Every finding on record at Landmark Nursing Center Hammond

Based on observation, record reviews and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#3) of 1 resident observed for incontinence care. The facility failed to ensure staff performed hand hygiene and proper glove use for Resident #3 during incontinence care. Review of the facility's policy dated 01/2024 and titled Perineal Care, revealed the following, in part: Preparing for care:6. Perform hand hygiene and apply gloves. Male resident without catheter: 16. Remove gloves and perform hand hygiene. Review of the facility's policy dated 01/2024 and titled Hand Hygiene, revealed the following, in part:Indications for hand washing: 2. Hand hygiene should be performed between all contact between residents or when entering and exiting a resident's room. 3. Before and after a procedure. 4. Before and after applying gloves. 5. When hands are visibly soiled. 9. Wearing gloves does not replace the need for hand hygiene. Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis of chronic kidney disease, stage 4; muscle weakness (generalized); primary generalized osteoarthritis; unsteadiness on feet; and dependence on renal dialysis. Review of Resident #3's Quarterly MDS with an ARD of 07/10/2026 revealed a BIMS score of 8, which indicated moderately impaired cognition. Further review revealed Resident #3 experienced bowel and bladder incontinence. Review of Resident #3's current Care Plan revealed the following, in part: Focus: The resident was always incontinent of bowel and bladder.Interventions: Clean peri-area with each incontinence episode. Review of Resident #3's current Physician Orders revealed the following, in part: Order Date: 10/22/2025; Enhanced Barrier Precautions- gown and gloves to be worn during high contact resident care activities (hygiene, changing briefs). On 07/27/2026 at 9:20 a.m., an observation was made of S3CNA providing pericare to Resident #3. An EBP sign was noted on the outside of Resident #3's door stating, in part the following: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and gown for high contact resident activities. S3CNA was observed entering Resident #3's room wearing a gown with one pair of gloves in her hands. Without performing hand hygiene, S3CNA was observed donning gloves. S3CNA removed Resident #3's brief and her gloves were observed to be soiled with feces. She removed the soiled gloves and disposed of them in the trash. She walked to the door and requested another pair of gloves from nearby staff. Without performing hand hygiene, S3CNA was observed donning the gloves. S3CNA proceeded to clean Resident #3's peri area. After S3CNA removed and disposed of all soiled items, including her soiled gloves, wipes and Resident #3's soiled brief, she disposed of them in the trash. Without performing hand hygiene, S3CNA donned new gloves and placed a fresh brief under Resident #3 and applied barrier cream. Without removing her soiled gloves, S3CNA applied barrier cream and proceeded to touch Resident #3's clothing, deodorant and bed remote. S3CNA removed her gloves and washed her hands in the bathroom after direct care was completed. S3CNA removed the trash bag without gloves and did not sanitize or perform hand hygiene after handling the trash. On 07/27/2026 at 9:38 a.m., an interview was conducted with S3CNA. She stated she should have sanitized her hands when entering Resident #3's room. She stated she should have brought hand sanitizer with her to the bedside and she should have sanitized her hands each time she changed gloves. On 07/28/2026 at 8:38 a.m. an interview was conducted with S4CNAM She stated she expected her care staff to sanitize or perform hand hygiene when changing gloves and transitioning from a dirty body surface to a clean one. On 07/28/2026 at 9:30 a.m. an interview was conducted with S1Admin. He stated it is the facilities expectation that all employees follow the facilities hand hygiene policy and procedures. He stated employees are expected to sanitize their hands when entering and exiting a resident's room as well as when going from dirty to clean procedures.

Based on record review, observations, and interviews, the facility failed to store food under sanitary conditions by failing to ensure food was properly labelled and stored in the unit refrigerators. This deficient practice had the potential to affect 131 residents who were capable of storing and consuming food in the facility's unit refrigerators.Findings: Review of the facility's policy titled, Rules for Food Brought in by Visitors with a revision date of 08/2025 revealed the following:The community shall permit residents the pleasure of consuming food made for them by family.while establishing safeguards to prevent foodborne illnesses.Food brought in to the community must be in a leak proof sealed container that is labeled with the resident's name, contents, and date.The food shall.discarded after 3 days from preparation. On 01/21/2026 at 8:40 a.m., an observation was made of Refrigerator A with a sign posted on the outside stating, resident use, please put name, room number and date. Further observation revealed the following food items:Freezer:1 pint of ice cream- no name or date; and4 frozen meals- no name or date. Refrigerator- 1 opened package of sliced cheddar cheese- no name or date;1 Styrofoam container with fried chicken, rice and a role- no name or date;1 lunchbox- no name or date;1 strawberry yogurt- no name or date;1 opened smoked sausage link- no name or date;1 whipped topping plastic container- no name or date;2 plastic maroon containers with plastic lid- no name or date;1 grocery bag with a plastic container with sausage- no name or date;1 plastic container with red food- no name or date;1 30-fluid ounce mayo container with no name or open date;1 8-ounce opened chocolate shake- no name or date;1 32 -ounce ketchup- no name or date;1 8-ounce BBQ sauce- no name or date;1 opened package pre sliced roasted turkey with a packed on date of 07/08/2025- no name;1 plastic container with cake- no name or date; and2 8-ounce containers of berry yogurt with expiration date of 03/19/2025- no name. On 01/21/2026 at 9:02 a.m., an observation and interview was conducted with S2DON. S2DON observed the above-named food items in Refrigerator A and confirmed they were not labeled with a date or name and should have been. On 01/21/2026 at 1:39 p.m., an interview was conducted with S1ADM. He stated housekeeping was responsible for monitoring and cleaning Refrigerator A. He confirmed the above items should have been labeled with a name and date and were not.

