. Resident #60's oxygen regulator verified, with Nurse #1 present, to be set at 3 liters per minute. An interview was conducted on 1/22/26 at 10:10 AM with Nurse #1 who was assigned to administer medication, treatments, and provide care for Resident #60 on 1/22/26 during the day shift (7:00 AM - 7:00 PM). Nurse #1 stated Resident #60 had a physician order for oxygen at 2 liters per minute via nasal cannula. He said he checked the yes radio button in the MAR that the oxygen was set at 2 liters per minute. Nurse #1 reported they were trained to visually check the oxygen flow rate. Nurse #1 further explained he usually checked when he went to the room to administer medication, but he had not checked it earlier when he was in Resident #60's room and administered her morning medications. Nurse #1 reported the settings needed to be corrected and he would need to report to his Unit Manager. An interview was conducted with the Unit Manager #1 on 1/22/26 at 10:20 AM. She stated oxygen should be delivered at the rate ordered by the provider. Unit Manager #1 stated the nurse was expected to visually confirm the rate of oxygen before they signed in the MAR that the oxygen was set at the provider ordered flow rate. An interview was conducted on 1/22/26 at 1:30 PM with the Nurse Practitioner (NP). She stated she expected nurses to ensure oxygen was set at the ordered rate and if they needed to titrate the oxygen rate, she expected nurses to call the provider to request adjustment to the oxygen rate. She stated the increased oxygen rate was not harmful to the Resident with her listed diagnoses. An interview was conducted on 1/22/26 at 2:48 PM with the Assistant Director of Nursing (ADON). She stated the nurses should administer oxygen at the provider ordered rate. She reported that the oxygen order details were located in the electronic medical record and the MAR. She stated they should have notified the provider immediately if they needed to change the oxygen rate. The ADON stated she expected nurses to follow provider orders or notify the provider if they thought changes were indicated. An interview was conducted on 1/22/26 at 3:25 PM with the Director of Nursing (DON). She stated Nurse #1 should have verified that Resident #60's oxygen regulator was set at the physician ordered rate. The DON explained she expected nursing staff to follow physician orders and to request an updated order if there was a need to titrate the oxygen. The DON stated nurses should verify oxygen rates when they assumed the residents' care. She stated when administering medications the nurses should visually confirm the rate of administration before they entered confirmation in the MAR that oxygen was administered at the provider ordered rate. During an interview on 1/22/26 at 4:00 PM with the Administrator, he stated he expected nurses to monitor the oxygen setting to ensure that it was set at the rate ordered by the provider.

Based on record review, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns voiced by residents during Resident Council meetings for 3 of 4 months reviewed (November 2025, December 2025, and January 2026).Review of the Resident Council meeting minutes for October 2025, November 2025, December 2025, and January 2026, revealed the following:a. The Resident Council minutes dated 10/08/25, revealed, under New Business, resident concerns regarding lack of available linen, towels, and washcloths.b. The Resident Council minutes dated 11/5/2025 revealed concerns regarding housekeeping staff not removing trash and failing to clean residents' bathrooms and bedrooms. There was no follow up information documented regarding the facility's response to address the concerns noted in the October 2025 meeting. c. The Resident Council minutes dated 12/5/2025 revealed concerns that housekeeping staff were leaving excessive water on the floor after mopping and not adequately cleaning bathrooms. There was no follow up information documented regarding the facility's response to address the concerns noted in the November 2025 meeting. d. The Resident Council minutes dated 1/8/2026 revealed concerns that beds were not being made, bathrooms were not being properly cleaned, and excessive water was left on the floor after mopping. There was no follow up information documented regarding the facility's response to address the concerns noted in the December 2025 meeting.A Resident Council group interview was conducted on 1/21/2026 at 1:30 PM. During the interview, Residents #1, #70, #73, #79, #88, #95, and #99, who attended Resident Council meetings regularly, all stated they felt facility staff did not really address their concerns or suggestions because the only response they typically received from staff, if they received one at all, was we are working on it, we are short staffed, or we don't have a housekeeping manager and some of the issues continued to happen. Resident #1, who was the Resident Council President, added housekeeping concerns, including trash left in rooms, bathrooms not properly cleaned, and laundry issues had been on-going. The Residents all agreed they wanted to know they were being heard and receive feedback from the administration on the efforts that had been made or attempted to resolve their concerns and/or suggestions.In an interview conducted on 01/21/2026 at 2:36 PM, the Activities Assistant stated she was aware of housekeeping concerns but was not aware that resident grievances related to housekeeping had not been addressed by the Housekeeping Manager. The Activities Assistant reported that department managers typically attended Resident Council meetings but had not attended in the past three months. The Activities Assistant stated that the former Activities Director maintained the grievances from Resident Council and was no longer employed at the facility. The Activities Assistant reported that written grievances were not consistently completed when concerns were voiced during Resident Council meetings. She indicated that issues were discussed, however, grievance forms were not initiated or documented for those concerns. The Activities Assistant also stated grievances were currently handled verbally and discussed during morning meetings. The Activities Assistant reported she informed the Administrator of the housekeeping concerns in November of 2025 and was instructed to follow up with the Housekeeping Manager once hired. The Activities Assistant indicated that the facility had since hired a new Housekeeping Manager and she planned to make him aware of the concerns. In an interview conducted on 01/22/2026 at 8:43 AM, the Housekeeping Manager, who had been employed at the facility for one month, reported he was not aware of the housekeeping concerns identified during Resident Council meetings.In an interview conducted on 01/22/2026 at 1:52 PM, the Director of Nursing (DON) stated her role in Resident Council was to address concerns related to nursing services and to follow up with the Administrator to ensure grievances were completed and resolved. The DON stated she was not aware of the concern that residents' beds were not being made by staff.In an interview conducted on 01/22/2026 at 3:20 PM. the Administrator stated he did not participate in Resident Council meetings and was unaware of the housekeeping issues raised by residents. The Administrator stated there was currently no Activities Director in place and stated he was not aware that staff were not utilizing the grievance forms for Resident Council concerns.

Based on record review and staff, Nurse Practitioner, Orthopedic Nurse Practitioner, and Physician's interviews the facility failed to provide monitoring for skin breakdown under a leg immobilizer for 1 of 3 residents (Resident #1) reviewed for wound care. Resident #1 developed a stage 3 pressure ulcer to her right thigh which was found on 2/19/2025, and a pressure ulcer to the right ankle. On 3/18/25 the pressure ulcer to the right ankle was assessed as an unstageable pressure ulcer. Findings included: Resident #1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of a right femur fracture. A Progress Note written 12/13/2024 at 3:19 pm by Nurse #3 stated Resident #1 arrived at the facility with a right femur fracture with a cast in place. A significant change Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and required extensive assistance with bed mobility and transfers. The assessment further indicated Resident #1 had a stage 3 pressure ulcer. An Orthopedic Office Visit Note dated 1/15/2025, which was written by the Orthopedic Physician's Assistant, stated Resident #1's cast was removed, and an immobilizer was placed on her right leg to stabilize her right, distal femur fracture. The Office Visit Note further stated the immobilizer should be worn full-time, and Resident #1 should continue to be non-weight bearing to her right leg. A Nurse's Progress Note written 1/15/2025 at 5:18 pm by Nurse #5 indicated Resident #1 was seen by the Orthopedist and her cast was removed and an immobilizer was applied to her right lower extremity. The Nurse's Progress Note further indicated Resident #1 was to keep the brace on at all times and was non-weight bearing on her right lower extremity. A review of the Physician's Orders for 1/2025 revealed no order was written for Resident #1's skin assessments under the right leg immobilizer to be checked for redness or skin breakdown each shift. Resident #1's Treatment Administration Record was reviewed for 1/2025 and there was no documentation found for nursing assessments of the skin under Resident #1's right leg immobilizer each shift to check for redness or skin breakdown. On 2/19/2025 at 5:18 pm Nurse #1wrote a Nurse's Progress Note that stated Resident #1's immobilizer to her right thigh leg was removed and she had developed a stage 3 pressure ulcer to her right lateral, upper femur and a red area on her lateral right ankle. The Nurse's Progress Note further indicated a skin assessment was completed, the hospice nurse was notified, the Responsible Party was notified, and the Physician was notified of the resident's pressure ulcers. On 2/19/2025 at 12:41 pm a Wound Ulcer Flowsheet, completed by the Director of Nursing, indicated Resident #1 had a stage 3 pressure ulcer to her right, posterior thigh that measured 5 centimeters long by 3 centimeters wide. During an interview with Nurse #1 on 4/23/2025 at 1:28 pm she stated Resident #1 returned from the hospital on 12/13/2024 with a cast to her right leg due to a femur fracture. She stated Resident #1 had a cast to her right leg when she returned to the facility and the hospital discharge summary indicated she was not a candidate for surgical repair of the right femur fracture. Nurse #1 stated she returned to the Orthopedist on 1/15/2025 and the cast was removed, and an immobilizer was placed on her right leg that extended from the top of her thigh to her ankle. Nurse #1 stated she was responsible for entering the orders from the Orthopedist Consult and failed to put orders into the system for Resident #1's skin to be checked under the immobilizer twice daily, on each shift for any skin breakdown under the immobilizer. She stated the Orthopedist's Nurse Practitioner had written the orders on the consultation that stated the immobilizer should be worn at all times and the staff thought they could not open the immobilizer and had not checked Resident #1's skin under the immobilizer. During a follow-up interview with Nurse #1 on 4/24/2025 at 12:46 pm she stated Resident #1 was complaining of pain to her right leg on 2/19/2025 and she asked Nurse Practitioner #1 if she could take the brace off Resident #1's leg and that was when she saw the pressure ulcers to her upper right thigh and right ankle. Nurse #1 stated the pressure ulcers were areas that had been against the hard areas on the immobilizer. Nurse #1 stated she asked Nurse Practitioner #1 to assess the wounds on Resident #1's right leg and she assessed her and ordered a soft brace to her right leg. A Physician's Order dated 2/21/2025 indicated Resident #1 should have an immobilizer brace to her right lower extremity to stabilize fracture to right distal femur. The order stated only remove the brace for skin check and skin care every day and night shift. The 2/2025 Treatment Administration Record (TAR) for Resident #1 indicated she should have the right lower extremity immobilizer brace in place to stabilize the right distal femur fracture and the immobilizer should only be removed to check her skin and skin care each shift beginning 2/21/2025. A Wound Ulcer Flowsheet dated 2/26/2025 at 1:53 pm, completed by Nurse #1, indicated Resident #1's stage 3 pressure ulcer to her right, posterior thigh measured 5 centimeters in length, 3.8 centimeters in width and .5 centimeters in depth, and the wound was improving. On 3/6/2025 at 1:54 pm Nurse #1 completed a Wound Ulcer Flowsheet which indicated Resident #1's right, posterior thigh stage 3 pressure ulcer measured 5 centimeters long, 7 centimeters wide, and 0.5 centimeters deep. The Wound Ulcer Flowsheet did not indicate if the wound had improved. Nurse #1 completed a Wound Ulcer Flowsheet on 3/18/2025 at 8:35 am which indicated Resident #1's right, posterior thigh stage 3 pressure ulcer was measured and was 3.2 centimeters long, 5.2 centimeters wide, and 0.5 centimeters in depth. The Wound Ulcer Flowsheet indicated Resident #1's right posterior thigh stage 3 pressure ulcer was improving. On 3/18/2025 at 1:46 pm a Wound Ulcer Flowsheet completed by Nurse #1 indicated Resident #1 had a right, outer ankle unstageable area that measured 2 centimeters in length, 2 centimeters in width, and 0.1 centimeters in depth. The Wound Ulcer Flowsheet further indicated the wound bed had eschar and there was dried, yellow drainage. Nurse #6 completed a Wound Ulcer Flowsheet on 3/24/2025 at 11:45 am and Resident #1's right, outer ankle wound continued to be unstageable and measured 2 centimeters long, 2 centimeters wide, and 0.1 centimeter deep. The Wound Ulcer Flowsheet did not indicate if the wound had improved. On 3/24/2025 at 5:10 pm the Director of Nursing completed a Wound Ulcer Flowsheet which indicated Resident #1's right, posterior thigh stage 3 pressure ulcer was improving and measured 2 centimeters long, 0.2 centimeters in width, and 0.3 centimeters in depth. Nurse #1 completed a Wound Ulcer Flowsheet on 4/1/2025 at 2:55 pm and indicated Resident #1's right, outer ankle pressure wound was unstageable and measured 2.7 centimeters in length, 2 centimeters in width, and 0.4 centimeters in depth. The Wound Ulcer Flowsheet described the wound as having 25% slough tissue and 75% eschar tissue, but did not indicate if the wound had improved or declined. A Wound Ulcer Flowsheet completed by Nurse #1 on 4/2/2025 at 3:27 pm indicated Resident #1's right, posterior thigh stage 3 pressure ulcer measured 3.3 centimeters in length, 6 centimeters in width, and 1 centimeter in depth and continued to improve. On 4/8/2025 at 1:20 pm Nurse #5 wrote a Progress Note that stated Resident #1 had no acute distress and the hospice nurse had evaluated her but Resident #1's family requested the resident be sent to the emergency department. Resident #1 was discharged from the hospital to home at the Responsible Party's request with hospice services. During a phone interview with the Responsible Party on 4/24/2025 at 3:46 pm she stated Resident #1had a cast on her right leg when she returned from the hospital on 12/13/2024. The Responsible Party stated Resident #1 had an Orthopedist follow-up appointment on 1/15/2025 and the Orthopedist removed the cast and placed an immobilizer on Resident #1's right leg. The Responsible Party stated no one opened the immobilizer and checked her skin until 2/19/2025 and she had developed pressure wounds on her thigh and ankle. The Responsible Party stated a nurse at the facility told her the nursing staff had failed to check Resident #1's skin under the immobilizer but she did not remember the Nurse's name. An interview was conducted with Nurse Practitioner #1 on 4/24/2025 at 1:18 pm and she stated she assessed Resident #1 on 2/20/2025 after the pressure ulcers were found on her right upper thigh and right ankle. Nurse Practitioner #1 stated the wounds were caused by pressure of the immobilizer against Resident #1's leg and she was not aware until the pressure wounds were found that the nurses were not opening the immobilizer and checking Resident #1's right leg for any skin breakdown. Nurse Practitioner #1 stated there should have been at least daily routine checks of the skin under the immobilizer. On 4/24/2025 at 3:02 pm the Orthopedist Nurse Practitioner was interviewed by phone, and she stated she did order Resident #1's immobilizer to be worn at all times but she did expect that the facility's Nursing staff would have known that the immobilizer should be opened at least daily and the skin checked for any redness or signs of skin breakdown. The Director of Nursing (DON) was interviewed on 4/24/2025 at 2:03 pm and she stated Resident #1 readmitted to the facility on [DATE] with a right femur fracture and she had a cast to her right leg. The DON further stated she went to an Orthopedist appointment on 1/15/2025 for a follow-up appointment and the cast was removed and an immobilizer was placed on Resident #1's right leg. The DON stated the order to check Resident #1's right leg for skin breakdown under the immobilizer was not put into place until 2/21/2025 after the pressure ulcers were found to her right upper femur and her ankle on 2/19/2025. The DON stated the nursing staff should have assessed Resident #1's skin under the immobilizer on her right leg every shift. The DON stated no one reported the pressure ulcers until 2/19/2025 and the areas were assessed as stage 3 pressure ulcers. The DON stated Resident #1 returned to the facility from the hospital on 12/13/2024 with orders for hospice care. On 4/24/2025 at 1:46 pm the Administrator was interviewed by phone and stated he was aware of Resident #1 having pressure ulcers that developed under the immobilizer on his right leg. The Administrator stated the Orthopedist had ordered the immobilizer be left in place and he would not make an assumption about whether the facility's nursing staff should have opened the immobilizer to check Resident #1 for skin breakdown. During an interview with the Physician on 4/23/2025 at 3:14 pm he stated Resident #1 returned to the facility with a cast on her right leg due to a fracture to her femur on 12/13/2024. The Physician stated Resident #1 returned from the hospital with a cast to her right leg and when she was seen for a follow-up with the Orthopedist, the Orthopedist ordered an immobilizer to her right leg and gave instructions for the immobilizer to be left on at all times. The Physician stated the nursing staff at the facility should have opened the immobilizer and checked Resident #1's skin at least daily. The Physician stated Resident #1's pressure ulcers were unavoidable due to her poor nutrition, decreased mobility and history of heart failure and dementia.

Based on observations, record reviews and staff interviews, the facility failed to protect resident privacy by leaving an unattended resident roster with personal health information (PHI) on top of a medication cart in the hallway and visible to the public. This was for 1 of 3 medication carts (700 Hall Medication Cart) reviewed for privacy and confidentiality. This deficient practice had the potential of effecting 22 residents on the 700 hall (Resident #98, #12, #96, #54, #82, #90, #97, #57, #33, #204, #88, #203, #55, #99, #91, #13, #83, #7, #20, #51, #35, and #60). The findings included: A continuous observation was completed on 10/21/2024 from 8:40 AM to 9:02 AM of the 700 Hall Medication Cart. Nurse #8 was working the medication cart, walked away from the cart, and left the resident roster unattended on top of the cart which had PHI and entered a resident's room. Two residents and one visitor were observed to pass by the medication cart. One resident was walking, and the other resident was propelling herself in a wheelchair. The visitor walked by the unattended medication cart. The resident roster was composed of room numbers, names, code status, history of diagnoses, and report items for 22 residents: Resident # 98, Resident # 12, Resident # 96, Resident # 54, Resident #82, Resident # 90, Resident # 97, Resident # 57, Resident # 33, Resident # 204, Resident # 88, Resident # 203, Resident # 55, Resident # 99, Resident # 91, Resident # 13, Resident # 83, Resident # 7, Resident # 20, Resident # 51, Resident # 35, and Resident # 60. During the continuous observation on 10/21/24 from 8:40 AM to 9:02 AM, Nurse #8 came back to the medication cart and was interviewed about the resident roster. The Nurse stated she was supposed to turn the resident roster paper over before she left the cart, but she just forgot. Then Nurse #9 approached the medication cart and was shown the resident roster that contained the PHI that was left visible to the public. Nurse #9 indicated the roster should not have been left visible to the public because it was a violation of the residents' privacy. An interview conducted with Unit Manager (UM) #10 at 12:48 PM on 10/23/2024 indicated nurses were expected to maintain resident privacy by turning over any PHI in view of the public. An interview conducted with Interim Director of Nursing (DON) on 10/24/2024 at 10:05 AM indicated the nurses were expected to turn the resident roster paper upside down on the medication carts or to take it with them when leaving the medication carts to protect the privacy of the residents.

Based on record review, and interviews with residents and staff, the facility failed to provide an ongoing individual activity program per resident's preference (Residents #49 and #76) and an ongoing group activity program per Resident Council (Residents #1, #5, #77 and #88) when residents expressed a request to play more Resident-led bingo. This failure occurred for 6 of 6 sampled residents reviewed for individual and group activities. The findings included: 1a. Resident #49 readmitted to the facility 6/13/24. A 2/19/24 annual Minimum Data Set (MDS) assessment indicated Resident #49 had adequate hearing/vision, clear speech, able to understand and be understood, intact cognition and that it was very important to participate in her favorite activities and participate in group activities. A care plan revised 9/3/24, recorded Resident #49 was able to structure her day and enjoyed both individual and group activities. Interventions included to encourage individual activities of interest and to notify of group activities of interest which included bingo. Resident #49 was observed on 10/21/24 and 10/24/24 at 1:30 PM participating in bingo. Resident #49 attended a Resident Council Meeting on 10/22/24 at 1:30 PM with the state surveyor. During the meeting Resident #49 stated that residents expressed during a Resident Council meeting a few months ago that they wanted to play bingo more often, and would prefer to play it daily, but they were told that twice per week was the limit. She stated that the residents expressed they offered to call bingo themselves, if it would allow them to play more often and then Resident-led bingo was added to the activity calendar on Saturdays, but that wasn't enough. She expressed residents still wanted to play more, daily if possible and would be willing to call bingo themselves, but when they expressed this during Resident Council, they were told three times per week was enough. 1b. Resident #76 was admitted to the facility 4/22/22. A 1/23/24 annual MDS assessment indicated Resident #76 had adequate hearing/vision, clear speech, able to understand and be understood, intact cognition and that it was very important to participate in her favorite activities and participate in group activities. A care plan revised 7/25/24, recorded Resident #76 was able to structure her day and enjoyed both individual and group activities. Interventions included to encourage individual activities of interest and to notify of group activities of interest which included bingo. Resident #76 was observed on 10/21/24 and 10/24/24 at 1:30 PM participating in bingo. Resident #76 attended a Resident Council Meeting on 10/22/24 at 1:30 PM with the state surveyor. During the meeting Resident #76 agreed when residents expressed that during a Resident Council meeting a few months ago residents stated that they wanted to play bingo more often, and would prefer to play it daily, but they were told that twice per week was the limit. She agreed that the residents expressed they offered to call bingo themselves, if it would allow them to play more often and then Resident-led bingo was added to the activity calendar on Saturdays, but that wasn't enough. She expressed that she still wanted to play more, daily if possible and that the residents would be willing to call bingo themselves, but when they expressed this during Resident Council, they were told three times per week was enough. 1c. Review of 2/8/24 Resident Council Meeting minutes, recorded by the Activity Director (AD) revealed the residents in attendance expressed they wanted to play more bingo, but the AD let them know two is our limit per week. Review of the 4/10/24 Resident Council Meeting minutes, recorded by the AD revealed the residents in attendance expressed they wanted to play more bingo. The AD recorded in the minutes that they would try Resident-led bingo on Saturdays two to three times per month. Review of the activity calendars February 2024 to April 2024 revealed bingo was offered twice per week. Review of the activity calendars May 2024 to October 2024 revealed bingo was offered three times per week; twice during the week and once on Saturdays. A Resident Council Meeting occurred with the state surveyor on 10/22/24 at 1:30 PM. Residents #1, #5, #77 and #88 voiced during the meeting that they expressed a few months ago that they wanted to play bingo more often, and would prefer to play it daily, but they were told that twice per week was the limit. The Residents expressed they offered to call bingo themselves, if it would allow them to play more often and then Resident-led bingo was added to the activity calendar on Saturdays. The Residents expressed they appreciated being able to play bingo three times per week, but that they still wanted to play more, daily if possible and would be willing to call bingo themselves, but when they expressed this during Resident Council, they were told three times per week was enough. The AD was interviewed on 10/22/24 at 3:14 PM. He stated he facilitated Resident Council Meetings and recorded the minutes. The AD stated that Residents expressed during a Resident Council Meeting in February 2024 that they wanted bingo more often, so a Resident-led bingo activity was added in May 2024 on Saturdays to offer bingo three times per week. The AD stated he asked Residents during the June 2024 Resident Council Meeting how did they like having a third bingo and they said they liked it. He further stated, some of the residents would play bingo every day if they could, but I want them to have a variety of activities and I think bingo three times a week is enough. During an interview on 10/24/24 at 12:01 PM with the Administrator and Interim Director of Nursing (DON), the Interim DON stated the activity program should be reasonable and based on resident preference. The Administrator stated that residents should be allowed to play bingo daily if they wanted and especially if they were willing to lead the activity.

Based on observations, record reviews and staff and resident interviews, the facility failed to ensure residents' toenails were trimmed and podiatry services were arranged for 3 of 4 residents (Resident #28, Resident #1 and Resident #63) reviewed for foot care. Findings included: 1. Resident 28 was admitted to the facility 08/07/24 with diagnoses that included diabetes type 2, and vascular dementia. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had no cognitive impairment. He was independent for eating and oral hygiene. He required moderate assistance to toilet and maximum assistance with bed mobility. Care plans reviewed for Resident #28 initiated 08/15/23 and revised on 08/27/24 included Resident #28 required assistance to put on and remove his socks and shoes related to a decline in functional status. Another care plan included that Resident #28 had diabetes type 2, was at risk for complications, had an intervention to monitor skin integrity and report abnormalities to the nurse or physician. On 10/22/24 at 8:01 AM an observation and interview conducted with Resident #28 revealed he was seated in his wheelchair with socks and shoes on both feet. Resident #28 reported he had not been seen by the facility podiatrist since admission and he needed his toenails clipped. On 10/23/24 at 3:00 PM Nurse Aide (NA) #3 removed the shoe and sock on Resident #28's left foot. The observation revealed Resident #28 had dry scaly skin on his left foot, his toenails were thick and extended over the ends of each toe. Resident #28 revealed that the toenails on his right foot looked the same and his skin was dry. Resident #28 verbalized he had not had a podiatry consult and he really needed one, but his toenails did not cause pain. NA #3 reported she had never observed Resident #28's toenails but she would have reported the condition of his toenails to the nurse. NA #3 explained that NAs were not able to cut or clip any resident's finger or toenails. On 10/24/24 at 10:31 AM Nurse #1 was interviewed. Nurse #1 reported that NAs were not allowed to provide finger or toenail care to any resident and were supposed to report nail care concerns to the nurse. Nurse #1 revealed she had not received any report of Resident #28 needing any nail care. A phone interview with Nurse #2 conducted on 10/23/24 at 3:14 PM revealed she had completed weekly skin checks of Resident #28 on 10/15/24 and 10/22/24. Nurse #2 revealed she did not identify any concerns with the toenails of Resident #28 and reported if she did have concerns they would have been reported to the physician and Social Worker (SW) to obtain a podiatry consult. An interview with the Social Worker on 10/23/24 at 9:36 AM revealed nurses were responsible to give her a referral for a podiatry consult for each resident and then she forwarded the resident information to the consulting podiatrist who would schedule a podiatrist consult on the next visit to the facility which was scheduled at the beginning of November. The SW revealed she did not recall a podiatry consult referral from nurse staff for Resident #28 to be seen by the podiatrist. The SW confirmed the podiatrist was expected to be at the facility monthly. A follow up interview with the SW conducted 10/23/24 at 3:46 PM revealed Resident #28's name was not listed on the podiatrist lists for September 2024 or October 2024. The SW reported she would notify Unit Manager (UM #2) and physician that Resident #28 requested a podiatry consult and she would add Resident #28's name to the November schedule. An interview with nurse Unit Manager (UM) #2 on 10/23/24 at 1:20 PM included that only licensed nurses were to provide any nail care to residents. UM #2 revealed that the nurse would check the resident's toenails during weekly skin checks and the NAs were to report the need of resident nail care on resident shower days and either clip the nails or notify the SW that the resident needed a podiatrist consult. UM #2 revealed that on review of Resident #28's weekly skin checks completed by Nurse #1 dated 09/09/24, 10/15/24, and 10/22/24 there were no finger or toenail concerns. UM #2 revealed she was not certain if Resident #28 had ever been consulted by the podiatrist. The facility physician was interviewed at 11:55 AM on 10/23/24. He revealed he was not aware that Resident #28 needed podiatry care. The physician explained the facility did have standing orders for residents to have podiatry consults. He was not aware that Resident #28 needed to be seen by the podiatrist, and he would follow up with Unit Manager #2. On 10/23/24 the Director of Nurses (DON) revealed during an interview at 4:39 PM that both NAs and nurses could provide finger and toenail care to Residents if the Resident did not have diabetes Type 2. The DON provided shower sheets dated 10/01/24 and 10/10/24 signed by an NA for Resident #28. No finger or toenail concerns were documented on the shower sheets. A follow up interview conducted with the DON on 10/24/24 at 11:41AM revealed both NAs and nurses could perform finger and toenail care to any resident if the resident had no diabetes type 2 diagnosis. The DON reported the nurse was responsible to notify the SW nail care was needed by the podiatrist for any reason. The DON expected the nurse staff to include toenail assessments on weekly skin check reports and make referrals for toenail care as indicated. 20934 2. Resident #1 was admitted to the facility 1/9/24. Diagnoses included atherosclerotic heart disease, cerebrovascular accident, chronic kidney disease, stage 4, chronic pain, and neuromuscular disorder. An 8/5/24 quarterly Minimum Data Set (MDS) assessment, indicated Resident #1 had adequate hearing and vision, clear speech, able to be understood by others and able to understand, and his cognition was intact. A care plan revised 8/29/24 identified Resident #1 was dependent on staff for activities of daily living (ADL) and at risk for a decline in skin integrity due to his diagnoses of a neuromuscular disorder. Interventions included staff would provide personal hygiene and weekly evaluation/assessment of skin with notification to the nurse or physician as necessary. A review of weekly Skin Check records dated 10/2/24, 10/9/24 and 10/16/24 completed by Nurse #7 recorded Resident #1's assessments were completed with no new skin concerns documented. A review of the medical record for Resident #1 revealed no documentation of podiatry services or for a podiatry referral. Resident #1 attended a Resident Council meeting with the state surveyor on 10/22/24 at 1:30 PM. During the meeting, Resident #1 stated that he had not received podiatry services since his admission and that he needed his toenails trimmed. He stated that staff looked at his skin and feet weekly but had not offered him podiatry services. A 10/23/24 11:00 AM observation with Nurse #7 of Resident #1 in his room revealed he was seated in his wheelchair with bilateral leg braces in place and both feet rested on the footrests on his wheelchair. When asked by Nurse #7 to assess his feet, Resident #1 agreed. Nurse #7 stated that she last observed his feet during a skin audit on 10/16/24, but that she did not recall the specific length of his toenails. During the assessment of the left foot, Resident #1 expressed that the left great toenail was painful. After assessing his left foot, Nurse #7 stated that the left great toenail was thick and long and could be trimmed. The left great toenail was observed to extend over the skin and curled towards his skin. Nurse #7 assessed the right foot and stated that the fourth toenail on the right foot was long and should be trimmed. The toenail was observed to extend over the skin and curled towards the skin. Nurse #7 stated that his toenails were the same length as she saw when she completed the skin assessments on 10/2/24, 10/9/24 and10/16/24, but that she did not offer to trim his nails or offer a podiatry referral because she was new to the facility and to the facility's process. She stated that due to the thickness of his nails and his complaints of pain he should be referred for podiatry services. Nurse #7 stated when she completed the skin audit for Resident #1 on 10/16/24 it was after 6:30 PM and the social worker (SW) had already left. Nurse #7 further stated that she did not communicate the need for a podiatry referral for Resident #1 to the SW, but that was the process. Nurse #7 stated that staff should communicate to the SW if staff observed that a resident needed podiatry services, but that she was new to the facility, and still learning the process. She stated that she should have left a note for the SW about the length of Resident #1's toenails so that the SW could add Resident #1 to the list for podiatry services, and stated, But I did not do that. Resident said yes when asked if he wanted a podiatry referral. He stated that his toenails were last trimmed by a nurse over a month ago, but he did not recall exactly when that was. He stated he did not know the podiatrist was in the facility in September 2024, so he did not ask to be seen. An interview with the Social Worker (SW) on 10/23/24 at 9:36 AM revealed nurses were responsible to give her a referral for a podiatry consult for each resident and then she forwarded the resident information to the consulting podiatrist who would schedule a podiatrist consult on the next visit to the facility. The SW confirmed the podiatrist was expected to be at the facility monthly. The SW reviewed the list of residents seen by the podiatrist in September 2024, and confirmed Resident #1 was not included. The SW stated she was not informed that Resident #1 needed a podiatry referral and so Resident #1 was not on the podiatry list for the next podiatry visit planned at the facility for 11/12/24 and 11/13/24, but he would be added. During a 10/23/24 1:20 PM interview with Unit Manager (UM) #2, she stated that only licensed nurses were to provide any nail care to residents. UM #2 revealed that the nurse should check the resident's toenails during weekly skin checks and notify the SW if a resident needed a podiatrist consult. A 10/23/24 12:30 PM interview with the physician revealed he was not aware that Resident #1 needed podiatry care, but that the facility did have standing orders for residents to have podiatry consults. A 10/23/24 4:42 PM interview with the Interim Director of Nursing (DON), she stated the nurse was responsible to notify the SW if podiatry care was needed. The DON expected the nurse to include toenail assessments on weekly skin check audits and make referrals for toenail care as indicated. The DON stated she could not find any record that Resident #1 had been referred for podiatry services. She stated that Resident #1 was not a diabetic, but if his toenails were thick, long and painful and required podiatry services then the SW and MD should be informed so that that the referral paperwork could be completed, and a referral for services made to the provider. 3. Resident #63 was admitted to the facility on [DATE]. Diagnoses included onychomycosis (fungal infection of the nails), mild hammertoe, and peripheral vascular disease. Podiatry consults dated 1/3/24 and 6/24/24 both recorded Resident #63 received follow-up podiatry services for routine footcare due to chronic onychomycosis. Both consults documented that conservative footcare was recommended due to marked limitation and pain from the thickening and dystrophy (tissue degeneration) of the affected nails. Both consults documented a care plan to maintain regular footcare visits as scheduled to decrease pressure and reduce pain and infection risk to his feet and toes. A review of the list of residents who received podiatry services in the facility in August 2024 revealed Resident #63 was not included in the list of residents who received podiatry services. A 9/3/24 podiatry consult recorded Resident #63 did not receive podiatry services because he was currently at the hospital. A review of the list of residents who received podiatry services in the facility in September 2024 revealed Resident #63 was not included in the list of residents who received podiatry services due to a hospitalization . A care plan revised 9/5/24 identified Resident #63 was dependent on staff for activities of daily living (ADL), at risk for a decline in skin integrity, and refused care at times. Interventions included staff would provide personal hygiene, inspect skin and notify nurse of any abnormal changes. Additionally, staff were to inform Resident #63 of ADL care to be provided ahead of time, give options of times care would be done to allow for flexibility and accommodate his mood, and if refused, reattempt at another time. A 9/13/24 significant change MDS recorded Resident #63 had adequate hearing and vision, clear speech, able to be understood by others and able to understand, and his cognition was intact. Review of Resident #63's Shower, Tub, Bath Sheets revealed the following: - 10/3/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if there was a need for podiatry services. The form was not signed by staff. - 10/7/24, documented Resident #63 refused a shower, it did not indicate if nails were cleaned or clipped or if there was a need for podiatry services. The form was not signed by staff. - 10/10/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if there was a need for podiatry services. The form was not signed by staff. - 10/17/24, documented Resident #63 refused a shower because that day was not his assigned shower day and that he wanted a shower on the next day. The document did not indicate if his nails were cleaned or clipped or if there was a need for podiatry services. - 10/21/24 documented Resident #63 refused a shower, but did not indicate if his nails were cleaned or clipped or if there was a need for podiatry services. Resident #63 was observed in bed and interviewed on 10/21/24 at 11:31 AM. He stated, Look at my toenails, how long they are, they need to be trimmed. Each toenail on each foot was observed extended over the skin and curled towards his skin. He stated that he was taken to the shower room on Monday, 10/21/24, for a shower, but that the shower room was full, he was cold, so he asked staff to bring him back to his room and to give him a shower on Friday, 10/25/24. He said no when asked if he was offered a bed bath, or to have his toenails trimmed. Resident #63 was observed in bed on 10/23/24 at 9:21 AM. The length of each toenail extended over the skin on each foot. During a 10/23/24 9:23 AM observation with Medication Aide (MA) #1 of Resident #63 in bed, his feet were observed. MA #1 stated each of his toenails were long and asked Resident #63 if he wanted them trimmed, Resident #63 stated yes. During a 10/23/24 9:25 AM interview with Nurse Aide (NA) #6, he stated he was a regular NA for Resident #63 and offered him a shower on Monday, 10/21/24, but he refused and did not want to be bothered. NA #6 stated he reported the refusal to the nurse, but did not report that his toenails were long, because Resident #63 said he did not want to be bothered. Nurse #7 observed the toenails of Resident #63 on 10/23/24 at 9:29 AM at the request of the surveyor. Nurse #7 stated during the observation that the toenails of Resident #63 were long and asked him if he wanted to have his nails trimmed, he replied Yes, they are too long. An interview with the Social Worker on 10/23/24 at 9:36 AM revealed nurses were responsible to give her a referral for a podiatry consult for each resident and then she forwarded the resident information to the consulting podiatrist who would schedule a podiatrist consult on the next visit to the facility. The SW confirmed the podiatrist was expected to be at the facility monthly. The SW reviewed the list of residents seen by the podiatrist in the facility in August 2024 and confirmed Resident #63 was not on the list, but stated she did not know why. The SW reviewed the list of residents seen by the podiatrist in September 2024, and confirmed Resident #1 was not included, because he was in the hospital. The SW stated that Resident #63 would have to wait for the next podiatry visit because the provider would not come back for one resident. The SW stated the next podiatry visit was scheduled for 11/12/24 and that Resident #63 would be added to the list to be seen. During a 10/23/24 1:20 PM interview with Unit Manager #2 (UM #2), she stated that only licensed nurses were to provide any nail care to residents. UM #2 revealed that the nurse should check the resident's toenails during weekly skin checks and notify the SW if a resident needed a podiatrist consult. A 10/23/24 12:30 PM interview with the physician revealed he was not aware that Resident #63 needed podiatry care, but that the facility did have standing orders for residents to have podiatry consults. A 10/23/24 4:42 PM interview with the Interim Director of Nursing (DON), she stated the nurse was responsible to notify the SW if podiatry care was needed. The DON expected nursing staff to include toenail assessments on weekly skin check audits and make referrals for toenail care as indicated. The DON stated she could not find any record that Resident #63 received podiatry services since June 2024.

Based on a breakfast meal test tray observation, minutes from Resident Council meetings, a Resident Council meeting, resident and staff interviews, the facility failed to provide food that was palatable and had an appetizing temperature for 8 of 8 residents reviewed for palatable foods (Resident #5, Resident #1, Resident #88, Resident # 77, Resident # 76, Resident #95, Resident #63, and Resident # 34). The findings included: Resident #95 was interviewed on 10/21/24 at 10:43 AM and he reported he was on a regular diet with ground meat. The resident was not happy with the breakfast meat and it had no taste. Resident #63 was interviewed on 10/21/24 at 11:28 AM and when asked about the food in general, he reported the food looks like [expletive] and tastes like it, too. Resident Council Meeting minutes for 12/6/23, 1/10/24, 2/8/24, 6/12/24, and 7/10/24 identified issues with food and coffee temperatures, food texture, and flavor. During the Resident Council meeting on 10/22/24 at 1:30 PM, 6 of 6 residents in attendance (Resident#1, #49, #88, #77, #5, and #76) identified ongoing issues with cold coffee and tough meat. The residents also noted the microwave was broken and they did not have coffee available at any time they wanted. A breakfast test tray was requested on 10/23/24 at 8:05 AM. The plate was placed on an insulating bottom and had an insulating cover. The tray left the kitchen at 8:17 AM on an open cart. The coffee had a plastic lid over the cup and was in a plastic cup. The cart arrived at the 400/500 halls at 8:19 AM. Staff delivered the breakfast meal to residents on the 400/500 halls from 8:20 AM until 8:30 AM. During the observation of staff delivering resident trays, a staff member lifted the insulated lid on the test tray and then replaced it askew. The DM noted the lid was not on the test tray plate correctly and she replaced it. The test tray was sampled with the Dietary Manager (DM) at 8:32 AM. When the DM removed the insulated cover from the plate of food, no steam was noted to rise off the food. No steam came from the cup of coffee and the temperature was tepid to taste. The fried eggs were cool to the touch and taste, the pancakes were cool to the touch and were not warm, and the sausage links were cool to the touch and were not warm. The DM agreed the food temperature was not warm and reported she thought it was because the insulated lid had not been placed on the plate of food correctly, which allowed the heat to escape. The DM reported she expected food to be delivered covered correctly with the insulated lid to prevent loss of temperature. Resident #5 was interviewed 10/23/24 after the breakfast tray sample, and she reported that her breakfast was not good; I don't like the eggs, the coffee was barely warm, and the pancakes were cold. Resident #34 10/23/24 was interviewed after the breakfast tray sample, and she reported her breakfast was awful. Resident #34 was noted to have eaten approximately 10% of her meal and she had replaced the cover over her plate. The DM was interviewed on 10/24/24 at 2:15 PM and she explained she was surprised by the results of the test tray and felt that breakfast was the best meal of the day with the residents feeling pleased with that meal. The DM reported the staff performed test trays for palatability and temperature, and she attended Resident Council meetings to talk about food preferences and food issues. The DM reported she ate at least one meal per day at the facility and they did test trays routinely but was unable to provide information for when the last test tray had been completed. The DM reported she had responded to the Resident Council concerns by changing the coffee vendor, offering flavored creamers for coffee, having more staff pass out the trays so the trays did not sit for a long time, and providing education to the kitchen staff for complaints of over-cooked foods. The Administrator was interviewed on 10/24/24 at 2:05 PM and he reported he expected the food to be served at the correct temperature and to be palatable.

Based on observations and staff interviews, the facility failed to dry metal pans before being stacked, clean 1 of 3 ice machines in 1 of 3 nourishment rooms (medical unit), and store dry goods off the floor. These failures had the potential to affect food served to residents. The findings included: a. The kitchen was toured on 10/21/24 at 9:28 AM with the Dietary Manager (DM). During the observation, the storage rack for metal pans was observed and 3 metal pans were noted to be stacked wet. Water was noted to drip down the sides of the pain when the pans were separated, and the interior of the pans felt wet. When asked, the DM reported the metal pans should have been air dried completely before stacking. The DM asked [NAME] #1 who stacked the pans and [NAME] #1 reported she did not know who stacked the pans while they were still wet. b. The medical unit nourishment room was observed on 10/24/24 at 9:50 AM with the DM. The ice machine was observed to have wet, slimy, black material along the seal of the ice machine door. The DM explained the Maintenance Director was responsible for cleaning the ice machines. The ice machine was observed with the Maintenance Director on 10/24/24 at 10:06 AM. The Maintenance Director explained he cleaned all ice machines once per month and he had cleaned the ice machine on the medical unit on 9/28/24. The Maintenance Director was able to rub the wet, slimy, black material off the seal and he stated it was mildew. c. The storage shed was observed on 10/24/24 with the DM at 9:56 AM. The storage shed was cluttered with boxed medical records, decorations, resident possessions, and dry food goods. There was not a clear path to the stored dry goods and the DM had to move things out of the way to get back to the stored dry goods. The DM reported the facility used the shed to store extra water and dry goods, and the emergency supplies of food were kept in the shed. Gallon jugs of water were noted to sit directly on the floor of the shed, and several were noted to be tipped over on their sides and appeared to be partially filled with water. A back support pillow was observed on top of the gallon jugs of water. The pillow was noted to have some yellow stains and was slightly dusty. A pallet of rolled oats was noted to be tipped over on its side and laying on the floor of the shed. The DM reported she had not been in the storage shed for a while, and the water and rolled oats should not have been directly on the floor. The DM reported the shed got very hot in the summer and this caused the water jugs to expand, which might cause the jugs to leak. The DM was interviewed on 10/24/24 at 2:15 PM and she reported she explained she had interviewed [NAME] #1 after the kitchen observation on 10/21/24 and [NAME] #1 reported she had stacked the metal pans with wet hands, and that's why the pans were stacked wet. The DM explained it had been a while since she had been in the storage shed to look at the food storage and she was not aware that it was cluttered with resident possessions, medical records, and decorations. The DM reported she expected all dry goods to be stored off the floor and the food storage area to be tidy and organized. The Administrator was interviewed on 10/24/24 at 2:05 PM. He reported the metal pans should be allowed to dry completely before they were stacked. The Administrator reported the ice machine had the potential to grow mildew because it was used often, and it was in a warm room and all ice machines should be checked for mildew growth. The Administrator reported the storage shed should be organized and the food stored off the floor of the shed.

Based on observations, resident and staff interviews, and record review, the facility failed to offer a bed bath for two days, provide nail care, and shave a resident dependent on staff for activities of daily living (ADL). This failure occurred for 1 of 4 sampled residents reviewed for ADL (Resident #63). The findings included: Resident #63 was admitted to the facility on [DATE]. Diagnoses included heart failure, dilated cardiomyopathy, presence of automatic cardiac defibrillator, and shortness of breath. A care plan revised 9/5/24 identified Resident #63 was dependent on staff for ADL and refused care at times. Interventions included staff would provide personal hygiene, inspect skin and notify nurse of any abnormal changes. Additionally, staff were to inform Resident #63 of ADL care to be provided ahead of time, give options of times care would be done to allow for flexibility and accommodate his mood, and if refused, reattempt at another time. A 9/13/24 significant change MDS recorded Resident #63 had adequate hearing and vision, clear speech, able to be understood by others and able to understand, and his cognition was intact. Review of Resident #63's Shower, Tub, Bath Sheets revealed the following: - 10/3/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if the nurse was notified of his refusal. The form was not signed by staff. - 10/7/24, documented Resident #63 refused a shower, it did not indicate if nails were cleaned or clipped. The form was not signed by staff. - 10/10/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if the nurse was notified of his refusal. The form was not signed by staff. - 10/14/24, documented Resident #63 refused a shower, but it did not indicate if the nurse was notified of his refusal. - 10/17/24, documented Resident #63 refused a shower because that day was not his assigned shower day and that he wanted a shower on the next day. The document did not indicate if his nails were cleaned or clipped. - 10/21/24 documented Resident #63 refused a shower, but did not indicate if a bed bath was offered, if his nails were cleaned or clipped or if the nurse was notified of his refusal. Resident #63 was observed in bed and interviewed on 10/21/24 at 11:31 AM. He stated, Look at my fingernails, how long they are, they need to be trimmed, and I need a shave. Resident #63 was observed with a thick beard that extended from both cheeks to his chin. The fingernails on each hand were observed extended over the skin. He stated that he was taken to the shower room on Monday, 10/21/24, for a shower, but that the shower room was full, he was cold, so he asked staff to bring him back to his room and to give him a shower on Friday, 10/25/24. He said no when asked if he was offered a bed bath, or to have his fingernails trimmed. Resident #63 was observed in bed on 10/23/24 at 9:21 AM with a thick beard that extended from both cheeks to his chin and the fingernails on each hand were observed extended over the skin. During a 10/23/24 9:23 AM observation with Medication Aide (MA) #1 of Resident #63 in bed, his fingernails and facial hair was observed. MA #1 stated each of his fingernails were long and asked Resident #63 if he wanted them trimmed, and if he wanted to be shaven, Resident #63 stated yes. During a 10/23/24 9:25 AM interview with Nurse Aide (NA) #6, he stated he was a regular NA for Resident #63 and offered him a shower on Monday, 10/21/24, but he refused and did not want to be bothered. NA #6 stated he reported the refusal to the nurse, but did not offer Resident #63 a bed bath, to have his fingernails trimmed or to be shaven because Resident #63 said he did not want to be bothered. Nurse #7 observed Resident #63 on 10/23/24 at 9:29 AM at the request of the surveyor. Nurse #7 stated during the observation that the fingernails of Resident #63 were long and asked him if he wanted to have his nails trimmed, and if he wanted to be shaven. Resident #63 replied Yes and further stated that his fingernails were too long. During a 10/23/24 1:20 PM interview with Unit Manager #2 (UM #2), she stated that the NA should report to the nurse if a resident refused ADL care. She further stated that fingernails should be trimmed by the NA and if the resident refused, the NA should report to the nurse so that the nurse could go to the resident to encourage care and provide the care if necessary. UM #2 stated that ADL care did not have to be provided when a resident received a shower but should be provided when needed. UM #2 stated the nurse should check the resident's nails during weekly skin checks and provide nail care as needed. UM #2 stated she was the charge nurse for Resident #63 on Monday, 10/21/24 and that she was not notified that he refused care. During a 10/23/24 3:53 PM interview with NA #7, she stated she was a new NA, she was the assigned NA for Resident #63 on Tuesday, 10/22/24, which was her second assignment since her training. NA #7 stated on Tuesday, 10/22/24 she thought that another team member was assigned to give showers/bed baths to residents, so that was the reason she did not offer him a shower/bed bath, to be shaven or nail care. The Scheduler stated in a 10/23/24 5:37 PM interview that on Tuesday, the NA schedule was updated before 7:00 AM that between 11:00 AM to 2:00 PM, NA #8 would take as many residents as she could to activities and assist as many residents as she could to be shaven. The Scheduler stated that the original plan was to have a shower team on Tuesday, but that was changed on the schedule before 7:00 AM and since Tuesday was not a scheduled shower day for Resident #63, ADL care should have been provided by NA #7. A 10/23/24 5:55 PM interview with NA #8 revealed she came in at 11:00 AM, Tuesday 10/22/24 and that she was assigned to take residents to activities, assist with showers, and to shave as many residents as she could until 2:00 PM. NA #8 stated that she did not make it to all the halls, and that she did not make it to Resident #63 on Tuesday, 10/22/24 to offer him ADL care. A 10/23/24 4:42 PM interview with the Interim Director of Nursing (DON), she stated a NA could trim the fingernails of residents and she expected the nurse to include nail assessments on weekly skin check audits. The Interim DON stated that fingernail care, and shaving should be provided when the staff identified that a resident needed this care. She further stated that staff did not have to wait until the resident received a shower to provide the ADL care that was needed. The Interim DON stated that the ADL care refusals should be reported to the nurse and the nurse should go and talk to the resident and offer the care again, so that care was offered about 3 times to give the resident an opportunity to receive the care. The Interim DON further stated that fingernail care should be provided as needed, especially if the resident refused a shower/bath. The Interim DON stated that if a resident refused a shower, the NA should inform the nurse, and the nurse should offer the resident alternatives like a different shower/bath schedule and offer a bed bath if the resident declined a shower.

Based on observations, record review, interviews with a resident and staff, the facility failed to provide larger portions per physician order to a resident at risk for weight loss due to a history of weight loss (Resident #73). The findings included: Resident #73 admitted to the facility on [DATE]. Diagnoses included Alzheimer's dementia, mild cognitive impairment, hyperlipidemia, and hypertension. Review of his medical record revealed Resident #73's monthly weight was assessed on 4/4/24 as 187.4 pounds. Review of his medical record revealed Resident #73's monthly weight was assessed on 5/10/24 as 180.6 pounds, approximately a seven-pound weight loss or approximately 3.7% weight loss in a month. A 5/16/24 Interdisciplinary Team progress note recorded Resident #73 was discussed for weight loss, decreased food intake, and disengagement with meals. A physician order was written to decrease the morning dose of Depakote (a mood stabilizer) to promote alertness and encourage food intake. Review of the medical record revealed a 7/3/24 physician order that recorded to provide 4 ounces of a high calorie nutritional supplement twice a day with breakfast and lunch. A nutrition care plan revised 7/12/24 documented Resident #73 at risk for nutritional decline due to weight loss related to a decline in intake. Interventions included to provide an appetite stimulant, high calorie supplements, encourage consumption of meals and provide a regular diet with double portions as ordered. Review of his medical record revealed Resident #73's monthly weight was assessed on 7/16/24 as 183.6 pounds. Review of his medical record revealed Resident #73's monthly weight was assessed on 8/7/24 as 178.6 pounds, a five-pound weight loss or 2.7% weight loss in a month and approximately 4.8% weight loss in four months. A 10/2/24 quarterly Minimum Data Set assessment indicated Resident #73 had clear speech, adequate vision, adequate hearing, usually understood by others, usually understood others, severely impaired cognition, and fed himself after staff set-up assistance with meals. Review of his medical record revealed Resident #73's monthly weight was assessed on 10/21/24 as 178.4 pounds or approximately 4.8% weight loss in six months. Review of the facility's Diet Order Report dated 10/21/24 recorded Resident #73 received a regular diet with larger portions, milk, and a peanut butter sandwich with each meal. Resident #73 was observed on 10/22/24 at 9:05 AM and 10/23/24 at 9:18 AM in his room, feeding himself breakfast. During each observation, he received a 4-ounce bowl of grits. The breakfast meal tray card recorded a diet order for larger portions. Resident #73 did not receive larger portions of grits for breakfast on 10/22/24 or 10/23/24. During each observation, Resident #73 was asked if he would like to receive a larger portion of grits, and he responded yes and stated that grits were the best part of his breakfast. During a 10/23/24 12:00 PM interview with the Physician, he stated that Resident #73 required encouragement to eat because his nutritional status had declined due to his worsening dementia. The Registered Dietitian (RD) was interviewed on 10/23/24 at 2:57 PM and stated that Resident #73 received an appetite stimulant, milk, and a peanut butter sandwich with each meal, a high calorie nutritional supplement twice a day and double portions for nutritional support due to his history of weight loss and dementia. She stated that in the last six months, Resident #73 had some weight loss, but had not experienced significant weight changes. The RD stated that residents with diet orders for larger/double portions should receive larger/double portions of vegetables, starches and meats. The RD stated that Resident #73 should have received an 8-ounce portion of grits for breakfast on 10/22/24 and 10/23/24 per his diet order. The Certified Dietary Manager (CDM) was interviewed on 10/23/24 at 4:00 PM. The CDM stated that a resident with a diet order for larger/double portions should receive larger/double portions of meats, starches, and vegetables. She stated that a 4-ounce portion of grits was the standard portion, but that Resident #73 should have received an 8-ounce portion of grits for breakfast from the dietary staff. The CDM stated that it was an oversight that Resident #73 did not receive a double portion of grits on 10/22/24 and 10/23/24 and that the terminology on the tray cards would be changed from larger portions to double portions so that dietary staff would provide the correct portion. The Interim Director of Nursing stated on 10/24/24 at 12:22 PM that residents should receive the portion size of foods as ordered.

Based on record review and staff interviews, the facility failed to accurately code the type of discharge on a Discharge Minimum Data Set (MDS) assessment for 1 of 4 sampled residents reviewed for discharge planning (Resident #102). The findings included: Resident #102 was admitted to the facility from the hospital on 7/16/24 for short-term rehab services. A 7/23/24 5-day MDS assessment indicated the overall goal for Resident #102 was to discharge to the community. A 7/25/24 10:22 AM Nurse Practitioner progress note recorded Resident #102 was admitted to the facility for rehab and assessed for discharge home with home health services as planned. A 7/25/24 2:49 PM nurse progress note recorded Resident #102 discharged home with family from the facility at 2:20 PM with home health arrangements, prescriptions and personal items and medications and discharge instructions were reviewed. A 7/25/24 Discharge MDS recorded the type of discharge as unplanned. During an interview on 10/23/24 at 9:46 AM, the Social Worker (SW) stated she completed the discharge section of the 7/23/24 5-day MDS and confirmed that the goal on admission was for Resident #102 to discharge home with family after her rehab services were completed. The SW stated Resident #102 expressed on admission to the facility that she came with the intentions to discharge home with family, which was discussed from the beginning of her stay and that home health services would be needed at discharge. MDS Coordinator #1 stated in an interview on 10/24/24 at 1:16 PM, that she reviewed the medical record for Resident #102 and did not see anything to support that the discharge for Resident #102 was unplanned. She stated that the MDS was coded in error. MDS Coordinator #2 stated in an interview on 10/24/24 at 1:17 PM, that Resident #102's discharge was planned, and it was coded as unplanned in error. The Interim Director of Nursing and Administrator were interviewed on 10/24/24 at 12:24 PM. The Interim DON stated the anticipated discharge plan should be initiated and carried out.

Based on record review, and resident, family member and staff interviews, the facility failed to provide residents with a summary of their baseline care plan within 48 hours of admission that included initial goals based on admission orders, physician orders, and a summary of services or treatments to be administered by the facility. This was for 4 of 4 residents reviewed for baseline care plan (Resident #203, Resident #33, Resident #88, and Resident #99). The findings included: a. Resident #203 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment was not completed. Review of Resident #203's medical record revealed no baseline care plan had been provided to the resident or her family. A baseline care plan dated 10/18/24 addressed Resident #203's potential for falling and potential for pain due to fracture with interventions in place. A phone interview was conducted with Resident #203's family member on 10/22/24 at 9:20 AM and the family member reported she had not been provided with initial goals, summary of Resident #203's medications, and a summary of services or treatments to be administered by the facility. b. Resident #33 was admitted to the facility 7/5/24 and readmitted [DATE]. The admission Minimum Data Set assessment dated [DATE] assessed Resident #33 to be severely cognitively impaired. A baseline care plan dated 7/5/24 addressed Resident #33's potential to fall, develop skin breakdown, and experience pain with interventions in place. A review of Resident # 33's medical record revealed no baseline care plan had been provided to Resident #33 or to her family. An interview was conducted with Resident #33's family member on 10/21/24 at 3:28 PM and the family member reported she had not been provided with initial goals, summary of Resident #33's medications, and a summary of services or treatments to be administered by the facility. c. Resident #88 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] assessed Resident #88 to be cognitively intact. Review of Resident #88's medical record revealed no baseline care plan had been provided to the resident or to her family. A baseline care plan dated 9/12/24 addressed Resident #88's potential for falling and potential for pain due to fracture with interventions in place. An interview was conducted with Resident #88 on 10/21/24 at 11:43 AM and she reported she had not been provided with the initial goals, summary of her medications, and a summary of services or treatments to be administered by the facility. d. Resident #99 was admitted to the facility 10/4/24. The admission Minimum Data Set assessment dated [DATE] assessed Resident #99 to be severely cognitively impaired. Review of Resident #99's medical record revealed no baseline care plan had been provided to Resident #99 or her family. A baseline care plan dated 10/18/24 addressed Resident #99's potential for falling and potential for pain due to fracture with interventions in place. Resident #99's family member was interviewed on 10/21/24 at 3:09 PM and she reported she had not been provided with initial goals, summary of Resident #99's medications, and a summary of services or treatments to be administered by the facility. The Social Worker (SW) was interviewed on 10/23/24 at 3:30 PM. The SW revealed she had been in her position for 4 1/2 months and had not provided any residents with a baseline care plan summary during that time. The SW reported the admission nurse initiated the baseline care plan, and she was responsible for the facility welcome meetings with the residents, their family members, and department managers, but she had never given a baseline care plan summary and was not aware she needed to provide residents with a baseline care plan. The Administrator was interviewed on 10/24/24 at 2:05 PM. The Administrator reported the SW was new and there was a lot of information she had not learned to implement. The Administrator reported he expected all new admission residents to receive a summary of their baseline care plan with initial goals, summary of the resident's medications, and a summary of services or treatments to be administered by the facility.

Based on observations, interviews and record review, the facility failed to post daily nurse staffing data at the beginning of the shift for 1 of 4 days reviewed. The findings included: An observation of the nurse staffing data occurred on 10/21/24 at 9:18 AM and 10/21/24 at 9:45 AM and revealed nurse staffing data was posted for 10/20/24. An interview with the scheduler occurred on 10/24/24 at 9:38 AM. The Scheduler stated she worked at the facility since February 2024, and she worked Monday through Friday from 8:00 AM or 8:30 AM until 5:00 PM or 5:30 PM. The Scheduler stated she was responsible for posting nurse staffing data for the 7 AM to 7 PM shift. The Scheduler stated that when she arrived at work, she completed a facility round to verify staffing per the schedule, adjusted the staffing data as needed and then posted the nurse staffing data, usually by 9:00 AM, after completing her round. The Scheduler stated when she arrived at 8:00 AM or 8:30 AM, each morning the nurse staffing data was posted for the previous shift and updated after she arrived. The Scheduler stated she was not aware that the nurse staffing data should be posted at the beginning of the 7 AM shift. The Administrator and Interim Director of Nursing were interviewed on 10/24/24 at 12:26 PM. The Interim DON stated the facility staffed the nursing department based on a 12-hour shift schedule, 7 AM to 7 PM and 7 PM to 7 AM. The Administrator stated that the facility would have to adjust who was responsible for posting nurse staffing data to ensure it was posted at the beginning of the 7 AM shift.

Based on record review, staff interviews, and family interview the facility failed to provide supervision to prevent accidents for a resident with a known history of falls, when Resident #1 was left unattended in the common area and had an unwitnessed fall. This occurred for 1 of 1 resident reviewed for accidents and resulted in the resident going to the hospital to receive 7 stitches to his face (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, lack of coordination, recurrent falls, dementia, and anxiety. A significant change Minimum Data Set for Resident #1 dated 8/15/23 revealed he was cognitively impaired. He had a short- and long-term memory problem in addition to inattention and disorganized thinking. Resident #1 required moderate assistance for transfers and mobility. In addition, Resident #1 had 2 falls with no injury since the last MDS assessment. Resident #1's care plan revised on 10/23/23 revealed he was at risk for falls characterized by a history of falls/actual falls and injury, related to Parkinson's disease. The interventions included keep bed in lowest position as tolerated, keep fall mat on the floor when resident is in bed. Toilet resident frequently and as needed, observe and intervene for factors causing falls, keep commonly used items in reach, keep environment free of clutter. Ensure the anti-slip mat and cushion are positioned properly in the wheelchair. Ensure report is given to next staff 1:1 (1 staff member to care for 1 resident that requires extra supervision for safety) every shift, to help prevent falls and impulsiveness. Educate on the importance of being in reach of the resident as he is impulsive. Ensure that constant supervision is in place for safety. Resident #1 also required assistance with Activities of Daily Living/ Personal care. The interventions included provide 1 person guidance and extensive physical assistance with transfers. Provide 1-person extensive physical assistance with bed mobility and ambulate with handheld contact guard assistance. During an interview on 11/3/23 at 8:40 AM NA #1 revealed she was working on 10/21/23, 7a-7p shift as Resident #1's 1:1. During the evening shift change she brought Resident #1 to the common area. NA #1 further revealed NA #2 was going to be the 1:1 for Resident #1 from 7p-7a shift. When NA #2 arrived, she wanted to put her things away. NA #1 decided to walk with NA #2 to put her things away and give her shift report while they were walking. NA #1 recalled NA #2 asking staff in the common area to watch Resident #1. She also recalled someone answered ok when NA #2 said watch Resident #1. NA #1 did not know which staff member said ok. She stated there were multiple staff members in the common area. After she reported to NA#2 she left the facility. NA #1 explained report is usually given while standing next to Resident #1. She further explained Resident #1 had poor impulse control and often stood up quickly and would fall if someone was not close to him. NA #1 indicated the reason report wasn't given in the presence of Resident #1 was NA #2 wanted to put her things away and there were multiple staff members in the common area to watch Resident #1. During an interview on 11/2/23 at 12:12 PM NA#2 revealed she was assigned as the 1:1 sitter for Resident #1 on 10/21/23 7 PM shift. She stated when she came in for her shift, herself, and NA #1 both went to the clock in room and left Resident #1 sitting in his wheelchair in the common area near the piano. NA #2 stated she was going to clock in and put her things away, she was unsure why NA #1 went to the clock in room. When she returned the resident had fallen. She indicated she thought they asked someone to watch Resident #1 as they walked away, but she could not recall who. She further indicated she was aware Resident #1 needed a staff member close for safety. She stated, He will jump up quickly, he can move fast. A statement written by Medication Aide (MA) #1 on 10/22/23 revealed on 10/21/23 during the evening shift change she recalled Sitter #1 bringing Resident #1 to the common area near the piano. MA #1 was counting the cart with the oncoming nurse, she did not recall her name, when they heard a loud sound, turned around, and observed Resident #1 on the floor. Other staff members were in the area, and she saw Nurse Aide (NA)#2 walking up the hall. During an interview on 11/3/23 at 10:40 AM MA #1 revealed she was working on 10/21/23, 7a-7p shift and NA #1 was the 1:1 for Resident #1. During the evening shift change MA #1 was counting the cart with the oncoming nurse. She recalled NA #1 bringing Resident #1 to the common area in his wheelchair. NA #1 told MA #1 she was about to leave. MA #1 also recalled while counting the cart she could hear NA #1 and NA #2 talking in the common area. She then heard NA #2 say she was going to put her things away, watch him. MA #1 was unsure who NA #2 was speaking to, her back was turned, still counting the cart. MA #1 revealed she heard Resident #1 fall, when she saw him, he was on the floor. A nurse and an NA went to help the resident. MA #1 stated she saw NA #2 coming back to the common area and NA #2 said, I can't believe y'all let him fall. An interview on 11/3/23 at 12:40 PM with NA #7 revealed she was working on 10/21/23 7p-7a shift. She was in the common area at the time of Resident #1's fall, but she was talking to another NA and her back was turned to the resident. She turned around when she heard a noise. Resident #1 was on the floor and had an injury above his right eye. She stated staff was assisting the resident after his fall. NA #7 revealed Resident #1 often tries to get up very quickly, sometimes every few seconds. Staff must be right next to him to prevent him from falling. She did not recall anyone asking her to watch Resident #1. During an interview on 11/3/23 at 10:18 AM NA #4 revealed she was working 10/21/23 and was in the common area when Resident #1 fell . She stated she saw the NAs that were his 1:1's giving report in the common area, then the oncoming NA for Resident #1 went to put her things away. NA #4 explained she was in the common area talking to another NA and their backs were turned to Resident #1, she heard him fall but did not see him fall. When she looked at him, he was on the floor and the nurses in the area went to Resident #1 and began caring for him and treating his injury. NA #4 stated she had never cared for Resident #1 and on that day, no one asked her to watch him, she also did not recall if the NAs asked anyone else to watch him. A statement written by Nurse #3 on 10/21/23 revealed she did not witness Resident #1's fall. She last observed the resident at 7:00 PM sitting in his wheelchair. Multiple unsuccessful attempts were made to contact Nurse #3. A nurse note dated 10/21/23 at 8:05 PM by Nurse #1 read in part: The writer was not present during the incident and was not providing care to Resident #1 on that day. The writer heard a loud noise that came from the common area. Upon arriving to the common area, Resident #1 was observed in the wheelchair with bleeding from the right side of his head. A laceration was noted to the right side of his head. The writer began neuro checks and contacted the provider and the resident was sent to the hospital. A statement written by Nurse #1 on 10/22/23 revealed at the time of Resident #1's fall on 10/21/23 she was in the nurse station area and did not witness the fall. The last time she observed the resident he was seated in the common area with his sitter. She heard a loud noise from the common area. In the common area she observed Resident #1 sitting in his wheelchair with a laceration to the right side of his head. She assisted with his care and sent him to the hospital. An interview was conducted with Nurse #1 on 11/2/23 at 12:53 PM. Nurse #1 revealed she worked on 10/21/23, 7 AM shift. She was not assigned as the nurse for Resident #1. During the evening shift change around 7PM she was in the nurses' station, preparing to leave the facility when she heard the resident fall. She went to the common area and observed the resident sitting in his wheelchair with blood dripping from the right side of his head. She stated there were multiple staff members in the area, but no one witnessed Resident #1's fall. Nurse #1 stayed and helped staff with the resident. She explained she called the provider; the oncoming nurse, Nurse #3, called the family. After emergency medical services arrived, she left the facility. Nurse #1 explained that NAs should give report in the presence of Resident #1, he needed 1:1 supervision. The NA always needed to be close to him. Nurse #1 indicated Resident #1 could get up from a seated position quickly but was very unsteady on his feet and would fall once in a standing position. Hospital records for Resident #1 dated 10/21/23 revealed Resident #1 was brought to the emergency department after an unwitnessed fall from his wheelchair causing a right facial laceration. Resident #1 received 7 stitches to repair the laceration. He also received a scan of his head a cervical spine, that were both negative. Resident #1 was then sent back to the facility. An observation of Resident #1 was made on 11/1/23 at 1:30 PM. He was in his room seated in his wheelchair slightly reclined. He was awake and dressed, the resident had a healing area with sutures above his right eye. There was a family friend sitting with the resident. An interview was conducted with Resident #1's family on 11/2/23 at 9:19 AM. Resident #1's family revealed he was admitted to the facility in May 2023 after having some falls at home. He initially received therapy, but he continues to have falls. He tries but cannot stand unassisted. Family further revealed the facility provided a 1:1 sitter for the resident 24/7 to keep the resident safe. The sitter was a facility staff member, usually a nurse aide. The only time there was no 1:1 was when family or friends visited. During an interview on 11/3/23 at 1:39 PM NA #8 revealed she worked on 10/21/23 7a-7p shift. She did not witness Resident #1 fall; she had already clocked out and left. She stated the last time she saw him he was seated in his wheelchair near the piano in the common area. She further stated his 1:1 NA was with him at that time. During an interview on 11/2/23 at 11:46 AM Nurse Aide (NA) #3 revealed she worked on 10/21/23 7 PM shift. She stated she did not witness Resident #1's fall, she had started passing ice to the residents assigned to her. An interview on 11/3/23 at 10:29 AM with NA #5 revealed she was working on 10/21/23 when Resident #1 fell , but she did not see the fall. She stated she was at the time clock when the fall occurred. As she walked back through the facility, she saw Resident #1 seated in his wheelchair in the common area. She explained he had an injury to his head that the nurses were treating. During an interview on 11/3/23 at 11:00 AM Nurse #2 revealed she worked on 10/21/23 7p-7a shift. She stated she did not witness Resident #1 fall, she was clocking in. She did hear the fall, and as she entered the common area, she saw Resident #1 was on the floor. Nurse #2 stated Resident #1 was surrounded by multiple staff members that were helping him. During an interview on 11/3/23 at 12:35 PM NA #6 revealed she worked on 10/21/23 7a-7p shift. NA #6 stated she did not witness Resident #1's fall. She was in the charting room and heard a boom, she ran to the common area and saw Resident #1 on the floor. She revealed there were many staff in the area assisting the resident. Resident #1 had bleeding from his head. NA #6 explained Resident #1 was quick when he moved, if you were his 1:1, you needed to always sit right next to him. During an interview with on 11/2/23 at 4:06 PM the Director of Nursing revealed Resident #1 has had multiple falls related to his disease process, he had Parkinson's and was impulsive. The facility had put multiple fall interventions in place for the resident including a 1:1 NA. The resident had a 1:1 NA because he would stand up quickly and then fall. Staff needed to be in reach of the resident, he could not be left alone. The DON further revealed on 10/21/23 Resident #1 had a fall in the common area during the 7 PM shift change. NA #1 was assigned as the 1:1 during the 7a-7p shift. Close to shift change Resident #1 was taken to the common area by NA #1. She stated there were staff in the area but not face to face with the resident and he had a fall. The DON indicated NA #1 had left to go home and she was unsure where NA #2 was at the time of the fall. Staff treated Resident #1's injuries and he was sent to the hospital. In the hospital he received sutures and returned to the facility the same night. The DON explained the NAs should report in the presence of Resident #1, hand off should be a tag in, tag out situation. She indicated if the resident was not left unattended, his fall could have been prevented. The DON stated although there were staff in the area, all staff denied seeing Resident #1 fall, and no staff recalled being asked to watch Resident #1.