Based on record review, observation, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure tube feeding formula and free water flushes were administered per physician's orders for 1 (#67) of 2 residents reviewed for tube feedings.Review of the facility's policy titled Tube Feedings with revision date of 12/2015, revealed in part, the following:1. All tube feedings will be administered in accordance with physician's orders.Review of Resident #67's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status, Dysphagia Following Cerebral Infarction, and Unspecified Diastolic Congestive Heart Failure.Review of Resident #67's current physician orders revealed in part, the following:Enteral feed, every shift, tube feeding formula at 70 mL/hr continuously. Start date 06/27/2025.Enteral feed, every shift, flush tube with 45 mL/hr of water continuously. Start date 06/27/2025.An observation was made on 01/20/2026 at 9:50 a.m. of Resident #67's tube feeding pump. Observed pump to be in use with feeding formula bag tubing loaded through water flush side of pump with the rate set at 0 mL/hr. Observed water flush bag tubing loaded through feeding formula side of the pump and set at 70 mL/hr. An interview was conducted on 01/20/2026 at 9:55 a.m. with S3LPN. She observed the aforementioned findings and confirmed the tubing was placed in the wrong sides of the pump. She confirmed the tube feeding formula was not infusing while water flushes were infusing at 70 mL/hr. She confirmed tube feeding formula and water flushes should be administered at the ordered rate.An interview was conducted on 01/22/2026 at 9:30 a.m. with S2DON. She confirmed the nurse starting the tube feeding pump should ensure tubing was appropriately inserted and administered at the ordered rate.

Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#70) resident out of a total of 28 sampled residents. The facility failed to ensure: 1.) Resident #70 was coded accurately for Restraints and Alarms; 2.) Resident #70 was coded accurately for current services provided by the facility. Findings: Review of Resident #70's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/2024 revealed the following: Section O0110: Special Treatments, Procedures and Programs: K1- Hospice Care- b. While a Resident Section P0200: Restraints and Alarms: E. Wander/Elopement Alarm- 0-Not Used Review of Resident #70's Clinical Record revealed she was admitted to the facility on [DATE]. Further review of the electronic health record revealed Resident #70 had a security bracelet placed on 09/12/2024. Review of the Physician Order's from Admission to present revealed no order for Hospice services being provided. On 01/15/2025 at 3:45 p.m. an interview was conducted with S4MDS. S4MDS confirmed Resident #70 currently had a security bracelet as part of the plan of care. S4MDS further confirmed Resident #70 had never received Hospice services. S4MDS reviewed the above MDS and confirmed it was coded inaccurately on the aforementioned Assessment Reference Date. On 01/15/2025 at 3:55 p.m. an interview was conducted with S1CN and S2DON. S1CN and S2DON reviewed the above MDS and Physician Orders and stated Resident #70 should have been coded for having a security bracelet in place and should not have been coded for receiving Hospice services. S1CN and S2DON confirmed the MDS was inaccurately coded to reflect the current services being provided.

Based on observations, interviews, and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1 (#31) of 2 (#31 and #105) residents reviewed for falls. Findings: Review of Resident #31's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed the resident had diagnoses which included Unsteadiness on Feet and Encounter for Orthopedic Aftercare. Review of Resident #31's Significant Change MDS with an ARD of 10/16/2024 revealed a BIMS of 10, which indicated she was moderately cognitively impaired. Review of Resident #31's current Care Plan revealed the following: Problem: Potential for further falls related to lack of coordination. Intervention: 01/06/2025 fall in room-turn bed against the wall On 01/14/2025 at 12:30 p.m., an interview was conducted with Resident #31's family member. He stated Resident #31 fell out of her bed last week and had to have surgery on her hip. On 01/14/2025 at 9:47 a.m., an observation was made of Resident #31 in her room. Her bed was not turned against the wall. On 01/15/2025 at 8:33 a.m., an observation was made of Resident #31 in her room. Her bed was not turned against the wall. On 01/15/2025 at 11:27 a.m., an observation was made of Resident #31 in her room. Her bed was turned against the wall. On 01/15/2025 at 12:13 p.m., an interview was conducted with S7CNA. She stated Resident #31 had a history of falling. She stated the nurses were responsible for implementing care plan interventions. She confirmed Resident #31's bed was not placed against the wall until today. On 01/15/2025 at 12:37 p.m., an interview was conducted with S6LPN. She stated Resident #31 had a history of falling. She verified the resident had a fall on 01/06/2025. She stated S3ADON was responsible for adding interventions to residents' care plans who were a fall risk, then S3ADON implemented them. She confirmed Resident #31's bed was not placed against the wall until today. On 01/15/2025 at 12:51 p.m., an interview was conducted with S3ADON. She stated she was responsible for adding fall interventions to residents' care plans, and she implemented the interventions. She stated she was aware Resident #31 had a fall on 01/06/2025. She stated the intervention put into place on 01/06/2025 was to move the resident's bed against the wall. She confirmed the intervention was not put into place until today, and should have been implemented when the resident returned from the hospital on 01/10/2025. On 01/15/2025 at 1:33 p.m., an interview was conducted with S2DON. S2DON stated care plan interventions should be implemented as soon as possible for a resident. She reviewed Resident #31's current care plan and verified she had a fall on 01/06/2025 with an intervention of placing her bed against the wall. She was notified the bed was not placed against the wall until 01/15/2025. S2DON confirmed Resident #31's bed should have been placed against her wall after she returned from the hospital on 01/10/2025.