Based on observations, record review, staff interviews, resident interview, and Physician interview the facility failed to administer scheduled pain medication after it was requested for a resident that was experiencing ten out of ten pain. This occurred for one of four residents reviewed for pain. (Resident #310) This failure resulted in Resident #310 experiencing her pain being off the charts and crying related to her pain. The findings included: Resident #310 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of the right knee, right knee replacement, right knee pain, and rheumatoid arthritis. A 5-day Minimum Data Set for Resident #310 dated 4/27/23 revealed she was cognitively intact with no behaviors. Resident #310 had a recent major joint surgery and required skilled nursing care. She was experiencing pain almost constantly and was on a pain regimen. A baseline care plan for Resident #310 initiated on 4/25/23 revealed she had the potential for actual acute and/or chronic pain. The interventions included acknowledging the presence of pain and discomfort and listen to the residents' concerns. Administer pain medication as ordered by the physician. Anticipate the resident's need for pain relief and respond appropriately. Document/report complaints and non-verbal signs of pain. Notify the physician if pain management was not effective. Review of a physician progress note dated 4/26/23 read in part: Resident #310 was being admitted to the skilled nursing facility after hospitalization for right total knee replacement per orthopedist and subsequently needing skilled care because she is unable to care for herself at home, unable to consistently bear weight and difficulty with persistent severe breakthrough pain. Reviewed for her ongoing treatment: We will change her analgesic regimen per her request to schedule her oxycodone at 20 mg every 4 hours as she does suffer from chronic pain issues due to her rheumatoid arthritis and recent exacerbation with ongoing treatment. Review of Physician orders for Resident #310 revealed: oxycodone 10 milligrams(mg), give 2 tablets by mouth every four hours for chronic pain 4/26/23. Review of the April 2023 Medication Administration Record (MAR) for Resident #310 revealed she had oxycodone 20mg due to be given every 4 hours at 8 AM, 12 noon, 4 PM, 8 PM, 12 midnight and 4 AM. During an interview on 5/2/23 at 9:20 AM Resident #310 revealed she had been in the facility for about a week, she was in the facility for rehab after a knee surgery. Resident #310 stated sometimes the nurses did not bring her pain medication when she requested it. She reported this to the physician. She further stated after she reported the issue, the physician changed her pain medication from as needed to scheduled times through the day to ensure she received her medication timely. Resident #310 revealed on the weekend of 4/29/23, she could not recall if it was Saturday or Sunday, she requested her 8 PM pain medication. Resident #310 explained she asked an NA to tell the nurse she needed something for pain, her pain was an eight out of 10. She was told by the NA that the nurse was busy, but she would let her know. Resident #310 further explained that after about 30 minutes she activated her call light because the nurse had not come. She activated her call light another time before calling a friend to come to the nursing home. Resident #310 stated when her friend arrived at the facility her pain was ten out of ten, my pain was off the charts and she was in the bed crying. She sent her friend to find a nurse and to ask for her pain medication. Resident #310 revealed the nurse brought her pain medication around 9:30 or 10 PM. She thought she waited more than two hours for her medication, this was not the first time her pain medication was late. Resident #310 stated she kept track of the time on her cell phone. During an interview on 5/2/23 at 3:32 PM NA #4 revealed she worked on the hall where Resident #310 resided on Sunday 4/30/23. She further revealed it was very busy on that day and she could not recall if Resident #310 asked her to tell the nurse she needed pain medication. NA #4 stated that Resident #310 resided on the rehab unit. Residents on the rehab unit frequently requested pain medication. She further stated when a resident asked her to tell the nurse they needed something, she told the nurse. An interview was conducted on 5/3/23 at 12:05 PM, Nurse #2 revealed she was the nurse on the hall where Resident #310 resided on Sunday 4/30/23 from 7 AM until 11 PM. She recalled that Resident #310 called for her pain medication around 7PM that evening, but she did not administer it because it was not due until 8 PM. It was also shift change and she was going to pass it on to the oncoming nurse. Nurse #2 explained it had been a challenging day, they were short staffed there was only an NA and herself working that hall with 20 something residents. She typically worked from 7PM until 7 AM, but she agreed to work 7 AM until 7PM on 4/30/23 because the facility was short staffed and there was not a nurse to cover that shift. Nurse #2 revealed she was allowed to give medications an hour before or an hour after and they would be considered on time. When Resident #310 requested pain medication it was around 7 PM and Nurse #2 expected to be relieved by another nurse at that time. She stated she was going to pass on Resident #310's pain medication request to the oncoming nurse but that nurse never came, she was a no call no show. She covered the shift until 11 PM until the facility could find another nurse to relieve her. Nurse #2 revealed she did not plan to stay until 11 PM, by the time she notified the facility about the no call no show and got her night started she was behind and had forgotten about Resident #310's request for pain medication. She stated when she remembered the resident needed pain medication, there was a friend of Resident #310 running up to the cart telling her that Resident #310 was in her bed crying and needed her pain medication. Nurse #2 stated when she went to Resident #310's room to give the pain medication she was in her bed crying. She thought it was around 9:30 PM when she gave the medication. She said her medication being late was the result of the staffing situation that day. Nurse #2 stated the facility was frequently short staffed. During an interview on 5/3/23 at 2:50 PM the Physician revealed Resident #310 mentioned to him that she was not receiving her pain medication when she requested it. Her pain medication was initially ordered as needed; he changed her medication to be given at scheduled times so she would not have to request it. The Physician further revealed he was not aware she was continuing to have trouble getting her medication as scheduled. The Physician stated he expected nurses to administer residents their pain medications as ordered. An interview was conducted with the Director of Nursing (DON) and the Facility Consultant on 5/4/23 at 4:41 PM. The DON revealed she expected the residents to receive their pain medications timely and as ordered. She further revealed she believed the issue with Resident #310 ' s pain medication was related to the staffing challenges the facility experienced on the weekend of 4/29/23. The DON stated there were multiple call outs on that weekend and this may have caused Resident #310's nurse to get behind.

Based on observations, record review, staff interviews, and resident interviews the facility failed to have sufficient nurse staffing to ensure residents received pain medication when needed. (Resident #310). The findings included: This citation is cross referenced to F697 B.) F697: Based on observations, record review, staff interviews, resident interview, and Physician interview the facility failed to administer scheduled pain medication after it was requested for a resident that was experiencing ten out of ten pain. This occurred for one of four residents reviewed for pain (Resident #310). This failure resulted in Resident #310 experiencing her pain being off the charts and crying related to her pain. During an interview on 5/3/23 at 11:34 AM Nurse #4 revealed staffing was bad at the facility and on the days they had two or three NAs on the medical unit it was terrible. She stated on days when they had two to three NAs on the medical unit, she did a lot of juggling, she would try to help the NAs pass and pick up meal trays, assist with feeding, and answer call lights. She further stated she knew all the baths and showers couldn't get done and residents didn't always get changed timely when they were short staffed. She explained she tried to help the best she could, but she had to be a nurse too. Nurse #4 revealed because of the staffing issues she often helped the NAs provide care to the residents and at times her medication pass would be late. An interview was conducted with Nurse #2 on 5/3/23 at 12:05 PM. Nurse #2 revealed staffing was not so great at the facility. She worked on the Rehabilitation Unit (Rehab unit) and there was one nurse on the Rehab unit for 23 residents. She stated she had to pass medications and there were a lot of residents on the unit that needed pain medications because they've had surgeries. She further stated it was a lot for one nurse. Nurse #2 revealed she worked the past weekend of 4/29/23 and the facility was very short staffed. She further revealed on Sunday 4/30/23 she worked from 7 AM until 7 PM and she was the only staff member on the Rehab unit until 9 AM. The NA was late and did not arrive until 9AM. Nurse #2 explained on that morning between 7 AM and 9 AM she answered call lights and passed breakfast trays. She could not start her medication pass until the NA came in, and because it was just the two of them, she helped turn and change residents. She stated because they were short staffed, she was behind on her medication passes and it was difficult to get caught up. During an interview on 5/3/23 at 3:49 PM the Scheduler revealed the facility was cutting back a little on agency staff, so staffing was a little more of a struggle. They were currently hiring facility staff. She indicated hiring staff was not an issue, but retention was. The facility would hire a NA, they would work a few shifts and then not return. The Scheduler stated she was aware that the facility was short staffed the weekend of 4/29/23. The Medical Unit had a NA walk out and the two remaining NAs had 30 something residents each. She further stated that was too many residents for the NAs to provide care for. Even when there were four NAs on the Medical Unit, they could have up to 20 residents and that was a lot for day shift. The Scheduler explained when the facility was short staffed, she would make phone calls to try to get staff to come in. She also used an app called schedule pop where staff can see vacancies, they offered bonuses for extra shifts, and she would call agencies to see if they had staff they could send. If they could not get enough staff, she, and the Director of Nursing (DON) would help on the unit. She stated the DON and Unit Manager came in on Sunday 4/30/23 to help when the facility was short staffed. During an interview on 5/4/23 at 3:37 PM Nurse #5 revealed she was working on the rehab unit and there were about 25 residents. She stated with that number of residents they should have two nurses and two NAs. On that day she stated it was only herself and the NA. Nurse #5 explained she would help the NA with residents, trays and call lights and it slowed her down with her medication passes. It makes me behind with meds. A telephone interview was conducted with Administrator #1 on 5/4/23 at 12:44 PM. She revealed when she was at the facility, they were experiencing staffing challenges and it was getting worse. She stated the facility was cutting some of the agency staff as they hired facility staff. When they hired a facility staff member, they would cut an agency staff member. Administrator #1 revealed on the weekend of 4/29/23 the facility was very short staffed and on Sunday 4/30/23 she came in to help, but they were still short. During an interview with the DON and the Facility Consultant on 5/4/23 at 4:41 PM DON revealed staffing was an issue and the facility was trying to increase their staff. They had been using word of mouth, advertising, and offering bonuses. She stated they recently hired 11 but only had four shown up for orientation. Until the staffing was better, they continued to use agency. If the facility was short staffed, they called around, and offered hourly incentives for extra shifts. The DON stated she encouraged staff to make the best out of the staffing situation until it gets better. #310). The findings included: This citation is cross referenced to F697 F697: Based on observations, record review, staff interviews, resident interview, and Physician interview the facility failed to administer scheduled pain medication after it was requested for a resident that was experiencing ten out of ten pain. This occurred for one of four residents reviewed for pain (Resident #310). This failure resulted in Resident #310 experiencing her pain being off the charts and crying related to her pain. During an interview on 5/3/23 at 11:34 AM Nurse #4 revealed staffing was bad at the facility and on the days they had two or three Nurse Aides (NA) on the medical unit it was terrible. She stated on days when there were two to three NAs on the medical unit, she did a lot of juggling, she would try to help the NAs pass and pick up meal trays, assist with feeding, and answer call lights. She further stated she knew all the baths and showers couldn't get done and residents didn't always get changed timely when they were short staffed. She explained she tried to help the best she could, but she had to be a nurse too. Nurse #4 revealed because of the staffing issues she often helped the NAs provide care to the residents and at times her medication pass would be late. An interview was conducted with Nurse #2 on 5/3/23 at 12:05 PM. Nurse #2 revealed staffing was not so great at the facility. She worked on the Rehabilitation Unit (Rehab unit) and there was one nurse on the Rehab unit for 23 residents. She stated she had to pass medications and there were a lot of residents on the unit that needed pain medications because they've had surgeries. She further stated it was a lot for one nurse. Nurse #2 revealed she worked the past weekend of 4/29/23 and the facility was very short staffed. She further revealed on Sunday 4/30/23 she worked from 7 AM until 7 PM and she was the only staff member on the Rehab unit until 9 AM. The NA was late and did not arrive until 9AM. Nurse #2 explained on that morning between 7 AM and 9 AM she answered call lights and passed breakfast trays. She could not start her medication pass until the NA came in, and because it was just the two of them, she helped turn and change residents. She stated because they were short staffed, she was behind on her medication passes and it was difficult to get caught up. During an interview on 5/3/23 at 3:49 PM the Scheduler revealed the facility was cutting back a little on agency staff, so staffing was a little more of a struggle. They were currently hiring facility staff. She indicated hiring staff was not an issue, but retention was. The facility would hire a NA, they would work a few shifts and then not return. The Scheduler stated she was aware that the facility was short staffed the weekend of 4/29/23. The Scheduler explained when the facility was short staffed, she would make phone calls to try to get staff to come in. She also used an app called schedule pop where staff can see vacancies, they offered bonuses for extra shifts, and she would call agencies to see if they had staff they could send. If they could not get enough staff, she, and the Director of Nursing (DON) would help on the unit. She stated the DON and Unit Manager came in on Sunday 4/30/23 to help when the facility was short staffed. During an interview on 5/4/23 at 3:37 PM Nurse #5 revealed she was working on the rehab unit and there were about 25 residents. She stated with that number of residents they should have two nurses and two NAs. On that day she stated it was only herself and the NA. Nurse #5 explained she would help the NA with residents, trays and call lights and it slowed her down with her medication passes. It makes me behind with meds. A telephone interview was conducted with Administrator #1 on 5/4/23 at 12:44 PM. She revealed when she was at the facility, they were experiencing staffing challenges and it was getting worse. She stated the facility was cutting some of the agency staff as they hired facility staff. When they hired a facility staff member, they would cut an agency staff member. Administrator #1 revealed on the weekend of 4/29/23 the facility was very short staffed and on Sunday 4/30/23 she came in to help, but they were still short. During an interview with the DON and the Facility Consultant on 5/4/23 at 4:41 PM DON revealed staffing was an issue and the facility was trying to increase their staff. They had been using word of mouth, advertising, and offering bonuses. She stated they recently hired 11 but only four had shown up for orientation. Until the staffing was better, they continued to use agency. If the facility was short staffed, they called around, and offered hourly incentives for extra shifts. The DON stated she encouraged staff to make the best out of the staffing situation until it gets better.

Based on observation, staff interviews and record reviews, the facility failed to remove expired medications in accordance with manufacturer's guidelines and failed to date an opened eye medication for 4 of 6 medications carts observed during medication storage checks (200 hall, 400 hall, 600 hall, and 700 hall). The findings included: 1. Review of manufacturer's package insert for Latanoprost eye drops revealed unopened bottle should be stored under refrigeration between 36 to 46 F and protected from light. Once opened, Latanoprost could be stored at room temperature up to 77 F up to six weeks. a. A medication storage audit was conducted on 05/02/23 at 3:18 PM for the 600-hall medication cart in the presence of Nurse #1. One bottle of Latanoprost 0.005% eye drop opened on 01/20/23 was found in the medication cart and ready to be used. The eye drop was dispensed from the pharmacy on 01/11/23. During an interview conducted on 05/02/23 at 3:28 PM, Nurse #1 thought the eye drop would be expired a year from the dispensing date on 01/11/24. She did not know that opened Latanoprost eye drop stored in the room temperature would be expired in 6 weeks. b. During a medication storage check conducted on 05/02/23 at 3:47 PM for 400-hall in the presence of Medication Aide (MA) #1, one bottle of Latanoprost 0.005% eye drop without opening date was found in the medication cart and ready to be used. The label indicated the eye drop would be expired 6 weeks after it was opened. An interview was conducted on 05/02/23 at 3:54 PM. MA #1 explained she had not worked with 400-hall medication cart for long time. She acknowledged that the eye drop should be dated when it was opened and discarded after 6 weeks. She could not explain why the eye drop was not dated when it was opened. 2. Review of manufacturer's package insert for Novolog, Lantus, and Admelog indicated unopened vials should be stored in refrigerator at 36 F to 46 F until expiration and kept away from direct heat and light. Once these insulins were opened, it could be stored at room temperature (below 86 F) or refrigerated up to 28 days. a. A subsequent medication storage audit was conducted on 05/02/23 at 4:59 PM for the 200-hall medication cart in the presence of Nurse #2. One vial of Lantus 100 unit/milliliter (ml) insulin opened on 03/27/23 and one vial of Novolog 100 unit/ml insulin opened on 03/01/23 were found in the medication cart under room temperature and ready to be used. During an interview conducted on 05/02/23 at 5:08 PM, Nurse #2 explained one of the nurses worked before her might have opened another Novolog and forgotten to discard the expired one in the medication cart. She stated both insulins should be discarded after they were opened and stored under room temperature for 28 days. b. A medication storage check was conducted on 05/02/23 at 5:25 PM for the 700-hall medication cart in the presence of Nurse #3. One vial of Admelog 100 unit/ml insulin opened on 03/31/23 was found in the medication cart under room temperature and ready to be used. An interview was conducted on 05/02/23 at 5:28 PM. Nurse #3 stated she was not the only nurse who used this medication cart. It was hard for her to keep up with the expiration date of insulin if other nurses did not do their part. She acknowledged that the insulin should be discarded after it had been opened and stored in room temperature for 28 days. An interview was conducted with the Director of Nursing (DON) on 05/02/23 at 5:54 PM. She stated nurses and MAs were instructed to check their respective medication cart for expired medications at least once every night. It was her expectation for the facility to remain free of expired medication and store all medications according to manufacturer's guidelines. During an interview with the Administrator on 05/04/23 at 4:38 PM, he expected all the nursing staff to follow facility's policy and procedure for medication storage and store all medications according to manufacturer's guideline.

Based on observations, record review, staff interviews, Physician interview, and Family interviews the facility failed to communicate and provide information in a language the resident could understand for 1 of 1 resident whose primary language was Spanish (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses that included pain in the right knee, arthritis, and infection related to an artificial joint. A quarterly Minimum Data Set (MDS) for Resident #29 dated 4/23/23 revealed Resident #29 had moderate cognitive impairment with no behaviors. The care plan for Resident #29 revealed Resident #29 had an inability to express emotion, listen and share information related to a hearing deficit and language barrier. The interventions included use the google app translator, Resident #29 was Spanish speaking only. Get the resident's attention before speaking and observe for and report any change in cognition. An observation was made of Resident #29 on 5/1/23 at 5:20 PM. Resident #29 was sitting on the side of her bed looking through bags of clothing. Resident #29 spoke to me in Spanish while motioning her hands. Her roommate said she only spoke Spanish. An interview was conducted on 5/1/23 at 5:25 PM with Nurse Aide (NA) #5. NA #5 revealed Resident #29 spoke Spanish only. She had not used google translate with the resident. Resident #29 usually gestured her needs. During an interview on 5/1/23 at 5:30 PM Nurse #3 revealed it was difficult communicating with Resident #29 because she did not speak English, so she called the family if needed and they would help translate. Nurse #3 further revealed she has never used an interpreter for Resident #29. During an interview on 5/3/23 at 2:50 PM the Physician revealed that it was difficult to communicate with resident #29 because her primary language was Spanish, and she did not speak English. He indicated he had not used an interpreter with this resident, and he thought she understood some basic phrases. The Physician revealed the resident was sent to the hospital in February 2023 and he thought she understood the word hospital meant she was being transferred to the hospital. On 5/2/23 at 3:57 PM an interview was conducted with NA #4. She revealed Resident #29 only spoke Spanish and it was hard to communicate with her. She reported she was not usually assigned to care for Resident #29 but there was an NA that spoke that was usually assigned to Resident #29. She stated she had tried google translate with Resident #29 in the past, but the app could not capture what the resident said. She was unsure if the resident did not speak clearly or slowly enough for the app to work. NA #4 explained she could ask a question to the resident through the google translate app, but the app would not capture the resident's response. She tried to use yes or no questions with Resident #29. She further explained she relied on the resident's gesturing to identify her needs. During an interview on 5/4/23 at 8:41 AM the MDS Coordinator revealed when completing Resident #29's MDS assessments they utilized the NA that spoke Spanish to help translate so they could complete the assessment. She stated there had been times when they obtained assistance from the family, but they mostly used the NA who spoke Spanish. During a telephone interview on 5/4/23 at 10:17 AM Resident #29's family revealed there was a staff member that spoke Spanish at the facility that could communicate with Resident #29, but it was not on a consistent basis. They thought it was only a couple times a week. On the other days the family felt Resident #29 had trouble communicating her needs due to the language barrier. She tells me sometimes they don't understand her when she needs to go to the bathroom. The Family stated Resident #29 called her last week and kept saying COVID, COVID. The Family was told by Resident #29 that the staff put her in a different room and kept saying COVID, but she did not understand what was going on. The Family stated shortly after the call from Resident #29, a Nurse called and told them that the resident tested positive for Covid and had been moved to another room for isolation. A few days later the resident called the family again and told them she needed some clothes from her old room, but the staff did not understand what she was saying. The family revealed she went to the facility to gather things from Resident #29's old room and asked staff to give it to her. The Family stated they visit around 3 times a week, and they try to meet as many of the residents needs as possible while visiting. They did not think Resident #29 could effectively communicate with staff. Staff rarely called the family to translate for Resident #29, they only called if there was a dire need. They further stated the resident had never used an interpreter to their knowledge. During an interview on 5/4/23 at 11:34 AM Nurse #4 revealed she uses the google translate app to ask Resident #29 yes or no questions. She stated she could also ask the NA that spoke Spanish to translate Resident #29's needs and stated that NA work 3 days per week. An interview was conducted with the Director of Rehab on 5/4/23 at 3:05 PM. The Director of Rehab revealed Resident #29 was Spanish speaking and was provided a communication board to express her needs. She stated that with the communication board Resident #29 could only express her basic needs such as eat, drink, pain, and bathroom. She further stated there was a Spanish speaking staff member that helped with translation. During an interview on 5/4/23 at 3:37 PM Nurse #5 revealed it was difficult to communicate with Resident #29, she did a lot of pointing to express her needs. She stated she never used any type of interpreter services for Resident #29, and she has never seen her communication board. An interview was conducted with the Unit Manager (UM) on 5/4/23 at 3:44 PM. The UM revealed she used gesturing to communicate with Resident #29. Staff could also use google translate, her communication board or call her family. The UM stated she had never used any interpreter services with Resident #29. An interview was conducted with the Director of Nursing (DON) and the Facility Consultant on 5/4/23 at 4:41 PM. The DON revealed Resident #29 used gesturing and her communication board to express her needs. They also utilized an NA that spoke Spanish. The DON stated she had not used an interpreter to communicate with the resident. The Facility Consultant explained she was not sure exactly when, but she implemented an interpreter line for Resident #29. She was not aware that it was not being used and did not know where the phone was. The Facility Consultant stated she was not sure if Resident #29 had ever used the interpreter line or if she had been care planned for it.

Based on observations, record review, resident interviews and staff interviews the facility failed to provide nail care for 2 of 6 sampled residents (#5 and #48) reviewed for activities of daily living (ADL). 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included anemia, chronic kidney disease, dementia, and seizure disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; total dependence on locomotion and bathing; supervision with eating. A revised care plan dated 12/23/22 revealed Resident #5 required assistance with ADLs to maintain or achieve the highest level of functioning by providing total care for personal hygiene/ grooming (face, skin, hands, nails, and perineum). A continuous observation and interview on 5/1/23 at 10:23 AM to 10:30 AM revealed Resident #5's fingernails on both hands were long with jagged edges. The observation further revealed his left arm/ hand was contracted and fingernails were long. Resident #5 reported he recently asked staff to cut his fingernails and was told they did not have nail clippers to cut his nails. A follow-up observation on 5/2/23 at 10 AM revealed Resident #5's fingernails on both hands remained long, jagged, and untrimmed. A review of bathing sheets and progress notes in the electronic medical record indicated Resident #5 had no refusals of nail care. During an interview on 5/3/23 at 12:17 PM, Nurse Aide (NA) #1 indicated she normally provided bed baths during the 7:00 pm- 7:00 am shift and that nail care was usually performed by the shower team, if they weren't pulled to work on the floor. She further indicated that she had been assigned to Resident #5 and did not notice that his nails were overgrown or needed care. During an interview on 5/2/23 at 4:03 PM, NA #2 revealed he started working at the facility on 4/28/23 and was assigned to Resident #5. He provided ADL care to Resident #5, noticed his nails needed to be trimmed and did not trim his nails because he did not have a nail clipper. He further revealed he asked a nurse (unable to recall the nurse's name) for clippers and was told they needed to check with the facility's corporate office. 2. Resident #48 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease and respiratory failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #48 had moderate cognitive impairment and required extensive assistance with bed mobility, toileting, and personal hygiene: total assistance with transfers, dressing and bathing; supervision with eating. A continuous observation and interview on 5/1/23 at 10:33 AM to 10:40 AM revealed Resident #48's fingernails on both hands were long, thick, and jagged with dark brown matter under his nails. Resident #48 further revealed he could not get staff to cut his fingernails, he wanted them cut and had not refused nail care especially since his left middle fingernail very thick, yellow in color and splitting. A follow-up observation and interview with the Unit Manager on 5/2/23 at 4:13 PM revealed Resident #5 and #48's fingernails on both hands remained long with jagged edges as they were observed on 5/1/23. The Unit Manager assessed the fingernails of both residents and determined their nails were overgrown and needed care. She further indicated she expected her staff to provide nail care during ADL care. During an interview with the Director of Nursing (DON) on 5/4/23 at 5:25 PM revealed she was not aware nail care was not provided during ADL care and expected this task to be routinely assessed and performed weekly on shower days by nursing staff.

Based on observations, staff interviews and record review the facility failed to provide adequate supervision for a resident with a history of falls. The resident fell out of bed and was injured. The resident was sent to the Emergency Department diagnosed with [REDACTED]. The facility also failed to ensure fall precautions were in place for 2 of 4 sampled residents (Resident #2 and #7). The findings included: 1. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was not assessed, the resident required extensive assistance with bed mobility and transfers and had 1 fall with a minor injury. A care plan (not dated with the most recent update) created for Resident #2's risk for falls identified measure in place to prevent a fall related injury. The measures included: - Bed in lowest position - Fall mat on floor - Sensor alarm while in bed and in chair A nurses' entry made by Nurse #2 on 03/24/17 at 4:00 AM specified Resident #2 was found in the floor next to her low bed with a 1 inch laceration to the cheek. Nurse #2 documented that she contacted the physician and received orders to send Resident #2 to the Emergency Department for evaluation of fall. Review of the Emergency Department evaluation dated 03/24/17 specified Resident #2 had a closed head injury without loss of consciousness (concussion) and received treatment to the facial laceration. A physician's orders [REDACTED].#2 to the Emergency Department for evaluation of a fall. There was no nurses' entry made in the medical record related to a fall on 03/26/17. The facility provided an incident report completed by Nurse #1 dated 03/26/17 at 7:18 PM that specified a nurse aide found the resident lying on her right side next to her bed. Nurse #1 assessed Resident #2 and noted the resident to have reopened the right cheek laceration and sustained an injury to the right eye. Nurse #1 documented that she contacted the on-call physician and received orders to send the resident to the Emergency Department for evaluation. The hospital records were obtained for Resident #2 and reviewed. Resident #2 remained in Intensive Care Unit (ICU) for sepsis from pneumonia. The Emergency Department evaluation dated 03/26/17 specified Resident #2 sustained a right eye contusion and subconjuctival hemorrhage. On 03/29/17 at 12:21 PM nurse aide (NA) #3 was interviewed on the telephone and explained he worked on 03/26/17 from 3 PM to 11 PM and was assigned Resident #2 starting at 7 PM. The NA added that he had been told that same day by another nurse aide that Resident #2 had been making several attempts to get out of bed. NA #3 reported that Resident #2 was at risk for falls and had a sensor alarm in her bed and chair, along with a fall mat and her bed was to be in low position. Adding, Resident #2 was unable to communicate her needs because she could not talk but would wink if she needed something. NA #3 explained that on 03/26/17 on the 3 PM to 11 PM shift the facility only had 3 nurse aides on the medical unit because of a shortage and usually the medical unit had 4 nurse aides. He added that during the evening meal, NA #5 was in the dining room assisting residents which left him and NA #4 to monitor about 30 residents, answer call lights, pass meal trays and feed dependent residents. The NA stated that he entered Resident #2's room to deliver a meal tray when he found the resident on the floor bleeding. He stated the alarm was not sounding. He called for help. NA #3 reported that he examined Resident #2's bed and noticed the alarm was not in place because it was still in her wheelchair. NA #3 added that he was unaware how long Resident #2 had been in the floor. NA #3 stated that he and NA #4 were unable to adequately supervise the residents on the floor and pass meal trays because of the short staffing. On 03/29/17 at 12:40 PM NA #4 was interviewed on the telephone and stated she was assigned to Resident #2 on 03/26/17 from 3 PM to 7 PM. She explained that during the shift she had to reposition the resident several times back in the bed because she was leaning to one side. The NA added that she was told in report that Resident #2 had a rough day and to encourage resident to stay in bed and rest. NA #4 reported that usually Resident #2 was up and ate in the dining room but on 03/26/17 stayed in bed for the evening meal. NA #4 also stated that around 5:30 PM she assisted the resident back in the bed, made sure the bed was in the lowest position and fall mat next to the bed. NA #4 stated that Resident #2 was to have a sensor alarm while in the bed but because the resident was already in bed when the shift started, she didn't check that the alarm was in place and/or functioning. NA #4 explained that she and NA #3 were the only nurse aides on the floor to pass trays and that Nurse #1 was in the dining room helping to feed residents because of short staffing. NA #4 added that around 7 pm she heard NA #3 call for help and was told Resident #2 had fallen. NA #4 stated that she was busy passing trays and had not been able to go back in the room to check on Resident #2 but had assumed she was sleeping because she seemed out of it. On 03/30/17 at 11:35 AM the Director of Nursing (DON) was interviewed and explained that fall precautions were expected to be in place and it was the responsibility of staff to put them in place. The DON was unaware of the staffing challenges on 03/26/17 on the 3 PM to 11 PM shift and stated there should have been 4 nurse aides on the medical unit. The DON stated that she was unaware Resident #2's sensor alarm was not in the bed at the time of the fall and should have been. On 03/30/17 at 12:00 PM observations were made of Resident #2's room that revealed a wheelchair folded beside the closet. Attached to the wheelchair was a sensor alarm. Inside the closet, Resident #2 had a care guide (not dated) that instructed staff to monitor the resident's whereabouts and an alarm while in bed. On 03/30/17 at 2:36 PM Nurse #1 was interviewed on the telephone and explained that she was assigned to work 7 AM to 3 PM but no one showed up to relieve her and she agreed to work until 7 PM on 03/26/17. She added that the day was very chaotic due to short staffing and during the 7 AM to 3 PM shift, Resident #2 had made attempts to get out of bed. Nurse #1 reported that she was in the dining room assisting residents with the evening meal when she was told Resident #2 had fallen. She explained that she assessed the resident and noted an injury to the right eye and the right cheek laceration from 03/24/17 had reopened. Nurse #1 stated she contacted the physician and received orders to send the resident to the Emergency Department. Nurse #1 reported that she was unaware if the resident's sensor alarm was sounding at the time of fall because NA #3 was with the resident and her priority was getting Resident #2 sent out to evaluate her injuries. 2. Resident #7 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A current care plan was developed for his risk of falls which originated on 02/17/16. The goal was for Resident #7 to not sustain any serious injury through the next review of 11/30/16. Interventions included his bed was to be in the lowest position, a fall mat was to be on the floor, and wedges were to be on each side of the bed to determine bed parameters. Under the section of Resident Care Guide initiated 02/16/16 interventions included an alarm in the bed and chair initiated on 02/27/16. The significant change Minimum Data Set ((MDS) dated [DATE] coded him with long and short term memory impairments and having severely impaired decision making abilities. He was coded as requiring extensive to total assistance with all activities of daily living skills (ADLs). In addition, Resident #7 was coded as having impaired balance, needing assistance to steady himself during transitions and having had 2 or more falls since the previous assessment. The quarterly MDS, dated [DATE], coded his cognition as not being assessed, requiring extensive to total assistance with ADLs, being nonambulatory, needing assistance to steady himself during transitions and having had 2 or more falls since the previous admission. A nurse aide care guide was located in Resident 7's the closet which directed nurse aides of individual needs for the resident. This care guide, dated 03/08/17, indicated alarms were to be in both the bed and the chair. Review of the medical record revealed nursing notes dated 03/28/17 at 11:25 AM which stated Resident #7 was found on the floor beside the bed. He was assessed as having no injury. The nursing note did not specify if the alarm was sounding. Review of the incident report dated 03/29/17 at 12:34 AM stated Resident #7 was observed on the floor beside the bed and received no injuries There was no indication if the alarm was in place or sounding. This was completed by the Assistant Director of Nursing (ADON). Observations dated 03/29/17 at 10:11 AM, Resident #7 was observed in a low bed with a mat on floor beside the bed. An alarm box was on the bedside table and blinking which indicated it was on. This box was not connected to anything. The resident was lying on a pressure alarm pad and the wire which led from the pad was traced to the floor under the bed. The wire was sheared and not connected to any type of plug as the end was frayed off. The alarm remained not connected during observations of Resident #7 in bed on 03/29/17 at 10:48 AM and at 11:03 AM. On 03/29/17 at 11:25 AM, Nurse Aide #1 entered the room, woke him from sleeping in bed, combed his hair, asked if he was ready to eat lunch and left the room without checking the alarm which remained not connected or functioning. On 03/29/17 at 11:46 AM, Resident #7 was observed in bed and the cord to the alarm was still not connected and was frayed at the end. On 03/29/17 at 11:58 AM, Medication Aide #1 was in the room and stated she had just entered and noticed the alarm was not connected. She stated she was not informed about the bed alarm but would replace it. Interview with NA #1 who was responsible for Resident #7's care on 03/29/17, was interviewed on 03/29/17 at 12:03 PM and stated that she did not think she checked the alarm this date. She further stated she provided him incontinent care while in bed this morning and rolled him from side to side and the alarm did not sound. She stated the resident was on a wide pressure alarm pad and believed that was why the alarm did not sound as she rolled him. During interview with the Director of Nursing (DON) on 03/30/17 at 12:00 PM, DON stated she expected Resident #7 to have a working bed alarm in place. She further stated that during care, she expected nursing assistants to review the care guide in the closet and make sure it was followed including checking for alarms in place and in functioning order. The Administrator stated during interview on 03/30/17 at 4:39 PM that alarms should be checked and in working order at each shift change.

Based on observations, staff interviews and record review the facility failed to have sufficient quantity of staff to monitor a resident at risk for falls; the resident fell and was injured for 1 of 4 sampled residents (Resident #2); and the facility failed to have sufficient quantity of staff to ensure dependent residents were fed and provided incontinence care for 4 of 7 sampled residents (Resident #4, #5, #6 and #7). The facility also failed to have sufficient quantity of staff to have a Registered Nurse function fulltime as a Director of Nursing. The findings included: 1. Cross refer to F 323: Based on observations, staff interviews and record review the facility failed to provide adequate supervision for a resident with a history of falls and ensure fall precautions were in place. The resident fell out of bed and was injured. The resident was sent to the Emergency Department diagnosed with [REDACTED].#2 and #7). On 03/30/17 at 10:35 AM the staffing coordinator was interviewed and stated that staffing was hard to maintain and that she used a list to call and beg nurses and nurse aides to fill in vacancies in the weekly schedule. She added that she was aware of instances when the vacancies had not been filled and staff had to work short. The staffing coordinator reported that the Administrator was aware of the staffing shortage. On 03/30/17 at 4:45 PM the Administrator was interviewed and stated she was aware the facility was under staffed. The Administrator explained that she was working to try to hire staff but faced with a serious challenge. The Administrator reported that she had been working with the facility's corporation to ways to encourage more employment. On 03/30/17 at 5:34 PM the Vice President of Operations was interviewed and stated he was aware of the staffing challenge within the facility. He added that he had implemented bonus pay for staff willing to cover extra shifts and other strategies for filling the vacancies each week. The Vice President of Operations reported that the facility might have to enlist the help of an agency staffing company. 2. Cross refer to F 224: Based on staff interviews and record review the facility neglected to feed and provide incontinence care for dependent residents for 4 of 7 sampled residents (Resident #4, #5 #6 and #7). On 03/30/17 at 10:35 AM the staffing coordinator was interviewed and stated that staffing was hard to maintain and that she used a list to call and beg nurses and nurse aides to fill in vacancies in the weekly schedule. She added that she was aware of instances when the vacancies had not been filled and staff had to work short. The staffing coordinator reported that the Administrator was aware of the staffing shortage. On 03/30/17 at 4:45 PM the Administrator was interviewed and stated she was aware the facility was under staffed. The Administrator explained that she was working to try to hire staff but faced with a serious challenge. The Administrator reported that she had been working with the facility's corporation to ways to encourage more employment. On 03/30/17 at 5:34 PM the Vice President of Operations was interviewed and stated he was aware of the staffing challenge within the facility. He added that he had implemented bonus pay for staff willing to cover extra shifts and other strategies for filling the vacancies each week. The Vice President of Operations reported that the facility might have to enlist the help of an agency staffing company. 3. Cross refer to F 354: Based on observations, staff interviews and record review the facility failed to have a fulltime Registered Nurse function as a fulltime Director of Nursing. On 03/30/17 at 10:35 AM the staffing coordinator was interviewed and stated that staffing was hard to maintain and that she used a list to call and beg nurses and nurse aides to fill in vacancies in the weekly schedule. She added that she was aware of instances when the vacancies had not been filled and staff had to work short. The staffing coordinator reported that the Administrator was aware of the staffing shortage. On 03/30/17 at 4:45 PM the Administrator was interviewed and stated she was aware the facility was under staffed. The Administrator explained that she was working to try to hire staff but faced with a serious challenge. The Administrator reported that she had been working with the facility's corporation to ways to encourage more employment. On 03/30/17 at 5:34 PM the Vice President of Operations was interviewed and stated he was aware of the staffing challenge within the facility. He added that he had implemented bonus pay for staff willing to cover extra shifts and other strategies for filling the vacancies each week. The Vice President of Operations reported that the facility might have to enlist the help of an agency staffing company.

Based on observations, staff interviews and record review the facility's Administration failed to manage the care and needs of residents in the building for Resident #s 4, 5, 6, 7, 9 and 2. The findings included: 1. Cross refer to F 224: Based on staff interviews and record review the facility neglected to feed and provide incontinence care for dependent residents for 4 of 7 sampled residents (Resident #4, #5 #6 and #7). On 03/30/17 at 4:45 PM the Administrator was interviewed and stated she was unaware that residents were not fed on 03/26/17 during the evening meal. The Administrator explained additional resources available for staff to use if they ever needed help feeding residents. She stated, the facility had access to her telephone number and that she lived 5 minutes away and would have come in to help feed. The Administrator also stated the facility had department heads that served as Manager on Duty and that person could have been called, the facility also had a corporate oversight and access to a corporate consultant for help. The Administrator reported that she should have been contacted on the evening of 03/26/17 so that arrangements could be made to feed residents. 2. Cross refer to F 241: Based on record review, staff interview and family interview, the facility failed to maintain the dignity of 1 of 2 residents sampled for dignity when staff failed to change Resident #7 timely when family informed staff he was soiled and needed assistance resulting in him being fed by family soiled. 3. Cross refer to F 312: Based on observations, record reviews and resident and staff interviews, the facility failed to provide incontinence care, showers, bed baths and oral care as needed for 1 of 6 residents (Resident #9) sampled for provide activities of daily living. 4. Cross refer to F 323: Based on observations, staff interviews and record review the facility failed to provide adequate supervision for a resident with a history of falls and ensure fall precautions were in place. The resident fell out of bed and was injured. The resident was sent to the Emergency Department diagnosed with [REDACTED].#2). 5. Cross refer to F 353: Based on observations, staff interviews and record review the facility failed to have sufficient quantity of staff to monitor a resident at risk for falls; the resident fell and was injured and the facility failed to have sufficient quantity of staff to ensure dependent residents were fed for 4 of 11 sampled residents (Resident #2, #4, #5, #6). The facility also failed to have sufficient quantity of staff to have a Registered Nurse function fulltime as a Director of Nursing. 6. Cross refer to F 354: Based on observations, staff interviews and record review the facility failed to have a fulltime Registered Nurse function as a fulltime Director of Nursing.

Based on interviews with resident, family, staff, physician assistant and physician, and record review, the facility failed to notify the resident's responsible party, the physician and the physician assistant of a resident's fall in the transportation van which resulted in a laceration at the back of the head for 1 (Resident #96) of 1 sampled resident. Immediate Jeopardy began on 9/22/16 when the physician or the physician assistant was not notified that Resident #96 and his wheelchair fell backwards in the transportation van and the resident sustained [REDACTED]. The immediate jeopardy was removed on 11/2/16 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedure for notification of responsible party and physician of a resident's significant change in condition. Findings included: Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 9/26/16 at 11:28 AM, the resident revealed he fell backwards in the wheelchair while he was being transported from the [MEDICAL TREATMENT] center to the facility via the facility van. The resident stated he landed on the van floor and hit his head. He had a little cut on his head but he was okay. There were three handwritten statements dated 9/22/16 from the maintenance staff who was driving the van at the time of the accident. The three written statements included that the maintenance staff fell as he was pulling the resident from the lift to the van and the resident fell backwards on top of the maintenance staff and hit his head on the chair or the seat behind the driver seat. The maintenance staff asked the resident if he was okay and the resident responded yes. The maintenance staff noticed a cut on the back of the resident's head, with no blood draining. They got back to the facility and got the resident off the van and took him to the DON (director of nursing) and told her what happened. An interview with the Physician Assistant (PA) was conducted on 9/26/16 at 5:30 PM. The PA said that she knew about the laceration today. She said if there was a fall with the resident hitting his head, she expected the facility to assess and do neurochecks. The staff were expected to call and notify her of the fall and about the resident hitting his head. On 9/27/16 at 9:20 AM, the resident's Medical Doctor (MD) was interviewed. The MD said he did not remember if he was notified about the resident's incident that happened last week in the van. He said he expected the staff to call him and let him know if there was head injury. He also expected the staff to assess the resident after a fall and do whatever was needed. On 9/26/16 at 3:55 pm, the resident was interviewed in the presence of the responsible party. The resident repeated the same description of the van incident on 9/22/16. The resident revealed he fell backwards in the wheelchair while he was being transported from the [MEDICAL TREATMENT] center to the facility via the facility van. The resident stated he landed on the van floor and hit his head. He had a little cut on his head but he was okay. The resident's responsible party said the facility called her and told her that the resident had a fall but they never told her exactly what happened. The resident told her what happened. Review of the Progress Note , written by the DON, dated 9/22/16 revealed the resident received a skin assessment and there was a laceration on the back of the head. Neurochecks were initiated and they were within normal limit at this time. Another Progress Note , written by Nurse #2, dated 9/22/16 revealed the resident received treatment to a small laceration to the back of the head. Per-wound area had slight [DIAGNOSES REDACTED]. The note indicated the physician was made aware and the responsible party was called and a message was left on the voice mail to return call. An interview was conducted with the director of nursing (DON) on 9/28/16 at 8:35 AM. When the resident arrived at the facility from [MEDICAL TREATMENT], the maintenance staff brought the resident to the DON and told her what happened. The DON said she notified the Doctor by sending him a phone text message via the phone. The DON stated the MD never received the text and the MD did not know about the accident until 9/27/16. The DON did not follow up with the doctor to make sure he received the text. On 10/27/16 at 4:08 PM, the administrator was notified of the immediate Jeopardy. The administrator provided the following credible allegation of compliance on 10/31/16 at 6:04 PM: A. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Outcome. On 9/22/16, the maintenance worker and housekeeper (floor technician) assisted the resident back in to an upright position in the wheelchair on the van and returned to the facility without an assessment by a qualified medical professional, registered nurse, nurse practitioner, physician assistant, or medical doctor or notifying the facility. On 9/22/16, the maintenance worker immediately returned the resident to the facility and informed the director of nursing (DON). On 9/22/16, the DON immediately assessed the resident. The resident had no complaint of pain and exhibited normal behavior and activity. The resident had a small scratch on the back of his head with two drops of blood. The director of nursing left a voice message for the responsible party to return her call, but did not speak to, the responsible party. The director of nursing sent a text message, but did not speak to the physician. The director of nursing notified the treatment nurse. The director of nursing performed a neuro check without negative findings. The director of nursing gave the neuro-check paperwork to the assistant director of nursing with verbal instructions to continue the neuro-checks through the night. The director of nursing did not notify the physician or the responsible party. The neuro-checks were not performed through the night. On 9/22/16, the treatment nurse immediately initiated a treatment to the back of the resident's head. The treatment nurse left a message for the responsible party. The responsible party returned the treatment nurse's call. The treatment nurse notified the resident's responsible party about the resident's head wound and that an investigation was in progress relating to how the head wound happened. The treatment nurse did not notify the physician. On 9/22/16, the administrator and director of nursing interviewed the resident involved in the incident on the van. The resident gave an account of the events and incident. On 9/26/16 the DON notified the nurse practitioner (NP) of Resident #96's fall with laceration. On 9/26/16, the DON notified the responsible party of what happened during the 9/22/16 accident on the van when the resident fell backwards in his wheelchair causing a laceration (scratch) to the of his head. On 9/27/16, the DON talked to the attending physician regarding Resident #96's fall with laceration. B. How did the facility identify other residents having the potential to be affected by the same deficient practice. On 10/20/16, an audit for the past 30 days of progress notes of 100% of residents was completed by the assistant director of nursing (ADON) to ensure the physician, nurse practitioner, and/or physician assistant has been notified of all falls including falls with injury. On 10/27/16, an audit for the past 30 days of incident reports was completed by the ADON to ensure the responsible party has been notified of change in condition related to incident/accidents. All responsible parties had been notified of significant changes, incidents/accidents. On 10/31/16, an audit for the past 34 days of progress notes was completed by the DON, ADON, staff facilitator, administrator, facility consultant, and corporate clinical director to ensure the physician and/or nurse practitioner and responsible party are notified of significant changes in condition, including falls. C. Give specific dates of the corrective actions. On 9/26/16, the DON notified the responsible party of what happened during the 9/22/16 accident on the van when the resident fell backwards in his wheelchair causing a laceration (scratch) to the of his head. On 9/26/16, the administrator and corporate clinical services director verbally instructed the DON she was not to communicate solely by text messages to the attending physician, nurse practitioner, and/or physician assistant when there is a resident incident/accident requiring physician notification. On 9/27/16, the administrator verified with the attending physician the DON would communicate a resident incident/accident, in addition to text messaging, by an in-person communication and/or phone call to the attending physician, nurse practitioner, and/or physician assistant. On 10/20/16, the DON began in-servicing all registered nurses (RNs) and licensed practical nurses (LPNs) on the importance of notifying the physician and/ or NP of all resident falls, including immediate notification regarding falls with injury. The in-service was completed 10/24/16. After 10/24/16, no RN or LPN was allowed to work until the in-service is completed. All RN and LPN new hires will receive the in-service during new employee orientation. On 10/28/16, the DON, ADON, staff facilitator, administrator, and corporate facility consultant, began in-servicing all RNs and LPNs on the requirement to contact the responsible party (RP) of any resident that has a fall to notify the RP of a change in condition. The in-service was completed 10/28/16 of all RNs and LPNs currently working. The in-services was changed and restarted on 10/31/16. On 10/31/16, the DON, ADON, staff facilitator, administrator, and department heads began in-servicing all staff on the importance of staff informing the nurse and the nurse notifying the physician, physician assistant, and/or nurse practitioner of a resident's change in condition (not just for falls). Also, the nurses must notify the resident's responsible party of a change in the resident's condition with basic information. If the RP has additional questions, the nurse is to inform the DON or administrator for follow-up with the RP. The in-service was completed 11/01/16 of all staff working. After 11/01/16, no staff is allowed to work until the notification in-service is completed. All new hires will receive the notification in-service during new employee orientation. Based on interviews with resident, staff, physician assistant and physician, and record review, the facility failed to notify the physician or the physician assistant of a resident's fall in the transportation van which resulted in a laceration at the back of the head for 1 (Resident #96) of 1 sampled resident. Findings included: Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 9/26/16 at 11:28 AM, the resident revealed he fell backwards in the wheelchair while he was being transported from the [MEDICAL TREATMENT] center to the facility via the facility van. The resident stated he landed on the van floor and hit his head. He had a little cut on his head but he was okay. There were three handwritten statements dated 9/22/16 from the maintenance staff who was driving the van at the time of the accident. The three written statements included that the maintenance staff fell as he was pulling the resident from the lift to the van and the resident fell backwards on top of the maintenance staff and hit his head on the chair or the seat behind the driver seat. The maintenance staff asked the resident if he was okay and the resident responded yes. The maintenance staff noticed a cut on the back of the resident's head, with no blood draining. They got back to the facility and got the resident off the van and took him to the DON (director of nursing) and told her what happened. An interview with the Physician Assistant (PA) was conducted on 9/26/16 at 5:30 PM. The PA said that she knew about the laceration today. She said if there was a fall with the resident hitting his head, she expected the facility to assess and do neurochecks. The staff were expected to call and notify her of the fall and about the resident hitting his head. On 9/27/16 at 9:20 AM, the resident's Medical Doctor (MD) was interviewed. The MD said he did not remember if he was notified about the resident's incident that happened last week in the van. He said he expected the staff to call him and let him know if there was head injury. He also expected the staff to assess the resident after a fall and do whatever needed. An interview was conducted with the director of nursing (DON) on 9/28/16 at 8:35 AM. When the resident arrived at the facility from [MEDICAL TREATMENT], the maintenance staff brought the resident to the DON and told her what happened. The DON said she notified the Doctor by sending him a phone text message via the phone. The DON stated the MD never received the text and the MD did not know about the accident until 9/27/16. The DON did not follow up with the doctor to make sure he received the text. The validation of the credible allegation was completed on 11/02/16 at 5:45 PM by doing the following: Inservice training material was reviewed which included: -Anytime a resident demonstrates a change in condition (changes in emotion, behavior, alertness, eating habit, talking, increased behaviors, sleeping, etc) or any time a resident acts different than normal tell the nurses what you saw/heard. -Nurses (Registered Nurses and Licensed Practical Nurses, not Medication Aides) must assess the resident's condition, document the assessment then notify the physician or nurse practitioner and the responsible party with the concern and assessment findings. If the resident has an incident/accident causing injury, notification must be done in person or via telephone in addition to the communication book. Follow-up until contact is made. -If an emergency call 911. If the responsible party has questions give basic information and let Director of Nursing/Administrator know a follow-up is needed. Inservice records were reviewed with staffing schedules and all staff working in the facility since 11/01/16 had participated in the notification of change inservice training. The Staff Development Coordinator had working plans to inservice licensed staff that had not participated in the inservice prior to their return to work. Staff representing all departments and all shifts were interviewed regarding the inservice training and demonstrated understanding and response in a situation involving a resident and notification of change. Seven medical records of residents with incidents involving falls and pressure ulcer development were reviewed and timely notification had been made to the physician/nurse practitioner and the responsible party. Audits were reviewed and included verification that notification of change had been made to the physician/nurse practitioner and responsible party.

Based on interviews with resident, staff, physician assistant and physician, and record review, the facility failed to get professional staff to assess the resident for possible injury after a fall in the transportation van and before moving and driving the resident to the facility for 1 (Resident #96) of 1 sampled resident with a van accident. Resident #96 sustained a laceration on the back of the head from the fall. The facility also failed to do neurochecks per nursing intervention. Immediate Jeopardy began on 9/22/16 when the facility staff failed to get professional staff to assess Resident #96 for possible injury after a fall in the transportation van and before moving and driving the resident from the [MEDICAL TREATMENT] center to the facility. Resident #96 sustained a laceration to the back of his head. The facility failed to do neurochecks per nursing interventions to monitor the resident for [MEDICAL CONDITION]. The immediate jeopardy was removed on 11/2/16 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedure for assessment and monitoring a resident's significant change in condition. Findings included: Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the facility for wound treatment and rehabilitation for his shoulder with a plan to return home. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/13/16 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 10 (score of 8-12 indicated the resident was cognitively moderately impaired). The resident required assistance of staff in activities of daily living (ADL). The resident was coded for impairment in the range of motion of both upper and lower extremities. The resident was coded as not steady and only able to stabilize with human assistance during transition and walking. Review of the resident's care plan of 9/26/16 revealed the resident was at risk for falls characterized by actual falls with injury. The resident had multiple risk factors related to impaired mobility. The goal was the resident will be free of falls through the next review. The interventions included for the staff to assist during transfer and mobility and provide frequent observation of the resident. During an interview on 9/26/16 at 11:28 AM, the resident revealed he fell backwards in the wheelchair while he was being transported from the [MEDICAL TREATMENT] center to the facility via the facility van. The resident stated he landed on the van floor and hit his head. He had a little cut on his head but he was okay. Review of a written statement by the administrator dated 9/22/16 revealed she interviewed the resident regarding a reported fall. The resident told the administrator he fell straight back hitting his head on a raised area on the van floor. The resident said that the driver pulled to the side of the road and the two men (the maintenance staff and floor technician) picked him up and asked him if he was okay. He told them he was fine and to just take him back to the facility. There were three handwritten statements dated 9/22/16 from the maintenance staff who was driving the van at the time of the accident. The three written statements included that the maintenance staff fell as he was pulling the resident from the lift to the van and the resident fell backwards on top of the maintenance staff and hit his head on the chair or the seat behind the driver seat. The floor technician jumped on the lift and picked up the resident and the wheelchair off of the maintenance staff. The maintenance staff asked the resident if he was okay and the resident responded yes. The maintenance staff noticed a cut on the back of the resident's head, with no blood draining. The floor technician sat next to the resident as they left [MEDICAL TREATMENT]. They got back to the facility and got the resident off the van and took him to the director of nursing (DON) and told her what happened. On 9/26/16 at 1 PM, the Floor technician was interviewed regarding the van accident. The floor technician stated when the resident fell on top of the maintenance staff, he (floor technician) got on the van and lifted the resident wheelchair off the maintenance staff and asked the resident if he was okay. The resident said he was okay. They secured the resident wheelchair in the van and brought him to the facility. On 9/26/16 at 3:14 PM, the maintenance staff was interviewed, in the presence of the administrator, regarding the accident in the van on 9/22/16. He said when the resident fell on him, the resident might have hit his head on the seat or on the seat belt buckle lying on the passenger bench which might have caused the laceration on the resident's head. The maintenance staff said that the floor technician got on the van and got the wheelchair off of him. The maintenance staff said he asked the resident if he was okay, and the resident said yes. The maintenance staff said he tried to call the DON's cell phone. She did not answer and he did not leave a message or try to call someone else. He said he did not think about asking the [MEDICAL TREATMENT] center to assess the resident before driving back to the facility. When asked if he received any training on transporting resident via the van, he said that he never received any training from this facility but he received training from another facility. During the interview, the administrator stated that there was a facility policy against the employees using their personal cell phone while on duty. So the maintenance staff was afraid he would get in trouble if he used his personal phone. The administrator said there was no facility phone on the van at the time of the accident, but a facility phone was available if the driver asked for it. The maintenance staff was interviewed again via telephone on 9/27/16 at 6:38 PM. The maintenance staff said the DON asked him to go pick up the resident from the [MEDICAL TREATMENT] center and bring him to the facility via the facility van. The [MEDICAL TREATMENT] center was about 20 -25 minutes away from the facility. The maintenance staff said we were right in front of the [MEDICAL TREATMENT] center. (The resident) said he was okay (after the resident fell ). I called from my phone (to let the facility know of the accident). (The) Receptionist could not find (the) DON. The Maintenance staff said he drove the van to the facility. The maintenance staff stated he did not think of calling 911 or getting the [MEDICAL TREATMENT] center's professional staff to assess the resident because the resident said he was okay. An interview was conducted with the DON on 9/28/16 at 8:35 AM. When the resident arrived at the facility from [MEDICAL TREATMENT], the maintenance staff brought the resident to the DON and told her what happened. The treatment nurse and the DON did a head to toe assessment. They noticed a scratch on him with no bleeding. There was some blood on the hair and that was how they knew there was a cut. There was no drip down of blood. They initiated neurochecks. They did not do range of motion. Then they used the slide board to put him in bed. The DON said she notified the Doctor by sending him a phone text message on the phone. The DON stated the MD never received the text and the MD did not know about accident until 9/27/16. Interview with the treatment nurse was conducted on 9/27/16 at 5:56 PM. This treatment nurse provided treatment for [REDACTED]. The treatment nurse stated the resident appeared alert and oriented and he answered her questions appropriately. The treatment nurse said the laceration was not bleeding but had some redness. Review of the document titled Neurological Observations revealed neurochecks were initiated on 9/22/16 at 3:30 PM. The neurochecks were scheduled to be done every 30 minutes for 4 hours (from 3:30 PM till 7:30 PM on 9/22/16), every hour for 4 hours (from 8:30 PM till 11:30 PM on 9/22/16), every 4 hours for 24 hours (from 3:30 AM on 9/23/16 till 3:30 AM 9/24/16), every shift starting on the 7:30 AM-3 PM shift on 9/24/16 and ending on the 3 PM-11 PM shift on 9/25/16. The neurochecks were done as scheduled on 9/22/16 at 3:30 PM, 4PM, 4:30 PM, and 5:00 PM and the neurochecks were within normal limits. Neurochecks were not documented as done on 9/22/16 at 5:30 PM, 6:00 PM, 6:30 PM, 7:00 PM, 7:30 PM, 8:30 PM, 9:30 PM, and 10:30 PM. Neurochecks were done as scheduled thereafter and they were within normal limits. The nurse that was on duty when the resident returned from [MEDICAL TREATMENT] (Nurse #5) on 9/22/16 was interviewed on 6:03 PM at 9/27/16. She said nothing was reported to her about the resident accident and the need to do neurochecks. The resident did not tell her about the incident when she went at 4:30 PM to do his accucheck. She did not do neurochecks on her shift (3PM-11 PM on 9/22/16). An interview with the Assistant Director of Nursing (ADON) on 11/2/16 at 2:25 PM revealed We have always used the Neurological Observation Sheet to document neurochecks. We write the resident's name and date on the sheet and implement neurochecks immediately after a fall with a suspected head injury. The ADON provided the following documentation of the frequency of the neurochecks posted at the nurses' station and used in the facility until 10/27/16: Neurological Record Frequency: Every 30 minutes X 4 hours Every 1 hour X 4 hours Every 4 hours X 24 hours Every 8 hours X for remaining 72 hours or as ordered by the MD An interview with the DON on 11/2/16 at 2:37 PM revealed, We have always used the Neurological Observation Sheet to document neuro checks. We used the parameters which were posted at the nurses' station (same as above) and that has been our practice for the five years I have worked at the facility. It was not a policy and not sure the origin of the parameters. Because it was not consistent with the standard of practice in the industry it was reviewed and revised by our medical director after the survey. Now we have new parameters for neurochecks which were put into place on 10/27/16 and include: Every 15 minutes X 1 hour Every 30 minutes X 2 hours Every hour X 4 hours Every 4 hours X 12 hours Then every shift till 72 hours. An interview with the Physician Assistant (PA) was conducted on 9/26/16 at 5:30 PM. The PA said that she knew about the laceration today. She said if there was a fall with the resident hitting his head, she expected the facility to assess and do neurochecks. The staff were expected to call and notify her of the fall and about the resident hitting his head. On 9/27/16 at 9:20 AM, the resident's Medical Doctor (MD) was interviewed. The MD expected the staff to assess the resident after a fall and do whatever needed. They can do neurochecks and monitor for a change in mental status. If the injury was superficial and the resident did not have any loss of consciousness, then it was okay to keep the resident in the facility and monitor for changes. If the resident complained of headache, had symptoms or change in level of consciousness, then they needed to send him to the hospital. The MD was told that the floor technician and the maintenance staff picked up the resident and drove him back to the facility without assessment. The MD said the risk of serious harm to the resident from moving and driving him to the facility without assessment was low because the resident was alert and oriented with no changes in his level of consciousness. The MD said the resident could have intracranial bleeding, whip lash or neck injury/discomfort from the fall. The MD said the resident could have internal injuries without symptoms for a while. On 10/27/16 at 4:08 PM, the administrator was notified of the immediate Jeopardy. The administrator provided the following credible allegation of compliance on 10/31/16 at 6:04 PM: A. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Outcome. On 9/22/16, the maintenance worker and housekeeper (floor technician) assisted the resident back in to an upright position in the wheelchair on the van and returned to the facility without an assessment by a qualified medical professional, registered nurse, nurse practitioner, physician assistant, or medical doctor. On 9/22/16, the maintenance worker immediately returned the resident to the facility and informed the director of nursing. On 9/22/16, the director of nursing immediately assessed the resident. The resident had no complaint of pain and exhibited normal behavior and activity. The resident had a small scratch on the back of his head with two drops of blood. The director of nursing left a message for, but did not speak to, the responsible party. The DON sent a text message to the attending physician. The director of nursing notified the treatment nurse. The director of nursing performed a neurological check assessment without negative findings. The DON gave the neurological check paperwork to the ADON with verbal instructions to continue the neurological checks throughout the night. The DON did not speak to the responsible party. The neurological checks were not performed through the night. There was no policy or standing order established at the time for neurological checks. On 9/22/16, the treatment nurse immediately initiated a treatment to the back of the resident's head in the presence of the DON, after assessing the resident's scalp. The treatment nurse left a message for the responsible party and the responsible party returned the call which was the first notification of the injury to the responsible party since the responsible party had not returned the call to the director of nursing. The treatment nurse did not notify the physician for additional assessment due to the injury presenting more like a scratch to the scalp. On 9/22/16, the administrator and director of nursing interviewed the resident involved in the incident on the van. The resident gave an account of the events and incident. On 9/26/16 the DON notified the nurse practitioner (NP) of Resident #96's fall with laceration. No new orders were received after the NP ' s assessment. On 9/27/16, the DON talked to the attending physician regarding Resident #96's fall with laceration (scratch) to the scalp. No new orders were received after MD assessment. On 9/27/16, the DON also spoke with the responsible party about the incident/accident on the van. As of 9/28/16, Resident #96 has been transported by contracted van services. The contracted van services are trained in safe transfer, safe transport, and safe securement techniques and equipped with a cellular telephone. The drivers know to call 911 if professional staff are not available to assess a resident. B. How did the facility identify other residents having the potential to be affected by the same deficient practice. On 9/28/16 at 1:15 pm, the corporate vice president of operations removed the Lake Park van from Lake Park premises indefinitely. Effective 9/28/16, the residents are transported by contracted services. On 10/27/16, the DON, ADON, administrator, and corporate facility consultant performed a 100% audit of residents with a fall involving a head injury within the past 72 hours to ensure assessment with neuro-checks are being performed and the physician has been notified of the fall. The audit findings reveled two residents neurological checks needed to be restarted. The neurological checks were restarted for the two residents on 10/27/16. C. Give specific dates of the corrective actions. On 10/20/16, the DON, ADON, staff facilitator, administrator, and corporate facility consultant, began in-servicing all RNs, LPNs, medication aides, nursing assistants, housekeepers, maintenance, dietary, administrative, activities, and therapy staff on the requirement to not move the resident after an incident/accident until a complete assessment has been completed by a nurse, nurse practitioner, physician assistant, or medical doctor. If no licensed professional is available, call 911. If the accident/incident happens outside the facility, the patient must still be assessed by a professional and if a licensed professional is not available, call 911. The in-service was completed 10/31/16 of all staff. After 11/1/16, no staff person is allowed to work until the in-service is completed. All new hires will receive the in-service during new employee orientation. On 10/27/16, the DON, ADON, staff facilitator, administrator, and corporate facility consultant, began in-servicing all registered nurses (RNs) and licensed practical nurses (LPNs) on the importance of performing neurological assessments, including a neurological check schedule according to nursing standard of practice, when a resident has an accident/injury involving their head. The in-service was completed 10/28/16 of all RNs and LPNs currently working. After 10/28/16, no RN or LPN is allowed to work until the in-service is completed. All RN and LPN new hires will receive the neuro-check in-service during new employee orientation. On 10/31/16, the DON, ADON, staff facilitator, administrator, and department heads began in-servicing all staff on the importance of staff informing the nurse and the nurse notifying the physician, physician assistant, and/or nurse practitioner of a resident's change in condition (not just for falls). Also, the nurses must assess the resident's condition, document the assessment, then notify the physician or nurse practitioner and resident's responsible party. To ensure proper assessment when a resident has an incident/accident causing injury, physician or nurse practitioner notification must be done in person or via telephone in addition to the communication book, including calling 911. The in-service will be completed 11/01/16 of all staff working. After 11/01/16, no staff is allowed to work until the notification/assessment in-service is completed. All new hires will receive the notification in-service during new employee orientation. The validation of the credible allegation was completed on 11/02/16 at 5:45 PM by doing the following: Inservice training material was reviewed which included: -If a resident has a fall the staff member must immediately notify the licensed staff for assessment to be completed prior to moving the resident. If resident is out of facility with a staff member when fall occurs resident must still be assessed by a professional. If a licensed staff member is not present to assess you should call 911 to assess. Inservice records were reviewed with staffing schedules and all staff working in the facility since 11/01/16 had participated in the inservice training. Staff representing all departments and all shifts were interviewed regarding the inservice training and demonstrated understanding and response in a situation involving assessment of a resident after a fall. Six medical records of residents with incidents involving falls were reviewed and documentation of a physical assessment had been completed by a licensed nurse. Neuro checks were implemented for residents with a suspected injury and completed consistent with parameters implemented by the medical director. Two of the six residents were interviewable and verified a licensed nurse had assessed them after a recent fall. Audits were reviewed and included verification that assessments after a fall had been completed and documented by a licensed nurse.