Based on interviews and record reviews, the administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. The administration failed to implement a system to help prevent the development and/or transmission of infections by failing to: 1 Utilize its Infection Control and Prevention Program, follow its policies and procedures to surveil, and isolate known clusters of rashes for 5 of 5 (#1, #2, #3, #4 and #R1) residents reviewed for rashes; and 2 Ensure 4 of 4 (S17CNA, S20LPN, S4HK and S10HK) staff adhered to proper infection control practices when providing care for 1 of 1 (#R2) of residents reviewed for Enhanced Barrier Precautions (EBP). This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 06/10/2024 when Resident #4 presented with generalized itching and a rash. Resident #2 presented with a similar rash on 07/16/2024. Resident #3 presented with a similar rash on 07/24/2024. On 07/26/2024, Residents #1 and #R1 presented with similar rashes. On 07/31/2024, Resident #4 was treated for Scabies. The facility failed to identify Resident's #1, #2, #3, #4, and #R1 similar rashes as a potentially transmittable skin infection and did not take precautions to prevent the spread of the rash from resident to resident S1ADM was notified of the Immediate Jeopardy situation on 08/07/2024 at 6:00 p.m. The Immediate Jeopardy situation was removed on 08/09/2024 at 1:32 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the remaining 137 residents residing in the facility. Findings: Cross Reference F-880 1 Observations were made of Resident's #1, #2, #3, #4 and #R1 rashes on 08/06/2024 and 08/07/2024. The rashes had similar characteristics and remained unresolved on 08/07/2024. The rashes were sporadic to diffuse, red with papules, pustules, and crusted areas which were located on their torsos, arms and legs. On 08/06/2024 at 3:27 p.m., an interview was conducted with S11WCN. S11WCN confirmed the rashes for Resident's #2, #3, #4 and R1 appeared similar. On 08/06/2024 at 1:35 p.m., an interview was conducted with S7IPN. S7IPN confirmed she was the infection preventionist nurse for the facility and was responsible for surveillance of possible infections within the facility. S7IPN confirmed she was aware Resident #4 started receiving treatment for Scabies on 07/31/2024 as ordered by a local Dermatologist. S7IPN confirmed she was aware Residents #1, #2, #3, #4 and #R1 had similar and persistent rashes. S7IPN confirmed Residents #2, #3, #4 and #R1 resided on Hall b and Resident #1 resided on Hall a, but received care from the same Hospice Nurse as Resident #3. S7IPN confirmed she did not implement surveillance and tracking for the similar skin rashes and should have. S7IPN stated she had not identified the rashes of these residents' rashes as having a potential for spreading or being a possible transmittable disease or infection and should have. S7IPN confirmed the failure to surveil and track these rashes resulted in a failure to recognize the clustering and increasing rate. S7IPN confirmed the aforementioned residents were not placed on Contact Isolation Precautions but should have been due to their rashes presenting and persisting with similarities within a short timeframe and within a close proximity. On 08/06/2024 at 10:16 a.m., an interview was conducted with S2DON. S2DON confirmed she was aware of Residents #1, #2, #3, #4 and #R1 had similar rashes and Residents #2, #3, #4 and #R1 resided on Hall b and Resident #1 resided on Hall a, but received care from the same Hospice Nurse as Resident #3. S2DON confirmed these residents' rashes should have been surveilled and tracked by S7IPN for the possibility of transmittable conditions. S2DON confirmed the aforementioned residents were not placed on contact isolation precautions. S2DON confirmed she was aware Resident #4 was receiving treatment for Scabies. After reviewing the facility's policy and procedure on Isolation Precautions, S2DON confirmed Resident #4 should have been placed on Contact Isolation Precautions after receiving new orders from the dermatologist to treat for Scabies on 07/31/2024. On 08/07/2024 at 11:50 a.m., an interview was conducted with S8NP after he assessed Residents #1, #2, #3, #4 and #R1's skin rashes. S8NP stated Resident #4's rash was consistent with Scabies and should continue treatment for Scabies as well as being put on Contact Isolation Precautions. He confirmed he could not rule out a transmittable condition for the aforementioned rashes. S8NP confirmed Resident #2, #3, #4 and #R1 should have been and should now be placed on Contact Isolation Precautions due to their rashes being similar in nature and located on Hall b. On 08/07/2024 at 7:22 p.m., S1ADM confirmed Resident's #1, #2, #3, #4, and #R1 should have been placed on Contact Isolation Precautions when each presented with similar rashes. On 08/08/2024 at 9:08 a.m., an interview was conducted with S5MD. S5MD confirmed Residents #1, #2, #3, #4 and #R1 should have been placed on Contact Isolation Precautions after each rash was identified with similarities and given the close proximity of the resident's rooms. On 08/08/2024 at 9:08 a.m., an interview was conducted with S5MD. S5MD confirmed Residents #1, #2, #3, #4 and #R1 should have been placed on Contact Isolation Precautions following the identification of similarities in the rashes and with the close proximity of the resident's rooms. S5MD confirmed any resident with suspected or known scabies must be placed on contact isolation precautions. S5MD stated scabies is most commonly diagnosed by visual assessment and signs and symptoms. S5MD confirmed it was hard to get a definitive diagnosis/confirmation of the presence of scabies by skin scraping or biopsy because they are not seen with the naked eye and a mite would have to present in the exact location of the tested area, which is very small. 