Based on observation, interviews with resident, family, facility staff, physician assistant and physician, and record review, the facility failed to transport a resident from the dialysis center to the facility in a safe manner with trained staff. The resident fell in the van and sustained a laceration in the back of the head. This is evident in 1 of 2 sampled resident (Resident # 96). Immediate Jeopardy began on 9/22/16 when Resident #96 and his wheelchair fell backwards in the transportation van and the resident sustained [REDACTED]. The immediate jeopardy was removed on 9/29/16 at 3 PM when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedure for residents' transportation to appointments and other activities. Findings included: Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the facility for wound treatment and rehabilitation for his shoulder with a plan to return home. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/13/16 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 10 (score of 8-12 indicated the resident was cognitively moderately impaired). According to the MDS, the resident had no symptoms of delirium and did not have behaviors. The resident required assistance of staff in activities of daily living (ADL). The resident was coded for impairment in the range of motion of both upper and lower extremities. The resident was coded as not steady and only able to stabilize with human assistance during transition and walking. The resident Care Area Assessment (CAA) for falls of 9/19/16 revealed the resident was at risk of falls related to impaired balance and mobility. The CAA indicated the resident had difficulty maintaining sitting balance and had impaired balance during transfer. The risk factors included neuromuscular and functional (impairment), loss of arm or leg movement, incontinence, arthritis, cognitive impairment, infection and pain. Care plan considerations included to minimize risks of falls and to proceed to care plan. Review of the PPS (prospective payment system) 14-day MDS with ARD of 9/20/16 revealed the resident BIMS was 14 (score of 13-15 indicated the resident was cognitively intact). Review of the resident's care plan of 9/26/16 revealed the resident was at risk for falls characterized by actual falls with injury. The resident had multiple risk factors related to impaired mobility. The goal was the resident will be free of falls through the next review. The interventions included for the staff to assist during transfer and mobility and provide frequent observation of the resident. An interview was conducted on 9/29/16 at 1 PM with the social worker who did the assessments of the cognitive pattern of the resident on the MDS of 9/13/16 and 9/20/16. The social worker stated the resident's cognition had improved since admission and that she believed that his assessment of BIMS 14 on the MDS of 9/20/16 was accurate. The resident was alert, oriented and credible. When the resident comes back from dialysis, he is tired and has trouble focusing and concentrating. During an interview on 9/26/16 at 11:28 AM, the resident revealed he had an accident in the van last week. The resident revealed there were two facility staff members on the van during transport. The resident revealed the driver did not know exactly how to tie down the wheelchair in the van, and the driver and the other person with him did not tie down the front wheels of the wheelchair correctly. When the van turned on highway 74, it accelerated to merge into traffic, the wheelchair flipped backwards, and the resident stated he landed on the van floor and hit his head. He had a little cut on his head but he was okay. On 9/26/16 at 3:55 PM, the resident was interviewed again with a family member present. The resident revealed (referring to the van accident on 9/22/16), the van turned on highway 74 and had to accelerate to merge into traffic when the wheelchair tilted backwards and he fell backwards on the van floor. When asked where he thought he hit his head, he said on the curb (a raised area in the back of the van) in the back of the van. The resident said one of the staff was training the other on how to secure the wheelchair and they did not know what they were doing. The family member said the facility never told her what happened but the resident told her that he fell backwards in the van as it accelerated into highway 74 to merge into traffic and the wheelchair tilted backwards and the resident fell on the floor. Review of a written statement by the administrator dated 9/22/16 revealed she interviewed the resident regarding a reported fall. The resident told the administrator he was picked up at the dialysis center by two men. The resident stated on their way back to the facility on highway 74, the van accelerated and the resident fell straight back hitting his head on a raised area on the van floor. The resident said that the driver pulled to the side of the road and the two men picked him up and asked him if he was okay. He told them he was fine and to just take him back to the facility. Review of a written statement by the director of nursing (DON) dated 9/22/16 at 4 PM revealed that both the administrator and the DON interviewed the resident together. The resident said that the accident happened when the van pulled out onto highway 74 and it accelerated and the resident did not. The resident told the administrator and the DON that when the van accelerated, he fell backwards and hit his head on the curved area at the door in the back. The resident noted that one staff member was being trained by the other. Review of an accident report prepared by the DON and dated 9/22/16 revealed the resident's wheelchair tilted backwards while being transported from the van lift to inside the van. Staff caught the resident and returned him to an upright position. The staff reported that the van was stationary at the time. Occipital (the back of the head) laceration was noted to be 0.5 centimeters (cm) by 0 cm. Under the section Incident Description, the resident described that he fell backwards in the wheelchair in the van. The incident report indicated the resident was oriented to person, situation, place and time. The employee reported that the employee slipped and the wheelchair fell backwards on the employee's lap. The report revealed the physician was notified on 9/22/16 at 3:45 PM. There were three handwritten statements dated 9/22/16 from the maintenance staff who was driving the van at the time of the accident. The three written statements contained the following description of the accident of 9/22/16: the maintenance staff was picking the resident up from the dialysis center around 3:00 or 3:15 PM. The floor technician went with him. The van had a side entrance door with the lift. As the maintenance staff was putting the resident on the lift, the maintenance staff started backing into the van and the maintenance staff fell backwards. The resident and the wheelchair came back on top of the maintenance staff. The floor technician jumped on the lift and picked up the resident and the wheelchair off of the maintenance staff. The three written statements included that when the resident fell backward his head hit either the side of the chair in the back of the van, the corner of a chair or the seat behind the driver seat. The maintenance staff asked the resident if he was okay and the resident responded yes. The maintenance staff strapped the back wheels and the floor technician strapped the front wheels of the wheelchair to the floor tie down. The floor technician sat next to the resident as they left dialysis. The maintenance staff noticed a cut on the back of the resident's head, with no blood draining. They got back to the facility and got the resident off the van and took him to the DON (director of nursing) and told her what happened. A typed written statement from the floor technician dated 9/23/16 revealed that, on Thursday, 9/22/16, the resident was being transferred in his wheelchair from the van lift to inside the van. The maintenance staff slipped backwards, and the resident in the wheelchair tilted backwards and landed on top of the maintenance staff. The floor technician helped with bringing the resident back to a sitting position. The resident repeatedly said he was okay. The resident seemed okay except for a small scratch on the back of his head. The resident bumped the back of his head on the back of the driver seat. Then they moved the resident in the wheelchair to the place to be strapped down in the van. The maintenance staff drove straight back to the facility while the floor technician sat next to the resident. The resident talked and seemed okay. The maintenance staff told the director of nursing what happened. On 9/26/16 at 1 PM, the Floor technician was interviewed regarding the van accident and also did a demonstration of how the resident and the wheelchair fell backwards in the van on 9/22/16. The floor technician revealed they were at the dialysis center picking up the resident. The floor technician stated he was on the ground operating the lift. The floor technician demonstrated with a wheelchair and a person sitting in the wheelchair how the maintenance staff placed the resident on the van lift, raised him to the van and walked backwards and parallel to the bench seat (perpendicular to the driver seat), with the wheelchair tilted on the rear two wheels only, to maneuver the wheelchair in the van. The floor technician described how the maintenance staff tripped as he was walking backwards (with the wheelchair on two wheels only) and fell on the floor and the resident with the wheelchair fell on top of him. The floor technician stated he got on the van and lifted the resident's wheelchair off the maintenance staff and asked the resident if he was okay. The resident said he was okay. They secured the resident's wheelchair in the van and brought him to the facility. On 9/26/16 at 3:14 PM, the maintenance staff was interviewed and also did a demonstration of how the resident and the wheelchair fell backwards in the van on 9/22/16. The maintenance staff demonstrated using a wheelchair and a person sitting in the wheelchair. The maintenance staff said he was on the lift with the resident in the wheelchair. He backed the wheelchair into the van perpendicular to the bench seat. He tripped and fell backwards and the wheelchair fell on top of him. The resident might have hit his head on the seat or on the seat belt buckle lying on the passenger bench which might have caused the laceration on the resident's head. The maintenance staff said that the floor technician got on the van and got the wheelchair off of him. The maintenance staff denied tilting the wheelchair back on only two rear wheels to maneuver the wheelchair in the van. The maintenance staff said he asked the resident if he was okay, and the resident said yes. The maintenance staff said he tried to call the DON's cell phone. She did not answer and he did not leave a message or try to call someone else. He said he drove the resident back to the facility. When asked if he received any training on transporting residents via the van, he said that he never received any training from this facility but he received training from another facility. The floor technician joined the demonstration and the interview with the maintenance staff. The floor technician recanted his description of how the maintenance staff tilted the wheelchair on only the two back wheels and agreed with the maintenance staff demonstration and statement. On 9/28/16 at 10:24 AM, the floor technician was interviewed again. The floor technician said he could not see the maintenance staff fall or the resident fall from where he was standing on the ground. When asked why there were discrepancies between his description of what happened (on 9/26/16 at 1 PM), the resident description and the maintenance staff description, he said, what happened is what I am describing now. Then the floor technician proceeded to describe what happened to match the description of the maintenance staff. When asked why he sat beside the resident on the way back, he said I did not want any more accidents. The floor technician said that he was never trained on safe transport of residents by the van, not even after the accident happened. The maintenance staff was interviewed again via telephone on 9/27/16 at 6:38 PM. The maintenance staff said the DON asked him to go pick up the resident from the dialysis center and bring him to the facility via the facility van. The maintenance staff stated he rode along with the previous driver but nobody gave him a skill test to make sure he knew how to transport residents safely in the facility van. The dialysis center was off highway 74. The maintenance staff said when the accident happened, the van was stationary. The dialysis center was about 20 -25 minutes away from the facility. The maintenance staff said we were right in the front of the dialysis center. (The resident) said he was okay (after the resident fell ). I called from my phone (to let the facility know of the accident). (The) Receptionist could not find (the) DON. The Maintenance staff said he drove the van to the facility. When the maintenance staff was told the resident said the accident happened on highway 74, the staff maintenance staff said We were definitely not on 74. An interview with the administrator on 9/27/16 at 8:45 AM was conducted. The administrator said there was no formal training for drivers before they drove the van. The administrator said the maintenance staff and the floor technician were never trained on how to transport residents in the facility's van. There was no policy on how to train staff on what to do with securing the wheelchair in the van. The administrator said that she asked the resident what happened and he told her a different story. She said that the resident told her that he fell backwards in his wheelchair when the van was turning on highway 74 when the driver had to accelerate to merge into traffic. The administrator said that the resident had periods of confusion so she did not believe he was accurately describing what happened. She had no reason to believe that the floor technician or the maintenance staff were not telling the truth. An interview with the administrator 9/27/16 at 10:22 AM revealed the facility had formal training for the van drivers. The administrator provided a transportation safety training test that was taken by the driver that left employment on 9/20/16. During an interview on 9/27/16 at 2:36 PM, the administrator confirmed again that the floor technician and the maintenance staff were not trained on van transportation of wheelchair bound residents. The maintenance staff was an employee of the facility and the floor technician was an employee of a contracted housekeeping company. The resident was transported to dialysis by a contracted transportation company on the morning of 9/22/16. The resident did not have anybody scheduled to pick him up from dialysis, therefore, the maintenance staff was asked to get the resident from dialysis. The floor technician and the maintenance staff never transported any residents of the facility before that date. Observation and demonstration of the van securement system was done on 9/28/16 at 10:10 AM. The floor technician and the maintenance staff were present, as well as the administrator and the corporate staff. The demonstration was done in the facility van. The wheelchair was raised via the lift with a surveyor and the maintenance staff on the lift. The maintenance staff secured the floor straps to the frame on the back of the wheelchair. The floor technician attached the straps to the loop attached to the front wheels instead of the wheelchair frame. When the wheelchair was pushed on from the back, the front wheels slightly raised up from floor. Review of the manufacturer's instructions of the securement system in the facility's van revealed the two front tie down straps should be attached to a solid frame close to the level of the seat. An interview with the Physician Assistant (PA) was conducted on 9/26/16 at 5:30 PM. The PA said that she learned about the van accident and the laceration today. The PA said staff told her today that the accident happened at the dialysis center when the maintenance staff fell and the resident fell on top of the maintenance staff. The PA said that the resident had problems with short term memory. The short term recall was not good. When she was told that the resident repeated the same description of the accident two times with the surveyors and one time with the family, she said I would believe him. On 9/27/16 at 9:20 AM, the resident's Medical Doctor (MD) was interviewed. He was oriented to self and place. When the MD was told that the resident repeated the same description of what happened on the van three separate times, the MD said, he would say the resident was not falsifying the facts. The MD said the resident goal was to go back home. Interview with the MD again on 9/27/16 at 10:15 AM revealed that he talked with the physical therapist and she told him that the resident was more confused when he was first admitted to the facility. He seemed to have improved cognition. On 9/28/16 at 11:16 AM, the physical therapist (PT) was interviewed. She said she was working with the resident on bed mobility and his slide board transfer. The PT saw him five times a week for therapy. The resident followed commands pretty well. He was improving and needing less help. He was oriented but the day he went to dialysis he was tired and lethargic. He was reliable and he can recall. On 9/22/16, the resident was already in the bed and he was lethargic and he did not want to get out of the bed so she worked with him on bed mobility. The PT saw a little blood on the pillow so she asked the resident what happened. The resident told her that the driver did not secure the strap tie down and when the van turned on highway 74, the van accelerated and the wheel chair fell backwards. Review of the PT notes of 9/22/16 revealed the resident stated he fell in the van, when they were coming back from dialysis. The resident told PT that the person who was bringing him back to the facility did not secure the strap and when the van accelerated, the resident fell backwards. Interview with the treatment nurse was conducted on 9/27/16 at 5:56 PM. This treatment nurse provided treatment for [REDACTED]. The resident did tell her that he fell in the van. He said something about falling on highway 74. He appeared alert and oriented. He answered her questions appropriately. The treatment nurse said I would believe him. The laceration was not bleeding but had some redness. On 9/28/16 at 6:55 PM, a nursing assistant (NA # 1) that worked with the resident on the 11PM-7AM shift was interviewed. The NA stated the resident told her the accident happened on the van on the way coming back from dialysis. The NA stated the resident was credible. An interview was conducted with the DON on 9/28/16 at 8:35 AM. When the resident arrived at the facility from dialysis, the maintenance staff brought the resident to the DON and told her what happened. On 9/27/16 on 7:24 PM, the administrator, the DON, the regional vice president and the corporate consultants were interviewed. The DON said that the resident was at dialysis and he needed to be picked up. So she asked the maintenance staff to go in the van and pick the resident up. The administrator said she was made aware of the fall. She instructed the staff to assess the resident right away. She began an investigation and suspended the maintenance staff. Then she took the keys to the van and put it in her office. The van had not been used for transportation since the accident. The administrator said she went to interview the resident and he told her that the accident happened on highway 74. The administrator said she asked the maintenance staff to reenact what happened. This is when the administrator found out that the floor technician was with them when the accident happened. The administrator said that she wanted the van to be taken out of service and get checked out for the functionality of the safety tie down. The next day (9/23/16) the facility management interviewed the floor technician and asked him to do a demonstration of what happened. On 9/27/16 at 7:15 PM, the administrator was notified of the immediate Jeopardy. The administrator provided the following credible allegation of compliance on 9/28/16 at 6:55 PM: How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 9/22/16, the maintenance worker and floor technician assisted the resident back in to an upright position in the wheelchair on the van and returned to the facility. On 9/22/16, the maintenance worker immediately returned the resident to the facility and informed the director of nursing. The maintenance worker submitted a written statement and performed a reenactment prior to leaving on administrative suspension. On 9/22/16, the director of nursing immediately assessed the resident. The resident had no complaint of pain and exhibited normal behavior and activity. The resident had a small scratch on the back of his head with two drops of blood. The director of nursing left a message for the responsible party. The director of nursing notified the treatment nurse. The director of nursing performed a neurocheck without negative findings. On 9/22/16, the treatment nurse immediately initiated a treatment to the back of the resident's head and notified the resident's responsible party. On 9/22/16, the administrator and director of nursing interviewed the resident involved in the incident on the van. The resident gave an account of the events and incident. On 9/22/16, the administrator interviewed the maintenance worker, had the maintenance worker re-enact the event, and obtained a written statement from the maintenance worker. The maintenance worker verified there was no other resident on the van. On 9/22/16, the administrator stopped all facility transports with facility van and secured the van keys. How did the facility identify other residents having the potential to be affected by the same deficient practice. On 9/22/16, the administrator interviewed and verified with the maintenance worker and floor technician there was only the one resident on the 9/22/16 and furthermore they had not previously transported other residents. On 9/22/16, the administrator validated the facility's use of three outside transportation services. In the event the scheduled outside transportation service was unable to provide pick-up or return transportation, other outside transportation services will be contacted. On 9/23/16, the corporate facility consultant and corporate clinical director reviewed the appointment book to identify residents requiring transports 9/23/16 - 9/27/16 and verified transportation from an outside transportation company was scheduled. Appointments had been scheduled with an outside transportation providers. On 9/26/16, the administrator reviewed the appointment book for all currently scheduled appointments and verified transportation will be provided by outside transportation providers. Specific dates of the corrective actions. On 9/22/16, the administrator collected the van keys and stopped all facility transports with facility van. On 9/22/16, the administrator verified there are three transport services used to provide transport services when needed. On 9/27/16, the facility administrator and Corporate Vice President of Operations determined the facility van will remain out of service indefinitely. On 9/28/16 at 1:15 PM, the Corporate Vice President of Operations removed the facility van from facility premises indefinitely. On 9/28/16, the administrator and the outside transportation services added an addendum to each of the three outside transportation service's contracts. The addendum included the outside transportation service had policies in place to ensure safety. In addition, the addendum included that transport staff have been trained in safe transfer, transport and securement while transporting residents in van. The validation of the credible allegation was completed on 9/29/16 at 3 PM by doing the following: Observation and demonstration on 9/27/16 at 12:05 PM were conducted. The resident arrived in the transportation van of a sister facility at 12:05 pm. The driver brought down the lift first and then he shook the wheelchair to demonstrate that it did not move and it was secure. The wheelchair did not move. The driver untied the straps and the resident was pushed to the lift facing the van door. The lift was lowered with the staff on the lift. Then the driver was asked to demonstrate how he secured the wheelchair. The driver put the wheelchair in place, pulled a strap anchored in the floor of the van and put it around the upper back frame of the wheelchair and hooked it back to the floor securement. Then he secured the front wheels to the frame of the wheelchair and tightened the straps and shook the wheelchair to make sure it did not move. On 9/29/16 at 11:55 AM, Resident #96 was observed being unloaded from the van at the facility. The resident was transported from dialysis to the facility. The van had the logo of one of the transportation company the facility contracted. The resident was in the wheelchair and the wheelchair had four point straps to the floor and seat belt across the resident. The driver unhooked the four point securement and then the seat belt and wheeled the resident out of the van backward. Interview with the administrator on 9/29/16 at 2:25 PM revealed she and the director of nursing received inservices about the ensuring the resident environment remains free of accident hazard and that the facility will ensure that staff are trained to perform the task that is asked of them. The facility provided a log of the QI meeting that happened on 9/28/16. The facility provided copies of the contracts of the three transportation company.

Based on staff interviews and review of facility records the nursing home administration delegated a transportation task to the maintenance man who was not trained in van transport at the nursing home to pick up 1:2 sampled residents from [MEDICAL TREATMENT] and return the resident to the nursing home. Resident #96 Immediate Jeopardy began on 9/22/16 when the administrative staff member assigned the maintenance man to transport Resident #96 in the facility van from the [MEDICAL TREATMENT] center back to the facility. The employee had not been trained on safe transporting of a resident. The resident fell in the van and sustained a laceration in the back of his head. The immediate jeopardy was removed on 9/29/16 at 3 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedure for residents' transportation to appointments and other activities. Findings included: Cross refer to F323- Based on observation, interviews with resident, family, staff, physician assistant and physician, and record review, the facility failed to transport a resident in a safe manner with trained staff from the [MEDICAL TREATMENT] center to the facility. The resident fell in the van and sustained a laceration in the back of the head. This is evident in 1 of 2 sampled residents (Resident # 96). During an interview on 9/28/16 at 7:24pm, the administrator, the Director of Nursing (DON), the regional vice president and the corporate consultants were interviewed. The DON said the resident was at [MEDICAL TREATMENT] and he needed to be picked up. So she asked the maintenance staff to go in the van and pick the resident up. The administrator said she was made aware of the fall. She instructed the staff to assess the resident right away. She began an investigation and suspended the maintenance staff. Then she took the keys to the van and put it in her office. The van has not been used for transportation since the accident. The administrator said she asked the maintenance staff to reenact what happened. This is when the administrator found out the floor technician was with the maintenance man when the accident happened. The administrator said that she wanted the van to be taken out of service and get checked out for the functionality of the safety tie downs. The next day (9/23/16) the facility management interviewed the floor technician and asked him to do a demonstration of what happened. The administrator at the time of the survey became employed in that role at the facility on 8/31/16 and the DON began her role on 2/19/16. The administrator was informed of immediate jeopardy on 9/27/16 at 7:15pm. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice? On 9/22/16, the maintenance worker and floor technician assisted the resident back in to an upright position in the wheelchair on the van and returned to the facility. On 9/22/16, the maintenance worker immediately returned the resident to the facility and informed the director of nursing. The maintenance worker submitted a written statement and performed a reenactment prior to leaving on administrative suspension. On 9/22/16, the director of nursing immediately assessed the resident. The resident had no complaint of pain and exhibited normal behavior and activity. The resident had a small scratch on the back of his head with two drops of blood. The director of nursing left a message for the responsible party. The director of nursing notified the treatment nurse. The director of nursing performed a neuro check without negative findings. On 9/22/16, the treatment nurse immediately initiated a treatment to the back of the resident ' s head and notified the resident ' s responsible party/wife. On 9/22/16, the administrator and director of nursing interviewed the resident involved in the incident on the van. The resident gave an account of the events and incident. On 9/22/16, the administrator interviewed the maintenance worker, had the maintenance worker re-enact the event, and obtained a written statement from the maintenance worker. The maintenance worker verified there was no other resident on the van. On 9/22/16, the administrator stopped all facility transports with facility van and secured the van keys. On 9/28/16, the Vice President of Operations in-serviced the Administrator and Director of Nursing regarding administration ' s responsibility to ensure staff are appropriately trained and working within their scope of practice; the administrator and director of nursing must avoid inappropriate delegation of duties. How did the facility identify other residents having the potential to be affected by the same deficient practice? On 9/22/16, the administrator interviewed and verified with the maintenance worker and floor technician there was only the one resident on the 9/22/16 and furthermore they had not previously transported other residents. On 9/22/16, the administrator validated the facility ' s use of three outside transportation services. In the event the scheduled outside transportation service is unable to provide pick-up or return transportation, other outside transportation services will be contacted. On 9/23/16, the corporate facility consultant and corporate clinical director reviewed the appointment book to identify residents requiring transports 9/23/16 - 9/27/16 and verified transportation from an outside transportation company was scheduled. Appointments had been scheduled with an outside transportation providers. On 9/26/16, the administrator reviewed the appointment book for all currently scheduled appointments and verified transportation will be provided by outside transportation providers. On 9/28/16, the Vice President of Operations in-serviced the Administrator and Director of Nursing regarding administration ' s responsibility to ensure staff are appropriately trained and working within their scope of practice; the administrator and director of nursing must avoid inappropriate delegation of duties. Give specific dates of the corrective actions. On 9/22/16, the administrator collected the van keys and stopped all facility transports with facility van. On 9/22/16, the administrator verified there are three transport services used to provide transport services when needed. On 9/27/16, the Lake Park administrator and Corporate Vice President of Operations determined the Lake Park van will remain out of service indefinitely. On 9/28/16 at 1:15 pm, the Corporate Vice President of Operations removed the Lake Park van from Lake Park premises indefinitely. On 9/28/16, the administrator and the outside transportation services added an addendum to each of the three outside transportation service ' s contracts. The addendum includes the outside transportation service has policies in place to ensure safety. In addition, the addendum includes that transport staff have been trained in safe transfer, transport and securement while transporting residents in van. On 9/28/16, the Vice President of Operations in-serviced the Administrator and Director of Nursing regarding administration ' s responsibility to ensure staff are appropriately trained and working within their scope of practice; the administrator and director of nursing must avoid inappropriate delegation of duties. On 9/28/16, the Vice President of Operations, Clinical Director, and Facility Consultant began providing supervision and oversight to the facility ' s administration of the facility to ensure the administration would not assign duties to staff out of the scope of practice. The validation of the credible allegation was completed on 9/29/16 by 3pm An observation and demonstration on 9/27/16 at 12:05PM was conducted. A resident arrived in the transportation van of a sister facility. The driver demonstrated that the wheelchair and the resident was secured properly in the van. On 9/29/16 at 11:55 AM, Resident #96 was observed being unloaded from the van at the facility. The resident was transported from [MEDICAL TREATMENT] to the facility. The van had the logo of one of the transportation company the facility contracted. The resident was in the wheelchair and the wheelchair had four point straps to the floor and seat belt across the resident. The driver unhooked the four point securement and then the seat belt and wheeled the resident out of the van backward. Interview with the administrator on 9/29/16 at 2:25PM revealed she and the DON received in services about the ensuring the resident environment remains free of accident hazard and that the facility will ensure that staff re trained to perform the task that is asked of them. The facility provided a log of the QI (Quality Improvement) meeting that on 9/28/16. The facility provided copies of the contracts of the three transportation companies.

Based on record review and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain compliance with administering the nursing home effectively (F 490); developing and implementing appropriate plans of action to correct identified quality deficiencies (F 520); assessing a resident immediately after an incident involving a head injury (F 309), and; maintaining accurate clinical records (F 514). These four regulations were also cited as deficiencies on 1/15/16 (490 & 514), 2/15/16 (309, 490, 514 & 520) and 3/14/16 (309, 490, 514 & 520). Immediate Jeopardy began on 9/22/16 when administration authorized an employee who was not trained at the facility in van transportation to pick up Resident #96 from [MEDICAL TREATMENT] (F 490 and F 520). The resident's wheelchair fell backwards in the transportation van and the resident sustained [REDACTED]. The immediate jeopardy was removed on 9/29/16 at 3:00 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor (F 520) and fully implement the new procedure for residents' transportation to appointments and other activities (F 490). The scope and severity of examples 3 & 4 is at level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). Findings included: This tag is cross referred to: 1) F 490: Administration During the complaint investigation dated 1/15/16, the recertification survey dated 2/15/16 and the subsequent revisit survey of 3/14/16, the nursing home was cited for failing to create and impose a culture that all residents would be protected from abuse and that staff would implement the facility's abuse policy and procedures to intervene, protect and immediately report abuse when witnessed. A combative resident experienced 2 episodes of physical abuse without immediate facility intervention, protection and implementation of abuse policies and procedures. This was cited at the immediate jeopardy level on two of the three surveys. On the current survey, the nursing home administration delegated a transportation task to an untrained staff member. The individual was assigned to pick up a resident from [MEDICAL TREATMENT] and return the resident to the nursing home. 2) 520 Quality Assurance and Assessment During the recertification survey dated 2/15/16 and the subsequent revisit survey of 3/14/16, the nursing home's Quality Assessment and Assurance (QAA) committee was cited for failing to maintain implemented procedures and monitor the interventions that the committee put into place (F 223, F 226, F 490 & F 514). This was cited at the immediate jeopardy level on one of the two surveys. On the current survey, the facility failed to maintain compliance with F 309, F 490, F 514 and F 520. On 9/27/16 at 7:15 PM, the administrator was notified of the immediate jeopardy related to an incident on the facility van on September 22, 2016. Nursing home administration authorized the transport of the resident (F 490). Lack of effective nursing home administration was cited repeatedly on 2/15/16, 3/14/16 and on the current survey (F 520). The administrator provided the following credible allegation of compliance on 9/28/16 at 6:55 PM: A. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 9/22/16, the maintenance worker and Floor Technician assisted the resident back in to an upright position in the wheelchair on the van and returned to the facility. On 9/22/16, the maintenance worker immediately returned the resident to the facility and informed the director of nursing. The maintenance worker submitted a written statement and performed a reenactment prior to leaving on administrative suspension. On 9/22/16, the director of nursing immediately assessed the resident. The resident had no complaint of pain and exhibited normal behavior and activity. The resident had a small scratch on the back of his head with two drops of blood. The director of nursing left a message for the responsible party. The director of nursing notified the treatment nurse. The director of nursing performed a neuro check without negative findings. On 9/22/16, the treatment nurse immediately initiated a treatment to the back of the resident's head and notified the resident's responsible party/wife. On 9/22/16, the administrator and director of nursing interviewed the resident involved in the incident on the van. The resident gave an account of the events and incident. On 9/22/16, the administrator interviewed the maintenance worker, had the maintenance worker re-enact the event, and obtained a written statement from the maintenance worker. The maintenance worker verified there was no other resident on the van. On 9/22/16, the administrator stopped all facility transports with facility van and secured the van keys. On 9/28/16, the Vice President of Operations in-serviced the Administrator and Director of Nursing regarding administration's responsibility to ensure staff are appropriately trained and working within their scope of practice; the administrator and director of nursing must avoid inappropriate delegation of duties. B. How did the facility identify other residents having the potential to be affected by the same deficient practice? On 9/22/16, the administrator interviewed and verified with the maintenance worker and floor technician there was only the one resident on the 9/22/16 and furthermore they had not previously transported other residents. On 9/22/16, the administrator validated the facility's use of three outside transportation services. In the event the scheduled outside transportation service is unable to provide pick-up or return transportation, other outside transportation services will be contacted. On 9/23/16, the corporate facility consultant and corporate clinical director reviewed the appointment book to identify residents requiring transports 9/23/16 - 9/27/16 and verified transportation from an outside transportation company was scheduled. Appointments had been scheduled with an outside transportation providers. On 9/26/16, the administrator reviewed the appointment book for all currently scheduled appointments and verified transportation will be provided by outside transportation providers. On 9/28/16, the Vice President of Operations in-serviced the Administrator and Director of Nursing regarding administration's responsibility to ensure staff are appropriately trained and working within their scope of practice; the administrator and director of nursing must avoid inappropriate delegation of duties. C. Give specific dates of the corrective actions. On 9/22/16, the administrator collected the van keys and stopped all facility transports with facility van. On 9/22/16, the administrator verified there are three transport services used to provide transport services when needed. On 9/27/16, the Lake Park administrator and Corporate Vice President of Operations determined the Lake Park van will remain out of service indefinitely. On 9/28/16 at 1:15 pm, the Corporate Vice President of Operations removed the Lake Park van from Lake Park premises indefinitely. On 9/28/16, the administrator and the outside transportation services added an addendum to each of the three outside transportation service ' s contracts. The addendum includes the outside transportation service has policies in place to ensure safety. In addition, the addendum includes that transport staff have been trained in safe transfer, transport and securement while transporting residents in van. On 9/28/16, the Vice President of Operations in-serviced the Administrator and Director of Nursing regarding administration's responsibility to ensure staff are appropriately trained and working within their scope of practice; the administrator and director of nursing must avoid inappropriate delegation of duties. On 9/28/16, the facility Executive QI Committee held a meeting. The Medical Director, Administrator, DON, QI nurse, MDS nurse, treatment nurse, staff facilitator, maintenance director, and housekeeping supervisor will attend QI Committee Meetings on an ongoing basis and will assign additional team members as appropriate. On 9/28/16, the regional facility consultant in-serviced the facility administrator, director of nursing, MDS nurse, treatment nurse, dietary manager, and housekeeping supervisor related to the appropriate functioning of the QI Committee and the purpose of the committee to include identify issues related to quality assessment and assurance activities as needed and developing and implementing appropriate plans of action for identified facility concerns, to include F 323 Accidents Hazards Supervision and F 490 Administration. As of 9/28/16, after the facility consultant in-service, the facility QI Committee will begin identifying other areas of quality concern through the QI review process, for example: environment, behavioral management, review of Point Click Care (Electronic Medical Record) orders and activities of daily living, and regional facility consultant recommendations. Corrective action has been taken for the identified concerns related to F 323 Accidents Hazards Supervision and F 490 Administration as reflected in the plan of correction. The Executive QI Committee, including the Medical Director, will review compiled QI report information, review trends, and review corrective actions taken and the dates of completion. The Executive QI Committee will validate the facility's progress in correction of deficient practices or identify concerns. The administrator will be responsible for ensuring Committee concerns are addressed through further training or other interventions. The administrator or his designee will report back to the Executive QI Committee at the next scheduled meeting. D. The alleged IJ removal date is 9/28/16. The validation of the credible allegation was completed on 9/29/16 at 3:00 PM by doing the following: On 9/29/16 at 11:55 AM, Resident #96 was observed being unloaded from the van at the facility. The resident was transported from [MEDICAL TREATMENT] to the facility. The van had the logo of a contracted transportation company. The resident was in the wheelchair and the wheelchair had four point straps to the floor and seat belt across the resident. The driver unhooked the four point securement and then the seat belt and wheeled the resident out of the van backward. Interview with the administrator on 9/29/16 at 2:25 PM revealed she and the Director of Nursing received in-services about ensuring the resident ' s environment remains free of accident hazard and that the facility will ensure that staff are trained to perform the task that is asked of them. The facility provided a log of the QI meeting that happened on 9/28/16. The facility provided copies of the contracts of the three transportation companies. 3) F 309 Acute Assessment During the recertification survey dated 2/15/16 and the subsequent revisit survey of 3/14/16, the nursing home was cited for failing to position a resident in her wheel chair with foot/leg support to prevent a decline in range of motion. On the current survey, the facility failed to get professional staff to assess a resident for possible injury after a fall in the transportation van before moving the resident and driving the resident to the facility. The resident sustained [REDACTED]. The facility also failed to do neuro-checks per nursing intervention. 4) F514: Accurate Records During the recertification survey dated 2/15/16 and the subsequent revisit survey of 3/14/16, the nursing home was cited for failing to transcribe a physician order [REDACTED]. On the current survey, the facility failed to update medication orders in the computerized record even though verbal orders had been received and medications had been discontinued. A medication order for [MEDICATION NAME] for Resident #60 appeared in the computerized record as an active medication even though it had been discontinued. A subsequent assessment and a psychiatric note inaccurately listed [MEDICATION NAME] as an active medication because the current medications were reviewed from the computer. A handwritten telephone order for [MEDICATION NAME] for Resident #28 was not discontinued per order on the medication administration record. An interview was conducted on 9/29/16 at 5:10 PM with the Administrator and Director of Nursing. During the interviews, the Administrator reported the facility's QAA Committee met quarterly. The Administrator said the facility was aware of inaccurate record keeping regarding prior deficiencies and changing a resident's catheter. Corporate oversight was in progress related to medication and treatment administration records. The Administrator had concerns and noted trending with these records. She said the facility looked for patterns and trends and then decided whether to take the problem to QAA. The current Administrator had met with the previous Administrator and verified actions and tracking tools were validated. New areas not identified by the QAA committee were based on survey findings. They were unsure of the reason for duplication of orders in the computer system and handwritten orders. The Administrator said the Pharmacy has to be fully integrated to use the computer software system to produce medication administration records. Corporate oversight was in progress related to medication and treatment administration records. The Administrator stated the facility should have noted the root cause of the van incident because there was no backup plan for transportation. She said you have to know the root cause before can resolve problems.

Based on staff interviews and record review, the facility failed to protect a resident's right to be free from physical abuse with immediate intervention when a resident became combative during nursing care. A resident was physically abused twice when a staff member slapped her on the face and then on the right thigh for 1 of 1 sampled residents reviewed for abuse. (Resident #6). Immediate Jeopardy began on [DATE] when Nurse Aide (NA) #1 slapped a combative resident on the face and again on the right thigh (Resident #6). Each incident of physical abuse occurred on the secure unit and was witnessed by NA #2. NA #2 did not immediately intervene or report to administrative staff that she witnessed physical abuse against Resident #6 and failed to protect this Resident and other residents on the secure unit from further abuse. Resident #6 was assessed with [REDACTED]. The immediate jeopardy is present and ongoing. The findings included: Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #6 was currently being treated and followed by ongoing psychiatric services. Medical record review revealed Resident #6 had physician orders [REDACTED]. A quarterly Minimum (MDS) data set [DATE] assessed Resident #6 with severely impaired cognition, required extensive staff assistance of 2 persons for activities of daily living (ADL) to include mobility, transfers, dressing and toileting, physically and verbally abusive and without impairments in range of motion. A care plan dated [DATE] recorded that Resident #6 had problematic behavior characterized by ineffective coping behaviors of verbal and physical abuse, resistive to treatment/care as evidenced by yelling, cursing, swinging arms and delusional behavior. The care plan's goal specified that staff were to ensure the resident's safety. The care plan's interventions included the following: approach calmly and slowly from the front, respect personal space, provide diversion activity, allow for flexibility in ADL routine to accommodate mood, and when care is refused, leave and return in ,[DATE] minutes. Review of the Resident care guide revealed staff were encouraged to approach Resident #6 in a calm, reassuring manner and if care was refused, to approach the Resident later. A progress note dated [DATE] by the nurse practitioner (NP) revealed Resident #6 was referred by nursing for evaluation of morning agitation and persevering behaviors. Nursing reported that Resident #6 was noted increasingly agitated primarily in the morning. The progress note recorded that Resident #6 was noted by the NP to be very agitated, angry, and confused. Medications were adjusted and staff were to continue to monitor. A Skin Monitoring Review for Resident #6 dated [DATE] did not record any changes or concern with skin integrity. Review of a nursing progress note dated [DATE] at 4:49 PM written by Nurse #1 and the February 2016 Medication Administration Record [REDACTED]. Nurse #1 documented that she administered [MEDICATION NAME] 1 mg by mouth as needed for agitation at 7:40 AM with some positive effects and then [MEDICATION NAME] 2 mg IM as needed for pain at 12:10 PM with slight positive effects. A nursing progress note dated [DATE] at 4:56 PM by Nurse #1 recorded that nursing assistant (NA #1) verbalized she slapped Resident #6 during care when the Resident pulled her hair. The Medical Director was notified and assessed the Resident. Nurse #1 performed a full body assessment for Resident #6 and noted a deep reddened area to the Resident's right upper thigh. A Skin Monitoring Review dated [DATE], completed by Nurse #1, recorded that Resident #6 had redness to her inner thighs and an irregular reddened area, approximately 3 inches long to the front of her upper right thigh. An incident report dated [DATE] at 5:03 PM completed by the Director of Nursing (DON), recorded that NA #1 stated she struck Resident #6 on the leg and afterwards the Resident was noted with red marks across the right thigh. A written statement by NA #1 dated [DATE] recorded that NA #1 struck Resident #6 on her leg on [DATE] around 10:00 AM when Resident #6 become combative and pulled the hair of NA #1. Review of a Health Care Personnel Registry (HCPR) 24 Hour Initial Report dated [DATE] completed by the Administrator, recorded that on [DATE] at 10:00 AM, NA #1 stated she struck Resident #6 on her leg to stop the Resident from pulling her hair. Resident #6 was noted with a red mark on her upper right thigh. Review of the facility's investigation revealed a written statement by the Administrator, dated [DATE], which recorded that she spoke to the Deputy Sheriff on [DATE] around 9:00 PM and was asked if she was aware that NA #2 also witnessed NA #1 slap Resident #6 on [DATE] about 8:00 AM. The written statement recorded that the Administrator was not aware. The Administrator documented that she spoke to NA #2 on [DATE] and was informed that NA #2 witnessed NA #1 slap Resident #6 on the face on [DATE] around 8:00 AM and again on the right thigh above her knee at 10:00 AM, when the Resident became combative. Written statements by NA #2, dated [DATE], recorded that on [DATE] at 7:30 AM, NA #2 witnessed Resident #6 become combative during morning care and NA #1 slapped Resident #6 on the left side of her face. NA #2 witnessed NA #1 leave the Resident's room and make a statement at the nurse's station that she popped Resident #6. Later in the morning around 9:45 AM on [DATE], while in the shower room, NA #2 witnessed Resident #6 grab the hair of NA #1 and NA #1 slapped Resident #6 on the leg. NA #2 then witnessed NA #1 leave the shower room and report the incident to Nurse #1 and Nurse #2. Review of a HCPR 5 Working Day Report dated [DATE], completed by the Administrator, recorded on [DATE] at 10:00 AM, NA #1 immediately reported that she slapped a combative resident on the leg during resident care. The physical abuse was witnessed, NA #1 was immediately suspended, the police was called at 6:00 PM, the allegation of abuse was substantiated and NA #1 was terminated. An interview with NA #2 was conducted on [DATE] at 10:30 AM. NA #2 stated that she received a lot of abuse training recently and knew that if she witnessed abuse she should tell the nurse/supervisor, remove the resident from harm, watch the perpetrator and don't let the perpetrator go into any resident rooms. NA #2 stated that on [DATE] around 7:30 AM Resident #6 would not cooperate with staff and became combative during morning care (kicking, yelling and hitting). NA #2 stated she witnessed Resident #6 hit NA #1 twice, then witnessed NA #1 slap Resident #6 on the left side of her face and said You are going to stop that. NA #2 stated the slap was more than just a pat on the face, but it wasn't a hard slap. NA #2 stated Resident #6 was already upset and remained upset. Both NAs continued getting Resident #6 dressed, placed her in her wheelchair and NA #1 took Resident #6 to the dining room. NA #1 stated that on the way to the dining room, NA #1 stopped at the nurse's station and told Nurse #1 I popped (Resident #6) and Nurse #1 said Ok. NA #2 stated that she found out later that Nurse #1 did not hear NA #1's statement. NA #2 stated she felt that when NA #1 slapped Resident #6 that the incident fit the definition of abuse, but that she didn't know how to separate NA #1 from Resident #6. NA #2 further stated she did not think it would happen again and thought Nurse #1 heard NA #1 report the incident and would take care of it. NA #2 further stated that later that morning around 10:00 AM, both NA #1 and NA #2 were toileting Resident #6 in the shower room when the Resident became combative again. During care, NA #1 bent down to pull up the Resident's pants and Resident #6 grabbed NA #1's hair. That's when NA #1 slapped Resident #6 on her right thigh. NA #2 stated the slap was loud enough to hear, but she didn't know what to do. Resident #6 released her grip on NA #1 hair and they finished pulling up the Resident's pants, transferred her to the wheelchair and NA #2 took Resident #6 to the dining room. NA #2 stated that she observed NA #1 immediately go to the nurse's station and told Nurse #1 and Nurse #2 that she popped Resident #6 on the leg. Nurse #2 immediately left the unit and Nurse #2 and the DON returned to the unit. NA #2 observed NA #1 talk to the DON and then NA #1 was escorted off the unit. NA #2 stated the DON asked her on [DATE] what happened and she told the DON that NA #1 slapped Resident #6 on the left side of her face about 8:00 AM and then on her right thigh about 10:00 AM. NA #2 stated she also informed the police officer on [DATE] when he interviewed her that evening on the phone and the Administrator on [DATE] when she talked to her on the phone. A telephone interview was conducted on [DATE] at 12:55 PM with NA #1. She stated that she worked on the facility's secure unit as her permanent assignment and had recently received abuse training. NA #1 stated she was trained on how to identify abuse and if abuse was witnessed, she should remove the perpetrator from the resident, call law enforcement or the Administrator, and make sure the perpetrator and resident were both watched. NA #1 stated that on, [DATE] Resident #6 slapped her on the face and she responded by gently touching the Resident's face and said Let's don't do that. NA #1 stated I just touched her face with my hand and NA #2 was present. NA #1 stated she went to the nurse's station after providing care to Resident #6 and told Nurse #1 that the Resident was a hand full, but she did not report touching her face because she did not think there was anything to it. NA #1 stated there was no mark left on the Resident's face. NA #1 stated later that morning around 10:00 AM, she and NA #2 were toileting Resident #6 in the shower room and the Resident became combative, worse this time. NA #1 stated that while she was pulling up the Resident's brief, the Resident grabbed her hair, pulling so hard I was up on my tip toes, so I smacked her on the right knee to get her to stop, I said stop and she stopped. NA #1 stated she struck her gently because it was not her nature to hurt anyone. Resident #6 continued yelling and hitting, we got her dressed and took her to the day room. NA #1 stated afterwards, she reported to Nurse #1 and Nurse #2 that she struck Resident #6 on the leg, the DON came and took a statement from her and she was suspended. A telephone interview was conducted on [DATE] at 11:10 AM and a follow up interview was conducted on [DATE] at 3:30 PM with Nurse #1. During the interviews, Nurse #1 stated that on [DATE] there were 14 residents on the secure unit. Around 10:00 or 10:15 AM, NA #1 informed her that while NA #1 and NA #2 provided care to Resident #6 in the shower room, the Resident became combative and grabbed NA #1 by the hair. NA #1 stated she popped Resident #6 to get her to let go. Nurse #1 stated Nurse #2 (supervisor) was also present and heard the conversation. NA #1 stayed at the nurse's station with Nurse #1, while Nurse #2 reported the incident to the DON. The DON came to the unit, took a statement from NA #1 and she was suspended. Nurse #1 stated that NA #1 worked with all residents on the secure unit that day from 7:00 AM until she was suspended around 10:30 AM, but Nurse #1 was not aware of any prior incidents of abuse regarding NA #1. Nurse #1 stated she had not been informed that NA #2 witnessed NA #1 slap Resident #6 on the face earlier that morning. Nurse #1 stated Resident #6 was combative at times, usually required 2 staff to give her care. Nurse #1 stated that staff were trained that when residents became combative, staff should give the resident time to calm down, try to redirect and come back later to provide care. Nurse #1 stated Resident #6 was very combative that day and received [MEDICATION NAME] (as needed) twice on her shift that day for agitation and later for pain. Nurse #1 stated Resident #6 did not cooperate initially with a skin assessment, and [MEDICATION NAME] was given to calm her down. Once Resident #6 was calm, a full body skin assessment was completed, around 12:30 PM and she was noted with a reddened area to her right thigh about 3 inches long and irregular in shape. Nurse #1 stated there were no other changes noted to her skin or face. The Administrator was interviewed on [DATE] at 3:52 PM. She stated that the DON informed her around lunch time on [DATE] that NA #1 popped Resident #6 on the knee in the shower room and reported herself. The DON told the Administrator that NA #1 was suspended and that she had started completing interviews for the investigation. The Administrator called the police around 6:00 PM. The Administrator stated she went to see Resident #6 for the first time that day around 7:00 PM when the police officer arrived. Both she and the police officer observed Resident #6 without any marks to either thigh. The Administrator stated later that evening, around 9:00 PM, the police officer caller her and asked if she knew about another incident of abuse that happened earlier that day, but the Administrator stated she was not aware and she had not looked at the DON's investigation. The Administrator stated she called NA #2 sometime the next morning on [DATE] and obtained a statement from her over the phone regarding both incidents of physical abuse that were witnessed by NA #2 on [DATE] and reported to the DON. The Administrator asked NA #2 to provide written statements about what she saw. Nurse #2 was interviewed on [DATE] at 10:28 AM. Nurse #2 stated she was the Nurse Supervisor on the 7AM - 3 PM shift on [DATE]. Nurse #2 and Nurse #1 were both at the nurse's station on the secure unit on [DATE] around 10:00 AM when NA #1 said I just want everybody to know that I just popped (named Resident). NA #1 proceeded to say that she popped Resident #6 because the Resident pulled her hair. Nurse #2 stated she asked NA #1 to stay at the nurse's station. Nurse #2 went to find the DON and report what occurred. The DON came to the secure unit, obtained a statement from NA #1 and she was suspended. Nurse #2 stated she was not aware of any previous incidents of abuse between NA #1 and Resident #6. Attempts to interview the DON were unsuccessful. The administrator was notified of immediate jeopardy on [DATE] at 5:27 PM.

Based on staff interviews and record review, the staff failed to immediately notify administrative staff of a witnessed incident of physical abuse in which a resident was slapped on the face. Once notified, the facility failed to report the incident of physical abuse to the Health Care Personnel Registry in 24 hours and the investigative findings in 5 working days for 1 of 1 sampled residents. (Resident #6). Immediate Jeopardy began on [DATE] when Nurse Aide (NA) #2 failed to immediately report that she witnessed physical abuse to a combative resident (Resident #6) on the secure unit which resulted in further physical abuse. NA #2 witnessed NA #1 slap Resident #6 on the face, but did not immediately report the abuse or protect the Resident from further abuse. NA #1 remained on the secure unit, working unsupervised and was witnessed again on [DATE], by NA #2, to slap Resident #6 on the right thigh. The facility failed to report physical abuse to the Health Care Personnel Registry within 24 hours and the investigation of the physical abuse within 5 working days. The immediate jeopardy is present and ongoing. The findings included: Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #6 was currently being followed and treated by ongoing psychiatric services. A quarterly Minimum (MDS) data set [DATE] assessed Resident #6 with severely impaired cognition, required extensive staff assistance of 2 persons for activities of daily living (ADL) to include mobility, transfers, dressing and toileting, physically and verbally abusive and without impairments in range of motion. A nursing progress note dated [DATE] at 4:56 PM written by Nurse #1 recorded that nursing assistant (NA #1) verbalized she slapped Resident #6 on her right thigh during care when the Resident pulled her hair. A Skin Monitoring Review dated [DATE], completed by Nurse #1, and an incident report dated [DATE] completed by the Director of Nursing (DON) recorded that Resident #6 had redness to her inner thighs and an irregular reddened area, approximately 3 inches long to the front of her upper right thigh. A written statement by NA #1 dated [DATE] recorded that NA #1 struck Resident #6 on her leg on [DATE] around 10:00 AM when Resident #6 become combative and pulled the hair of NA #1. A Consultation Report dated [DATE], completed by the DON, recorded a concern that NA #2 did not report abuse immediately, remove the employee from an abuse situation and report to another supervisor when the charge nurse was advised of abuse, but did not respond. Review of a Health Care Personnel Registry (HCPR) 24 Hour Initial Report dated [DATE] completed by the Administrator, recorded that on [DATE] at 10:00 AM, NA #1 stated she struck Resident #6 on her leg to stop the Resident from pulling her hair. NA #1 was immediately suspended. The report did not include the physical abuse that occurred on [DATE] at 8:00 AM. Review of the facility's investigation revealed a written statement by the Administrator, dated [DATE], which recorded that she spoke to the Deputy Sheriff on [DATE] around 9:00 PM and was asked if she was aware that NA #2 also witnessed NA #1 slap Resident #6 on the face on [DATE] at about 8:00 AM. The written statement recorded that the Administrator was not aware. The Administrator documented that she spoke to NA #2 on [DATE] and was informed that NA #2 witnessed NA #1 slap Resident #6 on the face on [DATE] around 8:00 AM and again on the right thigh above her knee at 10:00 AM, when the Resident became combative. Written statements by NA #2, dated [DATE], recorded that on [DATE] at 7:30 AM, NA #2 witnessed Resident #6 become combative during morning care and NA #1 slapped Resident #6 on the left side of her face. NA #2 witnessed NA #1 leave the Resident's room and make a statement at the nurse's station that she popped Resident #6. NA #2 stated that she did not report the witnessed physical abuse against Resident #6 because she thought the nursing staff heard NA #1's statement. Later in the morning around 9:45 AM on [DATE], while in the shower room, NA #2 witnessed Resident #6 grab the hair of NA #1 and NA #1 slapped Resident #6 on the leg. NA #2 then witnessed NA #1 leave the shower room and report the incident to Nurse #1 and Nurse #2. NA #2 stated she did not report the witnessed incident of staff to resident physical abuse at this time. Written statements by Nurse #1 dated [DATE] and the Administrator dated [DATE] both recorded that Nurse #1 stated she was not made aware that NA #2 witnessed NA #1 slap Resident #6 on the left side of her face on [DATE] at 8:00 AM. NA #1 did self -report that she popped Resident #6 on the right thigh on [DATE] around 10:00 AM. Review of a HCPR 5 Working Day Report dated [DATE], completed by the Administrator, recorded on [DATE] at 10:00 AM, NA #1 immediately reported that she slapped a combative resident on the leg during resident care. The physical abuse was witnessed, NA #1 was immediately suspended, the police was called at 6:00 PM, the allegation of abuse was substantiated and NA #1 was terminated. The report did not include the witnessed physical abuse that occurred on [DATE] around 8:00 AM. An interview with NA #2 was conducted on [DATE] at 10:30 AM. NA #2 stated that she received a lot of abuse training recently and knew that if she witnessed abuse she should tell the nurse/supervisor, remove the resident from harm, watch the perpetrator and don't let the perpetrator go into any resident rooms. NA #2 stated that on [DATE] around 7:30 AM Resident #6 would not cooperate with staff and became combative during morning care (kicking, yelling and hitting). NA #2 stated she witnessed Resident #6 hit NA #1 twice, then witnessed NA #1 slap Resident #6 on the left side of her face and said You are going to stop that. NA #2 stated the slap was more than just a pat on the face, but it wasn't a hard slap. NA #2 stated Resident #6 was already upset and remained upset. Both NAs continued getting Resident #6 dressed, placed her in her wheelchair and NA #1 took Resident #6 to the dining room. NA #1 stated that on the way to the dining room, NA #1 stopped at the nurse's station and told Nurse #1 I popped (Resident #6) and Nurse #1 said Ok. NA #2 stated that she found out later that Nurse #1 did not hear NA #1's statement. NA #2 stated she felt that when NA #1 slapped Resident #6 that the incident fit the definition of abuse, but that she didn't know how to separate NA #1 from Resident #6. NA #2 further stated she did not think it would happen again and thought Nurse #1 heard NA #1 report the incident and would take care of it. NA #2 further stated that later that morning around 10:00 AM, both NA #1 and NA #2 were toileting Resident #6 in the shower room when the Resident became combative again. During care, NA #1 bent down to pull up the Resident's pants and Resident #6 grabbed NA #1's hair. That's when NA #1 slapped Resident #6 on her right thigh. NA #2 stated the slap was loud enough to hear, but she didn't know what to do. Resident #6 released her grip on NA #1 hair and they finished pulling up the Resident's pants, transferred her to the wheelchair and NA #2 took Resident #6 to the dining room. NA #2 stated that she observed NA #1 immediately go to the nurse's station and told Nurse #1 and Nurse #2 that she popped Resident #6 on the leg. Nurse #2 immediately left the unit and returned to the unit with the DON. NA #2 observed NA #1 talk to the DON and then NA #1 was escorted off the unit. NA #2 stated the DON asked her on [DATE] what happened and she told the DON that NA #1 slapped Resident #6 on the left side of her face about 8:00 AM and then on her right thigh about 10:00 AM. NA #2 stated she also informed the police officer on [DATE] when he interviewed her that evening on the phone and the Administrator on [DATE] when she talked to her on the phone. A telephone interview was conducted on [DATE] at 12:55 PM with NA #1. She stated that she worked on the facility's secure unit as her permanent assignment and had recently received abuse training. NA #1 stated she was trained on how to identify abuse and if abuse was witnessed, she should remove the perpetrator from the resident, call law enforcement or the Administrator, and make sure the perpetrator and resident were both watched. NA #1 stated that on, [DATE] Resident #6 slapped her in the face and she responded by gently touching the Resident's face and said Let's don't do that. NA #1 stated I just touched her face with my hand and NA #2 was present. NA #1 stated she went to the nurse's station after providing care to Resident #6 and told Nurse #1 that the Resident was a hand full, but she did not report touching her face because she did not think there was anything to it. NA #1 stated there was no mark left on the Resident's face. NA #1 stated later that morning around 10:00 AM, she and NA #2 were toileting Resident #6 in the shower room and the Resident became combative, worse this time. NA #1 stated that while she was pulling up the Resident's brief, the Resident grabbed her hair, pulling so hard I was up on my tip toes, so I smacked her on the right knee to get her to stop, I said stop and she stopped. NA #1 stated she struck her gently because it was not her nature to hurt anyone. Resident #6 continued yelling and hitting, we got her dressed and took her to the day room. NA #1 stated afterwards, she reported to Nurse #1 and Nurse #2 that she struck Resident #6 on the leg, the DON came and took a statement from her and she was suspended. A telephone interview was conducted on [DATE] at 11:10 AM and a follow up interview was conducted on [DATE] at 3:30 PM with Nurse #1. During the interviews, Nurse #1 stated that on [DATE] there were 14 residents on the secure unit. Around 10:00 or 10:15 AM, NA #1 informed her that while NA #1 and NA #2 provided care to Resident #6 in the shower room, the Resident became combative and grabbed NA #1 by the hair. NA #1 stated she popped Resident #6 to get her to let go. Nurse #1 stated Nurse #2 (supervisor) was also present and heard the conversation. NA #1 stayed at the nurse's station with Nurse #1, while Nurse #2 reported the incident to the DON. The DON came to the unit, took a statement from NA #1 and she was suspended. Nurse #1 stated that NA #1 worked with all residents on the secure unit that day from 7:00 AM until she was suspended around 10:30 AM, but Nurse #1 was not aware of any prior incidents of abuse regarding NA #1. Nurse #1 stated she had not been informed that NA #2 witnessed NA #1 slap Resident #6 on the face earlier that morning. The Administrator was interviewed on [DATE] at 3:52 PM. She stated that the DON informed her around lunch time on [DATE] that NA #1 popped Resident #6 on the knee in the shower room and reported herself. The DON told the Administrator that NA #1 was suspended and that she had started completing interviews for the investigation. The Administrator continued working in her office and sometime before 4:00 PM she obtained the necessary information from the DON to complete the HCPR 24 Hour Initial Report. The DON left for the day around 4:00 PM, but informed the Administrator before she left that she had obtained all the written statements and interviews. The Administrator did not review the investigation before the DON left because she thought the DON had done everything. The Administrator called law enforcement around 6:00 PM. The Administrator stated she went to see Resident #6 for the first time that day around 7:00 PM when law enforcement arrived. Both she and the law enforcement observed Resident #6 without any marks to either thigh. The Administrator stated later that evening, around 9:00 PM, law enforcement called her and asked if she knew about another incident of abuse that happened earlier that day, but the Administrator stated she was not aware and she had not looked at the DON's investigation. The Administrator stated she called NA #2 sometime the next morning on [DATE] and obtained a statement from her over the phone regarding both incidents of physical abuse that were witnessed by NA #2 on [DATE] and reported to the DON. The Administrator asked NA #2 to provide written statements about what she saw. The Administrator stated she completed/faxed the HCPR 24 Hour Initial Report on [DATE] and the 5 Day Working Report on [DATE], but she did not report the incident of physical abuse that occurred on [DATE] around 8:00 AM because it was included in her investigation. The Administrator further said that now she realized that both incidents of physical abuse should have been reported to the HCPR. Nurse #2 was interviewed on [DATE] at 10:28 AM. Nurse #2 stated she was the Nurse Supervisor on the 7AM - 3PM shift on [DATE]. Nurse #2 and Nurse #1 were both at the nurse's station on the secure unit on [DATE] around 10:00 AM when NA #1 said I just want everybody to know that I just popped (named Resident). NA #1 proceeded to say that she popped Resident #6 because the Resident pulled her hair. Nurse #2 stated she asked NA #1 to stay at the nurse's station. Nurse #2 went to find the DON and report what occurred. The DON came to the secure unit, obtained a statement from NA #1 and she was suspended. Nurse #2 stated she was not aware of any previous incidents of abuse between NA #1 and Resident #6. Attempts to interview the DON were unsuccessful. The administrator was notified of immediate jeopardy on [DATE] at 5:27 PM.