2 On 08/06/2024 at 1:35 p.m., and interview was conducted with S7IPN. S7IPN confirmed she was the infection preventionist nurse for the facility and trained the staff on infection control practices. S7IPN confirmed Resident #R2 was on EBP. S7IPN confirmed that the gowns used at the facility for EBP were one time use, then laundered and reused. S7IPN confirmed the gowns should never be used more than once without laundering. S7IPN confirmed the gowns should be removed prior to exiting the room and placed in a yellow barrel which should be inside the resident's room. S7IPN confirmed the yellow barrels at the nurses' station were used for housing residents' laundry if they were not on any precautions. On 08/06/2024 at 10:16 a.m., an interview was conducted with S2DON. S2DON stated the gowns used for EBP should not to be used more than once before being laundered. S2DON stated gowns should not be removed after exiting a resident's room. S2DON confirmed gowns should be removed within the resident's room prior to exiting and placed in the proper receptacle in the Resident's room. S2DON confirmed the laundry receptacles located at the nurses' station were for housing dirty laundry of residents that were not on any precautions.

46645 Based on observations, interviews and record review, the facility failed to help prevent the development and/or transmission of infections by failing to: 1 Implement a system for controlling and preventing the spread of transmittable infections for 5 of 5 (#1, #2,#3, #4, and #R1) residents reviewed for rashes; and 2 Ensure 4 of 4 (S17CNA, S20LPN, S4HK and S10HK) staff adhered to proper infection control practices when providing care for 1 of 1 (#R2) of residents reviewed for Enhanced Barrier Precautions(EBP). This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 06/10/2024 when Resident #4 presented with generalized itching and a rash. Resident #2 presented with a similar rash on 07/16/2024. Resident #3 presented with a similar rash on 07/24/2024. On 07/26/2024, Residents #1 and #R1 presented with similar rashes. On 07/31/2024, Resident #4 was treated for Scabies. The facility failed to identify Resident's #1, #2, #3, #4, and #R1 similar rashes as a potentially transmittable skin infection and did not take precautions to prevent the spread of the rash from resident to resident S1ADM was notified of the Immediate Jeopardy situation on 08/07/2024 at 6:00 p.m. The Immediate Jeopardy situation was removed on 08/09/2024 at 1:32 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the remaining 137 residents residing in the facility. Findings: 1 Review of the facility's policy titled Infection Prevention and Control Program with a revision date of 08/21 (no year listed) revealed the following, in part: The facility has developed and maintains an infection prevention and control program that provides a safe, sanitary and comfortable environment to help prevent the development and transmission of infection. This program will: Develop prevention, surveillance, and control measures to protect residents and personnel from healthcare-associated infections. Perform surveillance activities to monitor and investigate causes of infection and manner of spread in order to prevent infections in the facility. Analyze, in a timely manner, clusters or trends of infection, changes in prevalent organisms, and any increase in the rate of infection. Develop procedures to be applied in certain individual residents, such as isolation. Develop specific policies and procedures governing such activities as aseptic technique, outbreak investigation, wound care . Review of the facility's policy titled Procedure for Isolation: Isolation Precautions with a revision date of 08/21 (no year listed) revealed the following, in part: 3. Contact Precautions: use for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact. This includes other transmissible conditions such as scabies and conditions such as rash of unknown origin. Review of the Center for Disease Control's (CDC) webpage article titled Scabies and Public Health Strategies for Scabies Outbreaks in Institutional Settings at www.cdc.gov revealed the following, in part: Overview: Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks, especially when providing hands-on care to patients/residents who might have scabies. Establish surveillance. Have an active program for early detection of infested patients/residents and staff. Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; evaluate and confirm suspected cases by obtaining skin scrapings. Signs and Symptoms: The most common symptoms of scabies are intense itching, especially at night, and a pimple-like skin rash. Crusted scabies?: Crusted scabies is a severe form of scabies that is very contagious. It spreads quickly and easily, even from limited direct contact or from contaminated bedding, clothing, or furniture. Delayed diagnosis and treatment of crusted scabies can often cause outbreaks. Risk Factors: Places where scabies outbreaks more commonly occur include Nursing homes. How it spreads: Direct, extended, skin-to-skin contact with a person who has scabies or Less commonly, sharing clothing, towels, or bedding used by an infected person. You may need retreatment if itching is present more than 2 to 4 weeks after treatment, new burrows appear, or new pimple-like rashes appear. Resident #4 Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #4's Nurses Notes dated 06/10/2024 through 08/06/2024 revealed a rash was identified on 06/10/2024 and had not resolved. Review of Resident #4's local Dermatologist's Physician Consultation Report dated 07/31/2024 revealed findings of erythematous heme crusted papules scattered especially to truck but extending down all extremities with significant scaling to hands and interweb spaces. To cover for Scabies if not done in past 4 weeks: Ivermectin 15mg X 1, then repeat in 1 week. Permethrin 5 % cream apply to entire body, leave on overnight and wash off in the morning; repeat in 1 week. Review of Resident #4's physician's orders revealed the following: 07/31/2024 Permethrin 5% cream; apply to the entire body and leave on overnight Stop date: 08/07/2024. 07/31/2024 Ivermectine 3mg tablet; give 5 tablets by mouth (15mg) total X 1 dose. Stop date: 08/07/2024 08/06/2024 Allegra 180mg tablet; one tablet by mouth every morning 08/08/2024 Ivermectin 3 milligram tablet; give 5 tablets oral (15mg total dose) at night every Thursday for 2 doses. Stop date: 08/22/2024 08/08/2024 Permethrin 5% topical cream; topical at night every Thursday for 2 doses. Apply to the entire body below the neck, leave on overnight and wash off in the AM X 2. Stop date: 08/22/2024. On 08/06/2024 at 1:05 p.m., an interview was conducted with S15LPN. S15LPN confirmed Resident #4 resided on Hall b and had a rash for over a month. S15LPN stated Resident #4 was always itching and was being treated for Scabies. She stated Resident #4 had not been placed on Contact Isolation Precautions. S15LPN confirmed Resident #4's rash looked similar to Resident #3 and #2's rashes. On 08/06/2024 at 3:10 p.m., an observation was made of S11WCN assessing Resident #4's rash, assisted by S12CNA. Resident #4's rash was diffuse to the back and sporadic to the backs of the legs abdomen and both arms. The rash was red with pustules and papules; some were crusted and more linear in nature. Resident #4 verbalized the rash caused itching and the rash/itching had been ongoing for more than a month. An observation was made of Resident #4 actively scratching her right arm. Resident #4 was not placed on Contact Isolation Precautions. On 08/07/2024 at 10:31 a.m., an interview was conducted with S6NP. S6NP confirmed she was aware Resident #4 had a persistent rash and itching for months. S6NP stated she was aware Resident #4 was being treated for Scabies. S6NP confirmed Resident #4 should have been put on Contact Isolation Precautions for the duration of the treatment for Scabies. On 08/07/2024 at 11:45 a.m., an observation was made of S8NP assessing Resident #4's skin rash. S8NP stated Resident #4's skin rash was consistent with Scabies. He stated Resident #4 should have been placed on Contact Isolation Precautions. Resident #2 Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #2's Nurses Notes dated 07/16/2024 through 08/01/2024 revealed a rash was identified on 07/16/2024 and had not resolved. On 08/06/2024 at 12:05 p.m., an observation and interview was conducted with Resident #2. Resident #2 stated there were bugs which climbed on him at night, and he had bites all on his chest. Resident #2 stated the rash was all over his shoulders and on his right leg. Resident #2 stated the facility ordered him medications, which helped with the itching but it did not help with the bugs crawling on him. Resident #2 stated the itching was off and on for the last 6 weeks. Observations of Resident #2 revealed a splotchy, raised red rash to his right and left hand, and a discolored raised patch to his right posterior thigh. Resident #2 was not on Contact Isolation Precautions. On 08/06/2024 at 1:05 p.m., an interview was conducted with S15LPN. S15LPN confirmed Resident #2 resided on Hall b. S15LPN confirmed Resident #2 had a rash and was being treated with a cream. S15LPN stated the rash started on Resident #2's right side and treated with a Clotrimazole-Betamethasone cream, but it did not help. S15LPN stated Resident #2 was currently taking Bactrim and Mupirocin cream, but they were not effective. S15LPN stated Resident #2 had complaints of the rash itching and reported it feels like something was biting him. S15LPN stated Resident #2's rash was red raised bumps on the right side of his torso, right thigh, and the back of the right thigh. Resident #3 Review of Resident #3's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #3's MDS with an ARD of 06/17/2024 revealed a blank BIMS score, which indicated the interview could not be completed. Review of Resident #3's Nurses Notes dated 07/24/2024 through 08/02/2024 revealed a rash was identified on 07/24/2024 and had not resolved. Review of Resident #3's visit note report from Hospice visits dated 07/18/2024 through 08/06/2024 revealed a rash was identified on 07/28/2024 and had not resolved. On 08/06/2024 at 1:05 p.m., an interview was conducted with S15LPN. S15LPN confirmed Resident #3 resided on Hall b. S15LPN stated Resident #3 had red raised bumps all over. S15LPN stated the rash started as a few little red pustules/raised areas on the on the resident's right side. S15LPN stated it was reported to the Hospice Nurse and she was instructed to monitor the rash. S15LPN stated the rash had gotten worse and Hospice ordered a Triamcinolone cream. S15LPN stated Resident #3 had a rash of raised bumps on her entire back, her shoulders, around her ankles, arm pit to the breast. S15LPN stated Resident #3 was started on Triamcinolone cream on 07/25/2024 and was now on a Medrol Dose pack, Doxycycline, and Benadryl PRN. S15LPN stated Resident #3's rash was not resolving and had spread all over her back and shoulders. On 08/06/2024 at 3:00 p.m., an observation was made of Resident #3 with S11WCN. Resident #3 was noted to have a raised red rash on her bilateral arms, upper thighs, right and left torso, the left shoulder, and the right neck. S11WCN described the red raised bumps as pustules. Resident #3's back was observed to be covered in a diffuse bright red rash with some raised areas and some areas of opened skin. Resident #3 was not on Contact Isolation Precautions. On 08/06/2024 at 2:36 p.m., an interview was conducted with Resident #3's Hospice Nurse. She stated Resident #3's rash started about 2 weeks ago and originally looked like 5-6 small ant bites. She stated Resident #3's rash had spread and worsened as of today. On 08/07/2024 at 9:33 a.m., an interview was conducted with Resident #3's Responsible Party. He stated Resident #3 had the rash for a few weeks. He stated the rash initially looked like few insect bites on her back and had got progressively worse. Resident #1 Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #1's quarterly MDS with an ARD of 06/25/2024 revealed Resident #1 had a BIMS of 9, which indicated she was moderately cognitively impaired. Review of Resident #1's Nurses Notes dated 07/01/2024 through 08/06/2024 revealed a rash was identified on 07/26/2024 and had not resolved. On 08/06/2024 at 12:48 p.m., a telephone interview was conducted with Resident #1's Hospice nurse. She confirmed she was the Hospice nurse for Residents #1 and #3 She stated on 07/26/2024 she identified Resident #1 had a rash of unknown origin similar to Resident #3's rash. She stated the rash on Resident #1 was sporadic over the torso, arms and thighs with some pustules and patches or plaques and had not improved as of today. On 08/06/2024 at 12:36 p.m., an interview was conducted with S9LPN. S9LPN stated she was the nurse for Resident #1. S9LPN confirmed Resident #1 was nonverbal and resided on Hall a. S9LPN confirmed Resident #1 had a rash to her left upper outer arm and left upper thigh. S9LPN stated she received a new order from Resident #1's Hospice Nurse to restart the Triamcinolone cream due to an unresolved rash. S9LPN confirmed Resident #1 was not placed on Contact Isolation Precautions. On 08/06/2024 at 3:27 p.m., an observation was made of S11WCN assessing Resident #1's rash, assisted by S21CNA. An observation was made of Resident #1's rash on her left elbow, left shoulder, legs, back of knees, face and left abdomen. The rash was sporadic, red, contained papules, pustules, nodules and some crusted dark brown areas. Resident #1 was not on Contact Isolations Precautions. Resident #R1 Review of Resident #R1's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #R1's MDS with an ARD of 05/17/2024 revealed a BIMS score of 11, which indicated moderately impaired cognition. Review of Resident #R1's Nurses Notes dated 07/26/2024 through 08/07/2024 revealed a rash was identified on 07/26/2024 and had not resolved. On 08/06/2024 at 1:05 p.m., an interview was conducted with S15LPN. S15LPN stated confirmed Resident #R1 resided on Hall b. S15LPN stated Resident #R1 had a red rash on him that started the first of August and he was receiving Hydrocortisone cream twice a day. S15LPN reported the rash was not improving. S15LPN stated his rash was a red circle area like a little mosquito bite. S15LPN stated Resident #4's rash looked similar to Resident #3 and Resident #2's rashes. On 08/06/2024 at 3:10 p.m., an observation was made of Resident #R1 with S11WCN. Resident #R1 stated the rash itched more at night when he was in bed. Resident #R1 stated he was treated with a medication cream and Benadryl, but it does not help. Resident #R1's rash was red and raised to his right torso, small of his back, and his left abdomen. Resident #1 was not on Contact Isolation Precautions. On 08/06/2024 at 3:27 p.m., an interview was conducted with S11WCN. S11WCN confirmed the rashes for Resident's #2, #3, #4 and R1 appeared similar. On 08/06/2024 at 1:35 p.m., an interview was conducted with S7IPN. S7IPN confirmed she was the infection preventionist nurse for the facility and was responsible for monitoring for possible infections within the facility. S7IPN confirmed she was aware Residents #1, #2, #3, #4 and #R1 had similar rashes and Residents #2, #3, #4 and #R1 