Based on staff interviews and record review, the facility failed to immediately stop nursing care when a resident (Resident #6) became combative to protect the resident and prevent an incident of physical abuse, intervene when physical abuse was observed, and immediately remove the perpetrator from a combative resident on a secure unit. The facility failed to report a witnessed incident of physical abuse to the Health Care Personnel Registry in 24 hours and the investigation in 5 working days. The facility failed to follow their abuse policy and procedures in the areas of prevention, protection, identification, training and reporting of physical abuse for 1 of 1 abuse investigation reviewed. Immediate Jeopardy began on [DATE] when Nurse Aide (NA) #1 slapped Resident #6 on the face when the Resident became combative during nursing care. NA #2 witnessed the physical abuse but did not immediately intervene or report to administrative staff. This resulted in a lack of protection to Resident #6 and other residents which led to a second incident of physical abuse toward Resident #6. NA #2 witnessed NA #1 slap Resident #6 on the face during morning care, but did not immediately report the abuse. NA #1 remained on the secure unit, working unsupervised and several hours later on [DATE], NA #2 witnessed NA #1 slap Resident #6 on the right thigh during the provision of care. The facility failed to report physical abuse to the Health Care Personnel Registry within 24 hours and the investigation of the physical abuse within 5 working days. The immediate jeopardy is present and ongoing The findings included: The facility's policy Abuse, Neglect, or Misappropriation of Resident Property Policy, revised [DATE], included in part: The facility will do whatever is in its control to prevent mistreatment, neglect, and abuse of our residents or misappropriation of their property. Any employee who witnesses or suspects that abuse, neglect, or misappropriation of property has occurred, will immediately report the alleged incident to their supervisor, who will immediately report the incident to the Administrator. Measures will be initiated to prevent any further potential abuse while the investigation is in progress. The Administrator is responsible to review the results of the investigation and report the alleged incident to the appropriate agencies in accordance with State and Federal regulations. The Administrator is responsible to direct the investigation process to ensure that appropriate agencies are notified, as indicated. Training: Training programs may include: Indicators of resident vulnerability to abuse and related interventions. Prevention: The facility will provide supervision to staff to identify inappropriate behaviors, such as rough handling. The facility will assess, care plan, and monitor residents with needs and behaviors that might lead to abuse, neglect, or misappropriation of property. Protection: Employees accused of being directly involved in allegations of abuse, neglect, or misappropriation of property will be suspended immediately from employment pending the outcome of the investigation. Review of the facility's Abuse, Neglect or Misappropriation of Resident Property policy revealed a definition of physical abuse was not included. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #6 was currently being treated and followed by ongoing psychiatric services. Medical record review revealed Resident #6 had physician orders [REDACTED]. A quarterly Minimum (MDS) data set [DATE] assessed Resident #6 with severely impaired cognition, required extensive staff assistance of 2 persons for activities of daily living (ADL) to include mobility, transfers, dressing and toileting, physically and verbally abusive and without impairments in range of motion. A progress note dated [DATE] by the nurse practitioner (NP) revealed Resident #6 was referred by nursing for evaluation of morning agitation and persevering behaviors. Nursing reported that Resident #6 was noted increasingly agitated primarily in the morning. The progress note recorded that Resident #6 was noted by the NP to be very agitated, angry, and confused. Medications were adjusted and staff were to continue to monitor. A Skin Monitoring Review for Resident #6 dated [DATE] did not record any changes or concerns with skin integrity. Review of a nursing progress note dated [DATE] at 4:49 PM by Nurse #1 and the February 2016 Medication Administration Record [REDACTED]. Nurse #1 documented that she administered [MEDICATION NAME] 1 mg by mouth as needed for agitation at 07:40 AM with some positive effects and then [MEDICATION NAME] 2 mg IM as needed for pain at 12:10 PM with slight positive effects. A nursing progress note dated [DATE] at 4:56 PM by Nurse #1 recorded that nursing assistant (NA #1) verbalized she slapped Resident #6 during care when the Resident pulled her hair. The Medical Director was notified and assessed the Resident. Nurse #1 performed a full body assessment for Resident #6 and noted a deep reddened area to the Resident's right upper thigh. A Skin Monitoring Review dated [DATE], completed by Nurse #1, recorded that Resident #6 had redness to her inner thighs and an irregular reddened area, approximately 3 inches long to the front of her upper right thigh. An incident report dated [DATE] at 5:03 PM completed by the Director of Nursing (DON), recorded that NA #1 stated she struck Resident #6 on the leg and afterwards the Resident was noted with red marks on the right thigh. A written statement by NA #1 dated [DATE] recorded that NA #1 struck Resident #6 on her leg on [DATE] around 10:00 AM when Resident #6 become combative and pulled the hair of NA #1. A Disciplinary Warning Notice dated [DATE], completed by the DON and signed by NA #1, recorded that NA #1 was suspended for an inappropriate way of dealing with a resident behavior. A Consultation Report dated [DATE], completed by the DON, recorded a concern that NA #2 did not report abuse immediately, remove the employee from an abuse situation and report to another supervisor when the charge nurse was advised of abuse, but did not respond. Review of a Health Care Personnel Registry (HCPR) 24 Hour Initial Report dated [DATE] completed by the Administrator, recorded that on [DATE] at 10:00 AM, NA #1 stated she struck Resident #6 on her leg to stop the Resident from pulling her hair. Resident #6 was noted with a red mark on her upper right thigh. NA #1 was immediately suspended. The report did not include the incident of physical abuse that occurred on [DATE] at 8:00 AM. Review of the facility's investigation revealed a written statement by the Administrator, dated [DATE], which recorded that she spoke to the law enforcement on [DATE] around 9:00 PM and was asked if she was aware that NA #2 also witnessed NA #1 slap Resident #6 on [DATE] about 8:00 AM. The written statement recorded that the Administrator was not aware. The Administrator documented that she spoke to NA #2 on [DATE] and was informed that NA #2 witnessed NA #1 slap Resident #6 on the face on [DATE] around 8:00 AM and again on the right thigh above her knee at 10:00 AM, when the Resident became combative. Written statements by NA #2, dated [DATE], recorded that on [DATE] at 7:30 AM, NA #2 witnessed Resident #6 become combative during morning care and NA #1 slapped Resident #6 on the left side of her face. NA #2 witnessed NA #1 leave the Resident's room and make a statement at the nurse's station that she popped Resident #6. NA #2 did not report the witnessed physical abuse against Resident #6 because she thought the nursing staff heard NA #1's statement. Later in the morning around 9:45 AM on [DATE], while in the shower room, NA #2 witnessed Resident #6 grab the hair of NA #1 and NA #1 slapped Resident #6 on the leg. NA #2 then witnessed NA #1 leave the shower room and report the incident to Nurse #1 and Nurse #2. Written statements by Nurse #1 dated [DATE] and the Administrator dated [DATE] both recorded that Nurse #1 stated she was not made aware that NA #2 witnessed NA #1 slap Resident #6 on the left side of her face on [DATE] at 8:00 AM. NA #1 did self-report that she popped Resident #6 on the right thigh on [DATE] around 10:00 AM. Review of a HCPR 5 Working Day Report dated [DATE], completed by the Administrator, recorded on [DATE] at 10:00 AM, NA #1 immediately reported that she slapped a combative resident on the leg during resident care and immediately knew what she did was wrong. The physical abuse was witnessed, NA #1 was immediately suspended, law enforcement was called at 6:00 PM, the allegation of abuse was substantiated and NA #1 was terminated. The report did not include the witnessed physical abuse that occurred on [DATE] at 8:00 AM. An interview with NA #2 was conducted on [DATE] at 10:30 AM. NA #2 stated that she received a lot of abuse training recently and knew that if she witnessed abuse she should tell the nurse/supervisor, remove the resident from harm, watch the perpetrator and don't let the perpetrator go into any resident rooms. NA #2 stated that on [DATE] around 7:30 AM Resident #6 would not cooperate with staff and became combative during morning care (kicking, yelling and hitting). NA #2 stated she witnessed Resident #6 hit NA #1 twice, then witnessed NA #1 slap Resident #6 on the left side of her face and said You are going to stop that. NA #2 stated the slap was more than just a pat on the face, but it wasn't a hard slap. NA #2 stated Resident #6 was already upset and remained upset. Both NAs continued getting Resident #6 dressed, placed her in her wheelchair and NA #1 took Resident #6 to the dining room. NA #1 stated that on the way to the dining room, NA #1 stopped at the nurse's station and told Nurse #1 I popped (Resident #6) and Nurse #1 said Ok. NA #2 stated that she found out later that Nurse #1 did not hear NA #1's statement. NA #2 stated she felt that when NA #1 slapped Resident #6 that the incident fit the definition of abuse, but that she didn't know how to separate NA #1 from Resident #6. NA #2 further stated she did not think it would happen again and thought Nurse #1 heard NA #1 report the incident and would take care of it. NA #2 further stated that later that morning around 10:00 AM, both NA #1 and NA #2 were toileting Resident #6 in the shower room when the Resident became combative again. During care, NA #1 bent down to pull up the Resident's pants and Resident #6 grabbed NA #1's hair. That's when NA #1 slapped Resident #6 on her right thigh. NA #2 stated the slap was loud enough to hear, but she didn't know what to do. Resident #6 released her grip on NA #1 hair and they finished pulling up the Resident's pants, transferred her to the wheelchair and NA #2 took Resident #6 to the dining room. NA #2 stated that she observed NA #1 immediately go to the nurse's station and told Nurse #1 and Nurse #2 that she popped Resident #6 on the leg. Nurse #2 immediately left the unit and returned to the unit with the DON. NA #2 observed the DON talk to NA #1 and NA #1 was escorted off the unit. NA #2 stated the DON asked her on [DATE] what happened and she told the DON that NA #1 slapped Resident #6 on the left side of her face about 8:00 AM and then on her right thigh about 10:00 AM. NA #2 stated she also informed law enforcement on [DATE] when he interviewed her that evening on the phone and the Administrator on [DATE] when she talked to her on the phone. A telephone interview was conducted on [DATE] at 12:55 PM with NA #1. She stated that she worked on the facility's secure unit as her permanent assignment and had recently received abuse training. NA #1 stated she was trained on how to identify abuse and if abuse was witnessed, she should remove the perpetrator from the resident, call law enforcement or the Administrator, and make sure the perpetrator and resident were both watched. NA #1 stated that on, [DATE] Resident #6 slapped her on the face and she responded by gently touching the Resident's face and said Let's don't do that. NA #1 stated I just touched her face with my hand and NA #2 was present. NA #1 stated she went to the nurse's station after providing care to Resident #6 and told Nurse #1 that the Resident was a hand full, but she did not report touching her face because she did not think there was anything to it. NA #1 stated there was no mark left on the Resident's face. NA #1 stated later that morning around 10:00 AM, she and NA #2 were toileting Resident #6 in the shower room and the Resident became combative, worse this time. NA #1 stated that while she was pulling up the Resident's brief, the Resident grabbed her hair, pulling so hard I was up on my tip toes, so I smacked her on the right knee to get her to stop, I said stop and she stopped. NA #1 stated she struck her gently because it was not her nature to hurt anyone. Resident #6 continued yelling and hitting, we got her dressed and took her to the day room. NA #1 stated afterwards, she reported to Nurse #1 and Nurse #2 that she struck Resident #6 on the leg, the DON came and took a statement from her and she was suspended. A telephone interview was conducted on [DATE] at 11:10 AM and a follow up interview was conducted on [DATE] at 3:30 PM with Nurse #1. During the interviews, Nurse #1 stated that on [DATE] there were 14 residents on the secure unit. Around 10:00 or 10:15 AM, NA #1 informed her that while NA #1 and NA #2 provided care to Resident #6 in the shower room, the Resident became combative and grabbed NA #1 by the hair. NA #1 stated she popped Resident #6 to get her to let go. Nurse #1 stated Nurse #2 (supervisor) was also present and heard the conversation. NA #1 stayed at the nurse's station with Nurse #1, while Nurse #2 reported the incident to the DON. The DON came to the unit, took a statement from NA #1 and she was suspended. Nurse #1 stated that NA #1 worked with all residents on the secure unit that day from 7:00 AM until she was suspended around 10:30 AM, but Nurse #1 was not aware of any prior incidents of abuse regarding NA #1. Nurse #1 stated she had not been informed that NA #2 witnessed NA #1 slap Resident #6 on the face earlier that morning. Nurse #1 stated Resident #6 was combative at times, usually required 2 staff to give her care. Nurse #1 stated that staff were trained that when residents became combative, staff should give the resident time to calm down, try to redirect and come back later to provide care. Nurse #1 stated Resident #6 was very combative that day and received [MEDICATION NAME] (as needed) twice on her shift that day for agitation and later for pain. Nurse #1 stated Resident #6 did not cooperate initially with a skin assessment, and [MEDICATION NAME] was given to calm her down. Once Resident #6 was calm, a full body skin assessment was completed, around 12:30 PM and she was noted with a reddened area to her right thigh about 3 inches long and irregular in shape. Nurse #1 stated there were no other changes noted to her skin or face. The Administrator was interviewed on [DATE] at 3:52 PM. She stated that the DON informed her around lunch time on [DATE] that NA #1 popped Resident #6 on the knee in the shower room and reported herself. The DON told the Administrator that NA #1 was suspended and that she had started completing interviews for the investigation. The Administrator continued working in her office and sometime before 4:00 PM she obtained the necessary information from the DON to complete the HCPR 24 Hour Initial Report. The DON left for the day around 4:00 PM, but informed the Administrator before she left that she had obtained all the written statements and interviews. The Administrator did not review the investigation before the DON left because she thought the DON had done everything. The Administrator called law enforcement around 6:00 PM. The Administrator stated she went to see Resident #6 for the first time that day around 7:00 PM when law enforcement arrived. Both she and law enforcement observed Resident #6 without any marks to either thigh. The Administrator stated later that evening, around 9:00 PM, law enforcement called her and asked if she knew about another incident of abuse that happened earlier that day, but the Administrator stated she was not aware and she had not looked at the DON's investigation. The Administrator stated she called NA #2 sometime the next morning on [DATE] and obtained a statement from her over the phone regarding both incidents of physical abuse that were witnessed by NA #2 and reported to the DON. The Administrator asked NA #2 to provide written statements about what she saw. The Administrator stated she completed/faxed the HCPR 24 Hour Initial Report on [DATE] and the 5 Day Working Report on [DATE], but she did not complete a separate report for the incident of physical abuse that occurred on [DATE] around 8:00 AM because it was included in her investigation. The Administrator further said that now she realized that both incidents of physical abuse should have been reported to the HCPR. Nurse #2 was interviewed on [DATE] at 10:28 AM. Nurse #2 stated she was the Nurse Supervisor on the 7AM - 3PM shift on [DATE]. Nurse #2 and Nurse #1 were both at the nurse's station on the secure unit on [DATE] around 10:00 AM when NA #1 said I just want everybody to know that I just popped (named Resident). NA #1 proceeded to say that she popped Resident #6 because the Resident pulled her hair. Nurse #2 stated she asked NA #1 to stay at the nurse's station. Nurse #2 went to find the DON and report what occurred. The DON came to the secure unit, obtained a statement from NA #1 and she was suspended. Nurse #2 stated she was not aware of any previous incidents of abuse between NA #1 and Resident #6. Attempts to interview the DON were unsuccessful. The administrator was notified of immediate jeopardy on [DATE] at 5:27 PM

Based on staff interviews and record review, the facility failed to follow the plan of care when a resident became combative during nursing care. Staff failed to immediately stop nursing care when the resident became combative and approach the resident at a later time. This resulted in 2 incidents of physical abuse for 1 of 3 sampled residents reviewed with care plans which addressed problematic behaviors (Resident #6). Immediate Jeopardy began on 02/16/16 when Nurse Aide (NA) #1 slapped a combative resident on the face and again on the right thigh (Resident #6). Each incident of physical abuse occurred on the secure unit and was witnessed by NA #2. NA #2 did not immediately intervene to protect Resident #6 and other residents on the secure unit from physical abuse. Resident #6 was assessed with [REDACTED]. The immediate jeopardy is present and ongoing. The findings included: Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #6 was currently being treated and followed by ongoing psychiatric services. Medical record review revealed Resident #6 had physician orders [REDACTED]. The resident had another physician's orders [REDACTED]. A quarterly Minimum (MDS) data set [DATE] assessed Resident #6 with severely impaired cognition, required extensive staff assistance of 2 persons for activities of daily living (ADL) to include mobility, transfers, dressing and toileting, physically and verbally abusive and without impairments in range of motion. A care plan dated 12/29/15 recorded that Resident #6 had problematic behavior characterized by ineffective coping behaviors of verbal and physical abuse, resistive to treatment/care as evidenced by yelling, cursing, swinging arms and delusional behavior. The care plan's goal specified that staff were to ensure the resident's safety. The care plan's interventions included the following: approach calmly and slowly from the front, respect personal space, provide diversion activity, allow for flexibility in ADL routine to accommodate mood, and when care is refused, leave and return in 5-10 minutes. Review of the Resident care guide revealed staff were encouraged to approach Resident #6 in a calm, reassuring manner and if care was refused, to approach the Resident later. A progress note dated 02/05/16 by the nurse practitioner (NP) revealed Resident #6 was referred by nursing for evaluation of morning agitation and persevering behaviors. Nursing reported that Resident #6 was noted increasingly agitated primarily in the morning. The progress note recorded that Resident #6 was noted by the NP to be very agitated, angry, and confused. Medications were adjusted and staff were to continue to monitor. Review of a nursing progress note dated 02/16/16 at 4:49 PM written by Nurse #1 and the February 2016 Medication Administration Record [REDACTED]. Nurse #1 documented that she administered [MEDICATION NAME] 1 mg by mouth as needed for agitation at 7:40 AM with some positive effects and then [MEDICATION NAME] 2 mg IM as needed for pain at 12:10 PM with slight positive effects. A nursing progress note dated 02/16/16 at 4:56 PM written by Nurse #1 recorded that nursing assistant (NA #1) verbalized she slapped Resident #6 during care when the Resident pulled her hair. The Medical Director was notified and assessed the Resident. Nurse #1 performed a full body assessment for Resident #6 and noted a deep reddened area to the Resident's right upper thigh. An incident report dated 02/16/16 at 5:03 PM completed by the Director of Nursing (DON), recorded that NA #1 stated she struck Resident #6 on the leg and afterwards the Resident was noted with red marks across the right thigh. A written statement by NA #1 dated 02/16/16 recorded that NA #1 struck Resident #6 on her leg on 02/16/16 around 10:00 AM when Resident #6 become combative and pulled her hair. Review of a written statement by the Administrator, dated 02/19/16, documented that she became aware on 02/16/16 around 9:00 PM that NA #2 also witnessed NA #1 slap Resident #6 on the face on 02/16/16 about 8:00 AM. The written statement recorded that the Administrator was not previously aware. The Administrator documented that she spoke to NA #2 on 02/17/16 and was informed that NA #2 witnessed NA #1 slap Resident #6 on the face on 02/16/16 around 8:00 AM and again on the right thigh above her knee at 10:00 AM, when the Resident became combative. Written statements by NA #2, dated 02/17/16, recorded that on 02/16/16 at 7:30 AM, NA #2 witnessed Resident #6 become combative during morning care and struck NA #1 twice. Nursing care continued and Resident #6 continued to be combative. During the care, NA #1 slapped Resident #6 on the left side of her face. Later in the morning around 9:45 AM on 02/16/16, while in the shower room, Resident #6 again became combative and struck NA #1. Nursing care continued and NA #2 witnessed Resident #6 grab the hair of NA #1 and NA #1 slapped Resident #6 on the leg. An interview with NA #2 was conducted on 02/24/16 at 10:30 AM. NA #2 stated that on 02/16/16 around 7:30 AM Resident #6 would not cooperate with staff and became combative during morning care, kicking, yelling and hitting. NA #2 stated she witnessed Resident #6 hit NA #1 twice, then witnessed NA #1 slap Resident #6 on the left side of her face and said You are going to stop that. NA #2 stated Resident #6 was already upset and remained upset. Both NAs continued getting Resident #6 dressed, placed her in her wheelchair and NA #1 took Resident #6 to the dining room. NA #2 stated she felt that when NA #1 slapped Resident #6 that the incident fit the definition of abuse, but that she didn't know how to separate NA #1 from Resident #6. NA #2 further stated she did not think it would happen again. NA #2 further stated that later that morning around 10:00 AM, both NA #1 and NA #2 were toileting Resident #6 in the shower room when the Resident became combative again and struck NA #1. During care, NA #1 bent down to pull up the Resident's pants and Resident #6 grabbed NA #1's hair. That's when NA #1 slapped Resident #6 on her right thigh. NA #2 stated she didn't know what to do. Resident #6 released her grip on NA #1 hair and they finished pulling up the Resident's pants, transferred her to the wheelchair and NA #2 took Resident #6 to the dining room. A telephone interview was conducted on 02/24/16 at 12:55 PM with NA #1. She stated that she worked on the facility's secure unit as her permanent assignment. NA #1 stated that on, 02/16/16 Resident #6 slapped her on the face and she responded by gently touching the Resident's face and said Let's don't do that. NA #1 stated I just touched her face with my hand and NA #2 was present. NA #1 stated she went to the nurse's station after providing care to Resident #6 and told Nurse #1 that the Resident was a hand full. NA #1 stated later that morning around 10:00 AM, she and NA #2 were toileting Resident #6 in the shower room and the Resident became combative, worse this time. NA #1 stated that while she was pulling up the Resident's brief, the Resident grabbed her hair, pulling so hard I was up on my tip toes, so I smacked her on the right knee to get her to stop, I said stop and she stopped. NA #1 stated she struck her gently because it was not her nature to hurt anyone. Resident #6 continued yelling and hitting, we got her dressed and took her to the day room. NA #1 stated she was trained to allow a combative resident time to calm down and come back later, but Resident #6 usually worked well with her. NA #1 stated that Resident #6 liked chocolate milk and this often worked to calm her down, but offering her chocolate milk did not work on 02/16/16. NA #1 confirmed that she did not stop providing nursing care to Resident #6 when the Resident became agitated, as she had been trained, but rather continued and completed the Resident care. NA #1 stated she knew striking Resident #6 was not the right thing to do, but NA #2 was not much help and so striking Resident #6, when she became combative, was just a reaction. A telephone interview was conducted on 02/24/16 at 11:10 AM and a follow up interview was conducted on 02/25/16 at 3:30 PM with Nurse #1. During the interviews, Nurse #1 stated that on 02/16/16 around 10:00 or 10:15 AM, NA #1 informed her that while NA #1 and NA #2 provided care to Resident #6 in the shower room, the Resident became combative and grabbed NA #1 by the hair. NA #1 stated she popped Resident #6 to get her to let go. Nurse #1 stated that NA #1 worked with all residents on the secure unit that day from 7:00 AM until she was suspended around 10:30 AM, but Nurse #1 was not aware of any prior incidents of abuse regarding NA #1. Nurse #1 stated she had not been informed that NA #2 witnessed NA #1 slap Resident #6 on the face earlier that morning. Nurse #1 stated Resident #6 was combative at times, usually required 2 staff to give her care. Nurse #1 stated that staff were trained that when residents became combative, staff should give the resident time to calm down, try to redirect and come back later to provide care. Nurse #1 stated Resident #6 was very combative that day and Nurse #1 heard Resident #6 yelling at staff during care both around 8:00 AM and 10:00 AM. Nurse #1 stated Resident #6 received [MEDICATION NAME] (as needed) twice on her shift that day for agitation and later for pain. Nurse #1 stated she did not assist the NAs with nursing care as it was only reported to her that Resident #6 was a hand full and thought the prn [MEDICATION NAME] Resident #6 received for agitation was effective. The Administrator was interviewed on 02/24/16 at 3:52 PM. The Administrator stated that it was her expectation that staff ensure the safety of combative residents during nursing care and if Resident #6 required the assistance of 2 nursing staff, then depending on whether or not the staff could get to the call bell would determine whether or not staff could call for additional assistance when Resident #6 became combative. The Medical Director was interviewed on 02/25/16 at 3:36 PM. The Medical Director stated he was in the facility on 02/16/16 and was informed that Resident #6 was combative that day, struck a staff member and the staff member was witnessed to strike back. The Medical Director stated that he was very familiar with Resident #6 and knew that at times she was quite combative, resistive to care and would strike out and try to hit at staff. The Medical Director stated he expected nursing staff to immediately stop nursing care if a resident became combative, allow the resident time to calm down, to notify the supervisor for assistance, to continue to monitor and approach later. Attempts to interview the DON were unsuccessful. The administrator was notified of immediate jeopardy on 02/24/16 at 5:27 PM.

Based on staff interviews and review of facility records, the facility administrative staff failed to create and impose a culture that all residents would be protected from abuse and that staff would implement the facility's abuse policy and procedures to intervene, protect and immediately report abuse when witnessed. A combative resident experienced 2 episodes of physical abuse without immediate facility intervention, protection and implementation of abuse policies and procedures for 1 of 1 sampled residents reviewed for abuse (Resident #6). Immediate jeopardy began on 02/16/16 when Nurse Aide (NA) #1 slapped Resident #6 on the face and the witness, NA #2 did not intervene and did not immediately report to administrative staff for protection of Resident #6 and other residents. A second incident of physical abuse occurred on 02/16/16 when NA #1 slapped Resident #6 on the right thigh and the witness, NA #2 did not intervene for the protection of Resident #6. Immediate jeopardy is present and ongoing. The findings included: Cross refer to F 223 - Based on staff interviews and record review, the facility failed to protect a resident's right to be free from physical abuse with immediate intervention when a resident became combative during nursing care. A resident was physically abused twice when a staff member slapped her across the face and then on the right thigh for 1 of 1 sampled residents reviewed for abuse. (Resident #6). Cross refer to F225 - Based on staff interviews and record review, the staff failed to immediately notify administrative staff of a witnessed incident of physical abuse in which a resident was slapped on the face. Once notified, the facility failed to report the incident of physical abuse to the Health Care Personnel Registry in 24 hours and the investigative findings in 5 working days for 1 of 1 sampled residents. (Resident #6). Cross refer to F 226 - Based on staff interviews and record review, the facility failed to immediately stop nursing care when a resident (Resident #6) became combative to prevent an incident of physical abuse, intervene when physical abuse was observed, and immediately remove the perpetrator from a combative resident on a secure unit. The facility failed to report a witnessed incident of physical abuse to the Health Care Personnel Registry in 24 hours and the investigation in 5 working days. The facility failed to follow their abuse policy and procedures in the areas of prevention, protection, identification, training and reporting of physical abuse for 1 of 1 abuse investigation reviewed. During an interview with the Administrator on 02/24/16 at 3:52 PM, she revealed she was informed by the Director of Nursing (DON) on 02/16/16 around lunch time that abuse occurred in the facility on 02/16/16 around 10:00 AM. The Administrator stated that the DON told her that she had begun the investigation, so the Administrator continued working in her office. The Administrator stated that around 4:00 PM, before leaving for the day, the DON came back to the Administrator's office and told her that she had written statements and interviews, but the Administrator did not review the investigation conducted by the DON and assumed the DON had it all together. The Administrator stated that later she realized that the DON had not been thorough in her investigation and that as the captain of the ship it was her responsibility to make sure all parts of the investigation was completed. The Administrator stated that it was her expectation that staff ensure the safety of combative residents during nursing care and if Resident #6 required the assistance of 2 nursing staff, then depending on whether or not the staff could get to the call bell would determine whether or not staff could call for additional assistance when Resident #6 became combative. The Administrator stated she attributed the failure of staff to immediately report abuse and protect a combative resident from further abuse was due to a lack of training that provided staff with the necessary tools to know how to respond to a combative resident and what to do when a combative resident was abused. The Medical Director was interviewed on 02/25/16 at 3:36 PM. The Medical Director stated he was in the facility on 02/16/16 and was informed that Resident #6 was combative that day, struck a staff member and the staff member was witnessed to strike back. The Medical Director stated that he was very familiar with Resident #6 and knew that at times she was quite combative, resistive to care and would strike out and try to hit at staff. The Medical Director stated he was involved in developing the plan of correction when abuse occurred in the facility in January 2016. He stated that staff were re-educated to report abuse immediately, if it occurred or was witnessed. If abuse was reported to administrative staff, the Medical Director stated he expected the facility to follow the abuse protocol for reporting to the proper authorities and continued monitoring to make sure abuse did not continue to occur. The Administrator was informed of immediate jeopardy on 02/24/2016 at 5:27 PM.

Based on staff interviews and review of facility records, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor these interventions that the committee put into place on February 05, 2016. This was for 4 recited deficiencies that were originally cited during a Complaint survey conducted on [DATE] and subsequently recited during a Recertification, Complaint and Follow up Complaint survey conducted on February 25, 2016. The deficiencies were in the areas of a resident's right to be free from abuse, the facility's implementation of abuse policies and procedures, administration and accuracy of the clinical record. Immediate jeopardy began on [DATE] when Nurse Aide (NA) #1 slapped Resident #6 on the face and the witness, NA #2 did not intervene and did not immediately report to administrative staff for protection of Resident #6. A second incident of physical abuse occurred on [DATE] when NA #1 slapped Resident #6 on the right thigh and the witness, NA #2 did not intervene for the protection of Resident #6. Immediate jeopardy is present and ongoing. The findings included: 1a. Cross refer to F 223 - Based on staff interviews and record review, the facility failed to protect a resident's right to be free from physical abuse with immediate intervention when a resident became combative during nursing care. A resident was physically abused twice when a staff member slapped her on the face and then on the right thigh for 1 of 1 sampled residents reviewed for abuse. (Resident #6). During a Complaint survey conducted on [DATE], the facility was cited for failure to protect a resident from sexual abuse. During a Recertification, Complaint and Follow up to Complaint survey conducted on February 25, 2016, the facility was cited for failure to protect a resident from physical abuse. 1b. Cross refer to F 226 - Based on staff interviews and record review, the facility failed to immediately stop nursing care when a resident (Resident #6) became combative to protect the resident and prevent an incident of physical abuse, intervene when physical abuse was observed, and immediately remove the perpetrator from a combative resident on a secure unit. The facility failed to report a witnessed incident of physical abuse to the Health Care Personnel Registry in 24 hours and the investigation in 5 working days. The facility failed to follow their abuse policy and procedures in the areas of prevention, protection, identification, training and reporting of physical abuse for 1 of 1 abuse investigation reviewed. During a Complaint survey conducted on [DATE], the facility was cited for failure to implement their abuse policy/procedures and have a policy that included assessment of a resident after abuse. During a Recertification, Complaint and Follow up to Complaint survey conducted on February 25, 2016, the facility was cited for failure to implement their abuse policy/procedures. 1c. Cross refer to F 490 - Based on staff interviews and review of facility records, the facility administrative staff failed to create and impose a culture that all residents would be protected from abuse and that staff would implement the facility's abuse policy and procedures to intervene, protect and immediately report abuse when witnessed. A combative resident experienced 2 episodes of physical abuse without immediate facility intervention, protection and implementation of abuse policies and procedures for 1 of 1 sampled residents reviewed for abuse (Resident #6). During a Complaint conducted on [DATE] the facility was cited for failure of administration to impose the expectation for implementation of the facility's abuse policy/procedures. During a Recertification, Complaint and Follow up survey of February 25, 2016, the facility was cited for failure of administration to create and impose a culture that protected residents from physical abuse. 1d. Cross refer to F 514 - Based on an observation, staff interviews and review of medical and facility records, the facility failed to transcribe a physician order [REDACTED]. During a Complaint survey conducted on [DATE] the facility was cited for failure to document an incident of sexual abuse in the medical record. During a Recertification, Complaint and Follow up to Complaint survey of February 25, 2016, the facility was cited for failure to transcribe a physician's orders [REDACTED]. During an interview with the Administrator on [DATE] at 4:29 PM and a follow up interview on [DATE] at 7:00 PM, she revealed that the facility's QAA met monthly and quarterly. She stated that the monthly QAA meetings focused on the same agenda each month, and the quarterly QAA meetings' agenda focused on unresolved or new concerns. The Administrator stated that since abuse was cited in [DATE] during a Federal Complaint survey, all department heads were responsible for monitoring for abuse on all shifts. The Administrator stated that staff had no observations of abuse noted or brought for discussion to the morning staff meetings since the [DATE] Federal Complaint survey. The Administrator stated that during these rounds, nursing staff were able to communicate the correct responses when quizzed regarding implementation of the facility's abuse policy/procedures. The Administrator stated that she attributed a repeat deficiency at F 223 to some nursing staff did not know how to respond when a resident became combative during care and that administration needed to provide more interactive in-services. The Administrator stated she attributed a repeat deficiency at F226 to staff not having the right understanding of the abuse policy/procedures or not getting enough information on how to implement the facility's abuse policy and procedures regarding what to report as abuse and when to report abuse. The Administrator also stated that she took responsibility for implementing the facility's abuse policy as it related to reporting abuse to the Health Care Personnel Registry (HCPR), as she did not initially identify the 2 incidents of abuse as 2 separate incidents. The Administrator further stated that she attributed a repeat deficiency at F490 to staff not feeling safe to report abuse, it was administration's responsibility to reassure staff that it was okay to report abuse and that administrative staff should have reported to the HCPR both incidents of abuse once administration became aware. The Administrator stated she attributed a repeat deficiency at F514 to a lack of staff training and a need for re-education on accuracy when documenting the medical record. The Medical Director was interviewed on [DATE] at 3:36 PM and stated he was involved in developing the plan of correction when abuse occurred in the facility in [DATE]. He stated that staff were re-educated to report abuse immediately, if it occurred or was witnessed. If abuse was reported to administrative staff, the Medical Director stated he expected the facility to follow the abuse protocol for reporting to the proper authorities and continued monitoring to make sure abuse did not continue to occur. The Administrator was informed of immediate jeopardy on [DATE] at 5:27 PM.

Based on record review and Physician and staff interviews the facility failed to change an indwelling urinary Foley catheter per physician order [REDACTED]. The findings included: Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #112 was moderately cognitively impaired and had an indwelling urinary catheter. Review of the care plan dated 01/28/16 revealed Resident #112 had an altered pattern of urinary elimination with an indwelling Foley catheter and was at risk for infection. The goal was for Resident #112 to be free from urinary tract infection through the next review. Interventions included catheter care per facility protocol and change Foley catheter per physician orders [REDACTED]. Review of physician order's dated 11/08/15 revealed Resident #112's indwelling urinary Foley catheter was to be changed every 30 days. Review of the treatment records (TAR) for Resident #112 revealed the following: · 11/01/15 through 11/30/15 - change the Foley catheter every 30 days. Documented on TAR as changed on 11/08/15. · 12/01/15 through 12/31/15 - no order to change the Foley catheter every 30 days on TAR. · 01/01/16 through 01/31/16 - no order to change the Foley catheter every 30 days on TAR. · 02/01/16 through 02/25/16 - no order to change the Foley catheter every 30 days on TAR. Review of the nurse's notes from 10/23/15 through 02/25/16 revealed no note that Resident #112's urinary Foley catheter had been changed. Review of the nurse's note dated 01/14/16 at 6:25 AM revealed Nurse #5 deflated the balloon of Resident #112's urinary Foley catheter and retracted the Foley catheter out some due to bleeding around the external urethra. Review of nurse's note dated 01/15/16 at 11:36 PM revealed Resident #112 had an episode of vomiting and an anti-nausea medication was administered. Vital signs were as follows: blood pressure - 140/78, pulse - 54, respirations - 18, temperature - 103 axillary. Nurse's note dated 01/16/16 at 12:20 AM revealed Resident #112 was sent to the emergency room via emergency management system. Review of the hospital discharge summary revealed Resident #112 was admitted to the hospital for [MEDICAL CONDITION] most likely due to catheter associated urinary tract infection from his indwelling Foley catheter. Resident #112 was managed in the intensive care unit [MEDICAL CONDITION] being gradually resolved at discharge back to the facility on [DATE]. An observation made on 02/22/16 at 11:30 AM revealed Resident #112 had an indwelling urinaryfoley catheter draining clear, yellow urine. An interview conducted with Nurse #4 on 02/24/16 at 9:40 AM revealed she did not know when Resident #112's urinary Foley catheter had last been changed. She stated the last documented urinary foley catheter change on the TAR was 11/08/15 and there were no orders on the TAR for 12/2015, 01/2016 and 02/2016 to change the urinary Foley catheter every 30 days. Nurse #5 stated the order to change the urinary Foley catheter every 30 days did not get transcribed to the TAR after 11/2015 so she wouldn't have known it needed to be changed. An interview conducted with Nurse #3 on 02/25/16 at 10:15 AM revealed she normally worked the 3:00 PM to 11:00 PM shift with Resident #112. She reviewed the February 2016 TAR for Resident #112 with the surveyor and confirmed there was no order to change Resident #112's urinary Foley catheter every 30 days. She stated she did not know when Resident #112's urinary Foley catheter had last been changed because it had not been documented on the TAR for February 2016 and stated it should have been written on the TAR what day of the month and what shift Resident #112's urinary Foley catheter was to be changed. Nurse #5 further stated each nurse on the floor was assigned a couple of charts each month to transcribe orders from the previous month to the next month to the TAR and was not sure if anyone checked the orders behind the person that transcribed them. An interview conducted with the facility Physician on 02/25/16 at 1:41 PM revealed he was not aware the urinary Foley catheter order had not been placed on the TAR for 12/2015, 01/2016 and 02/2016. He stated he expected the urinary catheters to be changed every 30 days as ordered. The physician further stated there was always the risk of infection from an indwelling urinary Foley catheter and not changing the catheter as ordered could have caused the infection leading to Resident #112's hospitalization on [DATE]. A phone call was attempted on 02/25/16 at 2:45 PM with Nurse #5 due to her no longer being employed by the facility. A message was left but Nurse #5 did not return surveyors call. During an interview conducted with the Interim Director of Nursing (DON) on 02/25/16 at 3:00 PM she revealed the order to change Resident #112's urinary catheter every 30 days had not been transcribed to the TAR in 12/2015, 01/2016 and 02/2016 and she could not find any documentation in the medical record of the urinary Foley catheter being changed since 11/08/15. The Interim DON further stated she had interviewed nurses that provided care to Resident #112 and none of them recalled changing Resident #112's urinary Foley catheter. The DON stated Resident #112's urinary Foley catheter should have been changed every 30 days and the order to change the catheter should have been documented on the TAR.