resided on Hall b. S7IPN confirmed Resident #1 resided on Hall a, but received care from the same Hospice Nurse as Resident #3. S7IPN confirmed the aforementioned residents were not placed on Contact Isolation Precautions but should have been. S7IPN stated she had not identified the rashes of these residents as having a potential for spreading or a possible transmittable disease or infection and should have. S7IPN confirmed Resident #4 started receiving treatment for Scabies on 07/31/2024 as ordered by a local Dermatologist. On 08/06/2024 at 10:16 a.m., an interview was conducted with S2DON. S2DON confirmed she was aware of Residents #1, #2, #3, #4 and #R1 had similar rashes. S2DON confirmed these residents were not placed on Contact Isolation Precautions. S2DON confirmed these residents' rashes should have been tracked by S7IPN for the possibility of transmittable conditions. S2DON confirmed she was aware Resident #4 was receiving treatment for Scabies. After reviewing the facility's policy and procedure on Isolation Precautions, S2DON confirmed Resident #4 should have been placed on Contact Isolation Precautions after receiving new orders from the dermatologist to treat for Scabies on 07/31/2024. On 08/07/2024 at 11:50 a.m., an interview was conducted with S8NP after he assessed Residents #1, #2, #3, #4 and #R1's skin rashes. He confirmed he could not rule out a transmittable condition for the aforementioned rashes. S8NP confirmed Resident #2, #3, #4 and #R1 should have been placed on Contact Isolation Precautions due to their rashes being similar in nature and located on the same hall (Hall b). On 08/07/2024 at 7:22 p.m., S1ADM confirmed Resident's #1, #2, #3, #4 and #R1 should have been placed on Contact Isolation Precautions when each presented with similar rashes. On 08/08/2024 at 9:08 a.m., an interview was conducted with S5MD. S5MD confirmed Residents #1, #2, #3, #4 and #R1 should have been placed on Contact Isolation Precautions following the identification of similarities in the rashes with the close proximity of the resident's rooms. S5MD confirmed any resident with suspected or known scabies must be placed on contact isolation precautions. S5MD stated scabies is most commonly diagnosed by visual assessment and signs and symptoms. S5MD confirmed it was hard to get a definitive diagnosis/confirmation of the presence of scabies by skin scraping or biopsy because they are not seen with the naked eye and a mite would have to present in the exact location of the tested area, which is very small. 2 A review of the facility's policy titled Enhanced Barrier Precautions, dated 03/24 (no year) revealed the following, in part: Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities. Changing linen is considered a high contact resident care activity; facilities should remember to have an appropriate disposal container available in the resident's room to allow for removal of Personal protective equipment (PPE) inside the room. A review of the facility's procedure titled Removing PPE, dated 08/21 (no year) revealed the following, in part: Remove PPE at doorway before leaving patient room Gown Unfasten neck, then waist ties Remove gown using a peeling motion, pull gown from each shoulder toward the same hand Gown will turn inside out Hold removed gown away from body, roll into a bundle and discard into waste or linen receptacle On 08/06/2024 at 9:35 a.m., an interview was conducted with S17CNA. S17CNA stated she had just completed incontinence care for Resident #R2. S17CNA stated she did not wear a gown while performing incontinence care on Resident #R2 whom was on EBP. S17CNA stated the gowns used for EBP were reusable and the used gowns were placed in a yellow barrel down the hall near the nurse's station for laundering. S17CNA confirmed Resident #R2's room did not have a yellow barrel in it. On 08/06/2024 at 9:42 a.m., an observation was made of S4HK prior to entering Resident #R2's room. S4HK confirmed Resident #R2 was on EBP. S4HK reached into the metal box on the door and pulled out a gown that was already tied at the neck. S4HK stated this was her gown which she reuses. S4HK confirmed she had previously worn this gown to enter Resident #R2's room. S4HK stated she had placed the used gown it back into the metal box for later use. She stated I save my gowns. An observation was made of S4HK slipping the previously tied gown over her head. S4HK stated she was unaware the gowns could not be used more than once prior to laundering. On 08/06/2024 at 9:46 a.m., an observation was made of Resident #R2's room. The room did not contain a yellow barrel to house used gowns. On 08/06/2024 at 9:48 a.m., an interview was conducted with S20LPN. S20LPN stated she was the nurse for Resident #R2. S20LPN confirmed Resident #R2 was on EBP. S20LPN stated for Enhanced Barrier Precautions, used gowns were to be discarded into a yellow barrel for laundering. S20LPN stated a yellow barrel should be located right outside the resident's room. She stated the gown was to be removed prior to exiting the resident's room. On 08/06/2024 at 9:58 a.m., an interview was conducted with S10HK. S10HK stated after exiting a resident's room, whom was on EBP, the gown was removed in the hallway and placed in a yellow bucket by the nursing station. S10HK confirmed she was