Based on record review, staff interviews and police interviews, the facility failed to maintain 1 of 4 sampled residents' right to be free of sexual abuse. (Resident #1). Immediate Jeopardy began on 01/06/16 when Nurse #1 saw a nurse aide place his penis in Resident #1's mouth. Immediate Jeopardy was removed on 01/15/16 at 11:06 AM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring system put into place are effective related to resident rights to be free from abuse. The findings included: Resident #1 was originally admitted to the facility on [DATE] and most recently on 08/07/14. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 with severely impaired cognitive skills (unable to answer any of the questions on the Brief Interview for Mental Status), having no behaviors, and needing extensive assistance with all activities of daily living skills. She weighed 76 pounds. The Care Area Assessment (CAA) for cognition dated 11/19/15 stated she was unable to make her needs known verbally, had confusion, disorientation and forgetfulness. Staff needed to anticipate her needs and provide for her as needed. Nurse #1 was interviewed on 01/13/16 at 7:12 AM. Nurse #1 stated that on 01/06/16 at approximately 3:30 AM to 4:00 AM, she tried to enter Resident #1's room to check her Wanderguard. The door was completely closed and when she tried to open it , the door hit against Resident #1's footboard. When her second attempt to open the door was unsuccessful, she looked into the opening of the doorway, which she stated was open approximately 6 inches open, enough where she could readily see but not fit her head through the doorway. Nurse #1 stated she saw Nurse Aide (NA) #1 standing next to Resident #1's bed, with his right hand holding Resident #1's head, his left hand holding his penis and he was pushing Resident #1's head forward and placing his penis into Resident #1's mouth. Nurse #1 stated she stood there long enough to make sure she saw what she thought she saw and when he placed his penis in Resident #1's mouth a second time, she shut the door without talking to NA #1 and went to another hall to get Nurse #2 to witness the incident. Nurse #1 stated there was a light on in the room which enabled her to see the incident. Resident #2's roommate was behind the pulled curtain. Nurse #2 was interviewed on 01/12/16 at 12:06 PM. Nurse #2 stated she arrived for work at the facility on 01/06/16 at 3:00 AM. Nurse #2 stated she was working at the nursing desk on the 700 hall around 3:30 AM to 3:45 AM and saw Nurse #1 walking down the hall very fast towards her. Nurse #1 stated she needed Nurse #2 to follow her and during the walk to Resident #1's room, Nurse #1 stopped and told Nurse #2 that she had seen Nurse Aide (NA) #1 put his penis in Resident #1's mouth. Nurse #1 and #2 proceeded to Resident #1's room on the 200 hall. The door to Resident #1's room was open and NA #1 was not in the room. Nurse #2 stated she observed Resident #1 was on her back with her mouth open and there was a white liquid, foamy, milkish substance in the resident's mouth. They did not touch Resident #1 and found her to be alert, nonverbal as she always was but no signs of being distraught. NA #1 was not interviewed. An incident report dated 01/06/16 at 4 am revealed an Allegation of staff to resident sexual abuse toward Resident #1, witnessed by Nurse #1 while the resident was in bed. Review of the Nursing Home to Hospital Transfer Form dated 01/06/16, Resident #1 was transferred to the hospital on [DATE] at 7:30 AM per physician order. On 01/13/16 at 10:19 AM, interviews were conducted with two detectives from the sheriff's office. Detective #1 stated the patrol officers were called to the facility and subsequently brought NA #1 to the sheriff's office. Detective #1 stated NA #1 confessed to placing his penis in Resident #1's mouth. Surveyors observed the video taped confession given by NA #1 admitting he placed his penis in Resident #1's mouth. On 01/13/16 at 7:04 PM the Administrator, DON, corporate nurse consultant and the corporate vice president was informed of Immediate Jeopardy. The Administrator provided an acceptable credible allegation of compliance on 01/15/16 at 9:14 AM. Credible allegation of Compliance: F223 On 1/6/16 the accused CNA employee was removed from resident care areas. On 1/6/16, the resident was assessed by the director of nursing (DON). On 1/6/16, the DON notified the resident ' s physician and an order was obtained to send the resident to the ED for further evaluation. On 1/6/16 the DON notified the resident's responsible party (RP). On 1/6/16, the assistant director of nursing (ADON) contacted the police department. On 1/6/16 the accused employee was suspended from employment. On 1/6/16 the accused employee left facility property with the police. On 1/6/16 the DON called report to the hospital. Resident #1 was sent to the emergency room for assessment after an allegation of sexual abuse on 1/6/16 per MD order and has not returned to this facility. On 1/7/16 the alleged employee remains in jail. On 1/7/16 the accused employee was terminated from employment with facility. On 1/6/16, the social worker and admissions coordinator interviewed all alert and oriented residents related to abuse asking the following questions;( Do you feel anyone has intentionally harmed you since you've been at Lake Park? If yes then who harmed you and who did you tell?, Where did it occur?, When did it occur?, Why do you feel you were harmed?, How were you harmed?) resulting in no negative findings. On 1/6/16, the RN supervisors, staff facilitator, and LPNs staff nurses completed 100% body audits of all residents for evidence of abuse with no negative findings. On 1/14/16 the nurse that witnessed the incident received disciplinary action, was drug tested , and the incident was reported to the North Carolina Board of Nursing. On 1/14/16 at 11:30 AM an in-service was completed for all staff including contract staff working today on: · The abuse policy ( Verbal, sexual, mental, or physical abuse, neglect, or mistreatment of [REDACTED]. · Immediately intervene and stop abuse · No employee will be allowed to work until all in-servicing is completed. · New hires will receive all training during orientation prior to taking an assignment. · Nurse #1 and Nurse #2 have completed all above in-services. Immediate jeopardy was removed on 01/15/16 at 11:06 AM when interviews with nursing staff and administrative staff and non-nursing staff confirmed they had received in-service training on the facility's policy to immediately intervene and stop abuse when witnessed, immediately remove the perpetrator from resident care areas and call the police.

Based on record review, staff interviews and police interview, the facility failed to immediately intervene and stop sexual abuse when observed, failed to immediately remove the perpetrator from resident areas, failed to immediately call law enforcement to report a crime and failed to immediately assess the resident for injuries. In addition the abuse policy did not include the resident involved in abuse would be assessed for injuries, when the assessment would occur, who would assess the resident, when the law enforcement would be notified of a crime and by whom. This affected 1 of 4 residents reviewed for abuse. (Resident #1). Immediate Jeopardy began on 01/06/16 when Nurse #1 observed a nurse aide place his penis in Resident #1's mouth, shut the door without intervening while the abuse was occurring, and then Nurse #1 and Nurse #2 allowed the perpetrator to move about the facility unsupervised while they called administration for instructions. Immediate Jeopardy was removed on 01/15/16 at 11:06 AM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated, no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and to ensure monitoring systems put into place are effective related to protecting residents from being abused. The findings included: The facility policy Abuse, Neglect, or Misappropriation of Resident Property Policy, with a revised date of 11/01/06, included in part: *Any employee who witnesses or suspects that abuse, neglect, or misappropriation of property has occurred, will immediately report the alleged incident to their supervisor, who will immediately report the incident to the Administrator; *Measures will be initiated to prevent any further potential abuse while the investigation is in progress; *Protection: Employees accused of being directly involved in allegations of abuse, neglect, or misappropriation of property will be suspended immediately from employment pending the outcome of the investigation. The policy did not include that the resident affected by the abuse would be assessed for injuries, who would assess the resident and when, nor did it include when law enforcement would be notified and by whom. Resident #1 was originally admitted to the facility on [DATE] and most recently on 08/07/14. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 with severely impaired cognitive skills (unable to answer any of the questions on the Brief Interview for Mental Status), having no behaviors, and needing extensive assistance with all activities of daily living skills. She weighed 76 pounds. The Care Area Assessment (CAA) for cognition dated 11/19/15 revealed she was unable to make her needs known verbally, had confusion, disorientation and forgetfulness. Staff needed to anticipate her needs and provide for her as needed. Nurse #1 was interviewed on 01/13/16 at 7:12 AM. Nurse #1 stated that on 01/06/16 at approximately 3:30 AM to 4:00 AM, she tried to enter Resident #1's room to check her Wanderguard. The door was completely closed and when she tried to open it, the door hit against Resident #1's footboard of her bed. When her second attempt to open the door was unsuccessful, she looked into the opening of the doorway, which she stated was approximately 6 inches open, enough where she could readily see into the room but not fit her head through the doorway. Nurse #1 stated she saw Nurse Aide (NA) #1 standing next to Resident #1's bed, with his right hand holding the Resident #1's head, his left hand holding his penis, and he was pushing Resident #1's head forward and placing his penis into Resident #1's mouth. Resident #1 made no movement, her eyes were barely open and she had no reaction. Nurse #1 stated she stood there long enough to make sure she saw what she thought she saw and when he placed his penis in Resident #1's mouth a second time, she shut the door without saying a word to NA #1 and went to another hall to get Nurse #2 to witness the incident. Nurse #1 stated there was a light on in the room which enabled her to see the incident. Nurse #1 could not recall passing any other staff member as she made her way down 200 hall, onto 100 hall and down to the end of 700 hall to find Nurse #2 at the nursing station. Nurse #1 stated on the way back to Resident #1's room, she told Nurse #2 what she saw NA #1 do to Resident #1. She stated she saw NA #1 at the 100 hall kiosk on the way back to Resident #1's room but did not speak to him. When Nurse #1 and Nurse #2 got to Resident #1's room, the resident was in bed, the bed was lowered to the floor and she was covered with linen. The two nurses then went to the 300 hall nursing station and called the Assistant Director of Nursing (ADON). Nurse #1 stated the ADON instructed her to get a drug screen, remove NA #1 from the patient care areas, and escort him out of the building. Then Nurse #1 stated she called the Administrator and explained what happened. The Administrator told her to do a drug screen and escort him out of the building. Nurse #1 stated she used her personal cell phone to make these calls and had gone into the medication room to have privacy. She stated Nurse #2 was with her during both of the phone calls. Nurse #1 checked her cell phone at this time during the interview and reported the call to the ADON was made at 3:57 AM and lasted 1 minute. The call to the Administrator was made at 4:00 AM and lasted 5 minutes. Nurse #1 stated she and Nurse #2 got the drug screen out of the medication room and walked to find NA #1 together. NA #1 was found on the 100 hall. Nurse #2 proceeded to take NA #1 to the bathroom to obtain a urine sample for the drug screen. As Nurse #2 was escorting NA #1 to the time clock, (he clocked out at 4:18 AM per the time card), the Administrator called Nurse #1 and told her to not let NA #1 leave the building. Nurse #1 stated she was taught to stop a perpetrator if she witnessed verbal or physical abuse. When Nurse #1 was asked why she left Resident #1 in the presence of NA #1 when she witnessed sexual abuse, Nurse #1 stated she did not feel Resident #1 was safe but did not stop NA #1 as he did martial arts and was afraid for herself and Resident #1. When asked if she would do anything differently if she had to do it over again, she stated no because she was afraid with NA #1's hand on the resident's head, NA #1 may have easily hurt the resident if she barged into the room since Resident #1 was a frail resident. Nurse #2 was interviewed on 01/12/16 at 12:06 PM. Nurse #2 stated she arrived for work at the facility on 01/06/16 at 3:00 AM. Nurse #2 stated she was working at the nursing station on the 700 hall around 3:30 AM to 3:45 AM and saw Nurse #1 walking down the hall very fast towards her. Nurse #1 stated she needed Nurse #2 to follow her and during the walk to Resident #1's room, Nurse #1 stopped and told Nurse #2 that she had seen NA #1 put his penis in Resident #1's mouth. Nurse #1 and #2 proceeded to Resident #1's room on the 200 hall. The door to Resident #1's room was open and NA #1 was not in the room. Nurse #2 stated she observed Resident #1 in bed, on her back, her mouth was open and there was a white liquid, foamy, milkish substance in the resident's mouth. Nurse #2 told Nurse #1 they had to call someone right then. Nurse #1 made multiple phone calls as Nurse #2 waited at the nurse's desk. Per administrative instructions, she and Nurse #1 obtained a drug test/urine kit, located NA #1 on the 100 hallway, and Nurse #2 walked him to the bathroom so he could give a urine sample. Once he came out of the bathroom, Nurse #2 walked him to the time clock and told him to go home. As Nurse #2 was walking him to the lobby to exit the facility, Nurse #1 came up and told Nurse #2 not to allow NA #1 to leave the premises. Nurse #2 stated they walked NA #1 to the phone where NA #1 spoke to the Administrator on the phone. Nurse #2 stated NA #1 was placed in the lobby where he could be seen until the Administrator arrived. Nurse #2 stated that she and Nurse #1 sat at the 300 hall nursing station where they could watch NA #1 as he waited in the lobby. (The 300 hall nursing station was at the end of 300 hall. The front of the 300 hall started at the lobby.) The administrator arrived at 5:12 AM. During a follow up interview with Nurse #2 on 01/13/16 at 2:19 PM, Nurse #2 stated she did not see NA #1 from the time Nurse #1 approached her at the 700 hall nurse's desk until after Nurse #1 had spoken to the ADON and the Administrator on the phone and she and Nurse #1 located NA #1 on the 100 hall to obtain the drug screen. The Assistant Director of Nursing (ADON) was interviewed on 01/12/16 at 2:57 PM. The ADON stated she was the administrative nurse on call during the 3rd shift of 01/05/16 into 01/06/16. The ADON stated at about 4:00 AM, Nurse #1 called her and stated she saw NA #1 put his penis in Resident #1's mouth. Nurse #1 repeated it again. The ADON stated she instructed Nurse #1 to get NA #1 off the floor, give him a drug test and call the Administrator. The ADON stated she asked no more questions and proceeded to go to the facility. She stated she arrived at the facility around 5:10 AM and the Administrator was already in the facility. The ADON and Nurse #1 stood at Resident #1's doorway, did not touch her and saw Resident #1 was sleeping. The ADON stated she did not talk to NA #1. The ADON stated the DON arrived at the facility around 5:30 AM to 5:45 AM and then together they completed a full head to toe assessment of Resident #1. The ADON stated there were 2 to 3 crumbs on her neck and she had a whitish shimmery substance on her collarbone about the size of a pencil eraser. The ADON stated she called the police around 6:40 AM per the Administrator's direction. The ADON stated she would have expected Nurse #1 to go and get help upon observing the abuse. The ADON stated Nurse #1 was a little woman and she needed help so it was okay to leave NA #1 in the room with the door closed with Resident #1 to obtain assistance from another staff member. On 01/12/16 at 12:33 PM the Administrator was interviewed. The Administrator stated that when Nurse #1 called and told her she had seen NA #1 place his penis in Resident #1's mouth, the Administrator told Nurse #1 to secure the room and treat it as a crime scene. She did not want anyone to touch Resident #1 or take anything out of the room. The Administrator stated she arrived at the facility at 5:12 AM on 01/06/16. NA #1 was in the lobby and opened the front door for her. The Administrator took NA #1 to the conference room to interview him. When confronted with the witness report alleging sexual abuse, NA #1 acted shocked and denied any abuse. She informed NA #1 she needed to investigate and call the police. The Administrator stated she instructed the DON and the ADON to complete a head to toe assessment on Resident #1. After the assessment was completed, the Administrator and the DON interviewed NA #1 who was consistent in his denial of abuse. The Administrator stated she had the ADON notify the police around 6:45 AM. Once the police arrived, the Administrator stated she had no more dealings with NA #1. The Administrator stated she spoke with Nurse #1 who stated she could not open the door all the way and once she saw the abuse, she shut the door and proceeded to find Nurse #2. During this interview, the Administrator was asked her expectations of what Nurse #1 should have done when she saw NA #1 put his penis in Resident #1's mouth. The Administrator stated she was not present when Nurse #1 walked in on NA #1, was not sure what Nurse #1 was thinking when she shut the door and left NA #1 sexually abusing Resident #1, and that she could not say what she expected Nurse #1 to do differently because she immediately got another nurse to help her. The Director of Nursing (DON) was interviewed on 01/12/16 at 3:27 PM. She stated on 01/06/16 between 4:00 AM and 4:10 AM she missed a phone call from the Administrator. The DON stated she immediately called the Administrator back who informed her there was an allegation of abuse and she was instructed to go to the facility as soon as possible. The DON arrived at the facility around 5:40 AM and was told by the Administrator to treat everything like a crime scene. She stated she and the ADON completed a head to toe assessment and found old bruising on Resident #1's right hand from previously hitting her hand on the wheelchair and found an abrasion on her coccyx area. The DON stated Resident #1's face was clean and there was a little spot on her collarbone that was not a bruise and looked a little flaky but she could not say what it was. The DON stated Resident #1 was sleeping before the examination and upon finishing the examination she fell back to sleep. The DON stated she and the Administrator interviewed NA #1 and he stated he was conducting his rounds and noticed Resident #1 had food debris in her mouth and her gown was dirty so he cleaned her mouth and changed her clothes. The DON stated they did not question any details of the story. The DON stated the police showed up around 7:00 AM. After the assessment the DON called the medical director (MD), Resident #1's physician. The MD instructed the DON to send Resident #1 to the emergency department. The DON notified Resident #1's responsible party of the abuse allegation. The DON stated that the ambulance arrived around 7:30 AM to take Resident #1 to the emergency department. The DON stated she called the hospital to give a verbal report and instructed them to do a rape kit. Police officers and a forensic investigator were in the facility when the ambulance took Resident #1 to the hospital. NA #1 was removed from the facility in handcuffs by the police. The DON stated she talked with Nurse #1 who informed her she (Nurse #1) saw NA #1's hand behind the resident's head and he was holding his penis in the resident's mouth. Nurse #1 was scared that something was going to happen to Resident #1 and she went to get help. When the nurses arrived back to the resident's room, NA #1 had already left the room. The DON stated she thought Nurse #1 reacted correctly by leaving Resident #1 in the room with NA #1 while she got help because Resident #1 was very frail and if Nurse #1 startled NA #1 he could have hurt Resident #1. Upon follow up interview with the DON on 01/13/16 at 6:23 PM, she stated the decision to call the police was up to the Administrator. NA #1 was not interviewed. An incident report dated 01/06/16 at 4:00 AM revealed an Allegation of staff to resident sexual abuse toward Resident #1, witnessed by Nurse #1 while the resident was in bed. Review of the Nursing Home to Hospital Transfer Form dated 01/06/16, revealed Resident #1 was transferred to the hospital on [DATE] at 7:30 AM per physician's orders [REDACTED].>On 01/12/16 at 5:31 PM Detective #1 from the sheriff's office was interviewed via phone. He stated the police received a call from the facility on 01/06/16 at 7:04 AM. Detective #1 stated NA #1 was in jail charged with 1 act of crime against nature, second degree sexual offense and sexual act by a custodian. On 01/13/16 at 8:50 AM, the Administrator was interviewed again. She stated she was the Abuse Coordinator and expected staff witnessing abuse to ensure the safety of the resident. She stated that the manner in which the staff ensure the resident's safety depended on the situation and time frame. She further stated that the police would be notified if the facility had reasonable suspicion of a crime. She further stated she was not aware of any policy related to calling the police and it would be determined on an individual basis. Once Resident #1 was assessed and a statement was taken from NA #1 the police was called. Another interview on 01/13/16 at 6:25 PM with the Administrator revealed she did not tell Nurse #1 to call the police when she spoke to her on the phone because she wanted to go to the facility and see what had transpired and be sure Nurse #1 saw what she reported she saw. The Administrator stated she had never called the police before unless she actually suspected a crime had been committed. She stated she did what she always did which was to assess and determine whether the situation warranted the call to the police. The Administrator then stated it was obvious the police needed to be called because of what she saw. When asked what she saw, she said she saw a white crusty something on Resident #1's neck. She further stated her job was to protect the resident, protect evidence and call the police and she secured NA #1 so he was in the building when the police arrived. On 01/13/16 at 10:19 AM, an interview was conducted with two detectives from the sheriff's office. Lieutenant #1 stated the patrol officers were called to the facility and subsequently brought NA #1 to the sheriff's office. Lieutenant #1 stated NA #1 confessed to placing his penis in Resident #1's mouth. Review of a video tape of NA #1's interview by Lieutenant #1 revealed that NA #1 admitted he put his penis in Resident #1's mouth. On 01/13/16 at 3:50 PM, the Corporate Nurse Consultant was interviewed. She stated that she expected staff to report abuse to their supervisor and protect the resident. She stated that Nurse #1 went to obtain help from another nurse when she saw the abuse taking place and that was appropriate as she immediately left to obtain assistance. On 01/13/16 at 7:04 PM the Administrator was informed of Immediate Jeopardy. The Administrator provided an acceptable credible allegation of compliance on 01/15/16 at 9:14 AM. Credible allegation of Compliance; F 226 On 1/6/16 the accused NA employee was removed from resident care areas. On 1/6/16, the resident was assessed by the Director of Nursing (DON). On 1/6/16, the DON notified the resident's physician and an order was obtained to send the resident to the ED (hospital's Emergency Department) for further evaluation. On 1/6/16 the DON notified the resident ' s responsible party (RP). On 1/6/16, the Assistant Director of Nursing (ADON) contacted the police department. On 1/6/16 the accused employee was suspended from employment. On 1/6/16 the accused employee left facility property with the police. On 1/6/16 the DON called report to the hospital. On 1/7/16 the accused employee was terminated from employment with facility Resident #1 was sent to the emergency room for assessment after an allegation of sexual abuse on 1/6/16 per MD order and has not returned to this facility. On 1/7/16 the alleged employee remains in jail. On 1/6/16 the administrator submitted the 24 hour report to DHSR (Division of Health Service Regulation) heath care registry and followed up with the 5 day report submission on 1/8/16. On 1/6/16, the Social Worker and Admissions Coordinator interviewed all alert and oriented residents related to abuse asking the following questions;( Do you feel anyone has intentionally harmed you since you've been at Lake Park? If yes then who harmed you and who did you tell?, Where did it occur?, When did it occur?, Why do you feel you were harmed?, How were you harmed?) resulting in no negative findings. On 1/6/16, the RN supervisors, staff facilitator, and LPN's (Licensed Practical Nurses) staff nurses completed 100% body audits of all residents for evidence of abuse with no negative findings. On 1/6/16, the social worker, MDS nurses, RN nursing supervisor, and LPN staff nurses contacted, by phone or in person, 100% of the responsible parties of residents, to notify that there had been an allegation of sexual abuse from an employee to resident. On 1/6/16, the administrator contacted the ombudsman to notify there had been an allegation of staff to resident sexual abuse. On 1/6/16 the ADON completed a 100% audit to verify current licensing/certification of all licensed nurses and certified nursing assistants are current, all licenses found to be current. On 1/6/16 completed an audit on all current personnel files for pre-hire background checks, reference checks, signed resident abuse policy on orientation at 100 %. On 1/14/16 the nurse that witnessed the incident received disciplinary action, was drug tested , and the incident was reported to the North Carolina Board of Nursing. On 1/14/16 the nurse on call at time of allegation, (assistant director of nursing) received drug testing and disciplinary action for failure to direct nurse #1 to call the police and keep alleged employee supervised, and failing to assess resident immediately after she entered the building. On 1/14/16 at 11:30 AM an in-service was completed for all staff including contract staff working today by the director of nursing and assistant director of nursing on: · The abuse policy (Verbal, sexual, mental, or physical abuse, neglect, or mistreatment of [REDACTED]. It is every employee's responsibility to immediately report any incident of resident abuse or suspected abuse to his or her supervisor. The supervisor and/or employee must report immediately to the administrator. If the immediate supervisor is the alleged perpetrator, the report is to be made to the administrator or director of nursing. Any employee who fails to immediately report suspected mistreatment, abuse including injuries. · On 1/14/16 all staff including contract staff working were in-serviced on the elder abuse act policy and how to report to the local law enforcement related to the elder justice act including the following; If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately to law enforcement, but not later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Staff must report the suspicion of an incident to their supervisor, who will report the incident to the administrator. · On 1/14/16 all staff including contract staff working were trained that any staff member can call local law enforcement with any type of observed abuse · Immediately intervene and stop abuse · Immediate removal of the employee or perpetrator, immediate notification to the Administrator, DON, and law enforcement. · The employee or perpetrator must remain supervised 1:1 until the Administrator, DON, or law enforcement arrives. · On 1/14/16 the ADON, DON, and Administrator were in-serviced on enforcing the policies of protection, identification and reporting abuse, the elder abuse act, and notification by the corporate vice president of operations related to the elder justice act including the following; If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately to law enforcement, but not later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Staff must report the suspicion of an incident to their supervisor, who will report the incident to the administrator · On 1/14/16 an in-service was completed that when there is an allegation of abuse the resident involved and roommate are to be assessed immediately for injury and the resident involved in allegation is to be immediately sent to hospital emergency department for further evaluation and treatment. · On 1/14/16 an in-service related to action check list for allegation of abuse neglect was completed for all licensed staff. The action check list includes the following: 1. Remove involved employee. 2. Notify Administrator and/or DON immediately. Document notification in chart 3. Assess resident. Document assessment in chart. 4. Notify attending MD. Document notification in chart. 5. Implement MD orders as indicated. 6. Notify resident representative. Document notification in chart. 7. Obtain employee witness statement of incident. 8. Drug test employee per personnel policy as applicable or as instructed by administrator or DON. 9. Punch out employee. 10. Implement corrective measures to protect resident. 11. Completion of resident QUI reporting form. 12. Continue to monitor resident. · No employee will be allowed to work until all in-servicing is completed. · New hires will receive all training during orientation prior to taking an assignment. · Nurse #1 and Nurse #2 have completed all above in-services. Immediate jeopardy was removed on 01/15/16 at 11:06 AM when interviews with nursing staff and administrative staff and non-nursing staff confirmed they had received inservice training on the facility's policy to immediately intervene and stop abuse when witnessed, immediately remove the perpetrator from resident care areas and call the police.

Based on record review, staff interviews and police interviews, the administration failed to impose expectations related to immediately intervening when sexual abuse is witnessed, failed to impose expectations related to immediately removing a perpetrator from resident care areas, failed to impose expectations related to immediately calling law enforcement when a crime is witnessed, failed to empower staff to make the call to law enforcement when a crime is witnessed or when staff have knowledge of such crime, failed to recognize that a nurse that witnessed a crime to a resident reacted in a manner that was not in the best interest of all the residents. Immediate Jeopardy began on 01/06/16 when Nurse #1 failed to intervene when she witnessed a sexual abuse incident, failed to immediately call law enforcement, and when she called administrative staff, administrative staff failed to provide her the direction to call law enforcement immediately. Immediate Jeopardy was removed on 01/15/16 at 11:06 AM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated, no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and to ensure monitoring systems put into place are effective related to protecting residents from being abused. The finding included: Cross refer to F 223: Based on record review, staff interviews and police interviews, the facility failed to maintain 1 of 4 sampled residents' right to be free of sexual abuse. (Resident #1). Cross refer to F 226: Based on record review, staff interviews and police interview, the facility failed to immediately intervene and stop sexual abuse when observed, failed to immediately remove the perpetrator from resident areas, failed to immediately call law enforcement to report a crime and failed to immediately assess the resident for injuries. In addition the abuse policy did not include the resident involved in abuse would be assessed for injuries, when the assessment would occur, who would assess the resident, when the law enforcement would be notified of a crime and by whom. This affected 1 of 4 residents reviewed for abuse. (Resident #1). On 01/13/16 at 7:04 PM the Administrator, DON, corporate nurse consultant and the corporate vice president was informed of Immediate Jeopardy. The Administrator provided an acceptable credible allegation of compliance on 01/15/16 at 9:14 AM. Credible allegation of Compliance: F490 On 1/6/16 the accused CNA employee was removed from resident care areas. On 1/6/16, the resident was assessed by the director of nursing (DON). On 1/6/16, the DON notified the resident's physician and an order was obtained to send the resident to the ED for further evaluation. On 1/6/16 the DON notified the resident's responsible party (RP). On 1/6/16, the assistant director of nursing (ADON) contacted the police department. On 1/6/16 the accused employee was suspended from employment. Resident #1 was sent to the emergency room for assessment after an allegation of sexual abuse on 1/6/16 per MD order and did not return. On 1/6/16 the accused employee left facility property with the police. On 1/6/16 the DON called report to the hospital. On 1/7/16 the accused employee was terminated. On 1/7/16 the accused employee is in jail. On 1/6/16, the social worker and admissions coordinator interviewed all alert and oriented residents related to abuse asking the following questions;( Do you feel anyone has intentionally harmed you since you've been at Lake Park? If yes then who harmed you and who did you tell?, Where did it occur?, When did it occur?, Why do you feel you were harmed?, How were you harmed?) resulting in no negative findings. On 1/6/16, the RN supervisors, staff facilitator, and LPNs staff nurses completed 100% body audits of all residents for any evidence of abuse with no negative findings. On 1/6/16, the social worker, MDS nurses, RN nursing supervisor, and LPN staff nurses contacted, by phone or in person, 100% of the responsible parties of residents, to notify that there had been an allegation of sexual abuse from an employee to resident. On 1/6/16, the administrator contacted the ombudsman to notify there had been an allegation of staff to resident sexual abuse. On 1/6/16 the ADON completed a 100% audit to verify current licensing/certification of all licensed nurses and certified nursing assistants are current, all licenses found to be current. On 1/6/16 completed an audit on all current personnel files for pre-hire background checks, reference checks, signed resident abuse policy on orientation at 100 %. On 1/6/16 the administrator submitted the 24 hour report to DHSR heath care registry and followed up with the 5 day report submission on 1/8/16. On 1/14/16 the nurse that witnessed the incident received disciplinary action, was drug tested , and the incident was reported to the North Carolina Board of Nursing. On 1/14/16 the administrator was drug tested and received disciplinary action for failure to provide proper direction to a nurse who reported an allegation of sexual abuse. On 1/14/16 the nurse on call at time of allegation, (assistant director of nursing) received drug testing and disciplinary action for failure to direct nurse #1 to call the police and keep alleged employee supervised, and failing to assess resident immediately after she entered the building. On 1/14/16 the following in-services were completed by the corporate vice president of operations. related to the elder justice act including the following; If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately to law enforcement, but not later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Staff must report the suspicion of an incident to their supervisor, who will report the incident to the administrator. · On 1/14/16 the administrator was in-serviced by the corporate vice president of operations related to as the administrator of the nursing home you are the leader and required to enforce the policy on abuse. You must establish a no tolerance for an abusive environment. You must also enforce the elder abuse act policy. · On 1/14/2016 the administrator was trained on enforcing the policies of protection, identification and reporting abuse, the elder abuse act, and notification by the corporate vice president of operations including related to the elder justice act including the following; If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately to law enforcement, but not later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Staff must report the suspicion of an incident to their supervisor, who will report the incident to the administrator. All staff including contract staff were trained that any staff member can call local law enforcement with any type of observed abuse · On 1/14/2016 the administrative staff, (administrator, director of nursing, and assistant director of nursing) were trained on enforcing the policies of protection, identification and reporting abuse, the elder abuse act, and notification by the corporate vice president of operations related to the elder justice act including the following; If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately to law enforcement, but not later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Staff must report the suspicion of an incident to their supervisor, who will report the incident to the administrator. · On 1/14/2016 the departments heads were trained,( secretary, dietary manager, housekeeping manager, accounts receivable book keeper, payroll book keeper, maintenance director,, admissions coordinator, activities director, social worker, and therapy director) on enforcing the policies of protection, identification and reporting abuse elder abuse act, and notification by the corporate vice president of operations related to the elder justice act including the following; If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately to law enforcement, but not later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Staff must report the suspicion of an incident to their supervisor, who will report the incident to the administrator. · ON 1/14/16 the ADON trained all staff including contract staff working today on the elder abuse act policy and how to report to the local law enforcement related to the elder justice act including the following; If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately to law enforcement, but not later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Staff must report the suspicion of an incident to their supervisor, who will report the incident to the administrator. All staff including contract staff working today were trained that any staff member can call local law enforcement with any type of observed abuse · On 1/14/16 the elder abuse act instructions was posted at each nurse station and employee break room. · No employee will be allowed to work until all training is received. · New hires will receive all training during orientation prior to taking an assignment. · Nurse #1 and Nurse #2 have completed all above in-services. Immediate jeopardy was removed on 01/15/16 at 11:06 AM when interviews with nursing staff and administrative staff and non-nursing staff confirmed they had received inservice training on the facility's policy to immediately intervene and stop abuse when witnessed, immediately remove the perpetrator from resident care areas and call the police.