unaware the gown should be removed in the resident's room and placed in a receptacle in the resident's room. On 08/06/2024 at 1:35 p.m., and interview was conducted with S7IPN. S7IPN confirmed she was the infection preventionist nurse for the facility and trained the staff on infection control practices. S7IPN confirmed Resident #R2 was on EBP. S7IPN confirmed that the gowns used at the facility for EBP were one time use, then laundered and reused. S7IPN confirmed the gowns should never be used more than once without laundering. S7IPN confirmed the gowns should be removed prior to exiting the room and placed in a yellow barrel which should be inside the resident's room. S7IPN confirmed the yellow barrels at the nurses' station were used for housing residents' laundry if they were not on any precautions. On 08/06/2024 at 10:16 a.m., an interview was conducted with S2DON. S2DON stated the gowns used for EBP should not to be used more than once before being laundered. S2DON stated gowns should not be removed after exiting a resident's room. S2DON confirmed gowns should be removed within the resident's room prior to exiting and placed in the proper receptacle in the Resident's room. S2DON confirmed the laundry receptacles located at the nurses' station were for housing dirty laundry of residents that were not on any precautions.

Based on interviews and record review, the facility failed to ensure medications were administered to meet the needs of each resident by failing to ensure orders were entered correctly and administered for 1 (#2) of 5 (#1, #2, #3, #4, and #R1) residents reviewed for rashes. Findings: Review of the facility policy titled, Elements of a Medication Order with a revision date of 11/2017 revealed the following, in part: Medication orders should specify the following: d. Time or frequency of administration PRN (as needed) clearly states the reason/condition for which they are being administered. Review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Pruritus and Disorder of the Skin and Subcutaneous Tissue, Unspecified. Review of Resident #2's Physician Order's revealed the following, in part: 08/01/2024 Mupirocin 2% cream apply to affected area twice daily and as needed. Review of Resident #2's Medication Administration Record (MAR) from 08/01/2024 to 08/07/2024 revealed the following, in part: Mupirocin 2% cream apply to affected area twice daily and as needed. Further review of Resident #2's MAR revealed the record did not have scheduled times for administration and the following doses were administered: 08/01/2024 at 7:09 p.m. - Administered 08/02/2024 at 8:43 p.m. - Administered 08/05/2024 at 8:18 a.m. - Administered 08/05/2024 at 9:18 p.m. - Administered 08/06/2024 at 5:39 p.m. - Administered On 08/09/2024 at 11:41 a.m., an interview was conducted with S16LPN. S16LPN confirmed she worked a double shift on 08/03/2024 and 08/04/2024. S16LPN stated if Resident #2's Mupirocin 2% cream was entered on the MAR as a scheduled medication she would have administered the medication. S16LPN stated if the medication was entered as a PRN medication, the resident would have to request it for it to be administered. S16LPN stated if there was an order for a medication to be administered at a scheduled time and PRN two separate orders would have to be entered in the MAR. S16LPN confirmed if a medication was not signed out on the MAR it was not administered. On 08/09/2024 at 12:44 p.m., an interview was conducted with S15LPN. S15LPN confirmed she entered Resident #2's Mupirocin 2% order. S15LPN confirmed she entered the order as a PRN order to be applied twice daily. S15LPN stated she should have entered the medication order as twice daily and an additional order for as needed. S15LPN confirmed she did not administer Resident #2's morning dose on 08/02/2024. S15LPN further confirmed if the medication was not marked off on the MAR the medication was not administered. On 08/09/2024 at 1:44 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #2's MAR and confirmed Mupirocin 2% order had been entered wrong. S2DON confirmed the order should have been entered a scheduled order and as a PRN order. S2DON confirmed the resident did not get administered scheduled doses of the medication because the order was entered as PRN. S2DON confirmed Resident #2's Mupirocin 2% was not administered as ordered.

Based on observation, interviews, and record review, the facility failed to ensure nurse staffing data, including actual hours worked for licensed and unlicensed nursing staff, was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 139 residents residing in the facility. Findings: Review of the facility's policy dated October 2022 and titled Posting of Staff revealed in part, the following: As required by Federal mandate, on a daily basis, the facility must post the following data: 6. Actual time worked for the specified categories of nursing staff. At the end of each shift the actual hours worked will be entered on the form. An observation was made on 06/17/2024 at 7:00 a.m. of the staffing data sheets dated 06/14/2024 - 06/16/2024. Further review revealed no documentation of the actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. An interview was conducted on 06/17/2024 at 7:05 a.m. with S2DON. She reviewed the nurse staffing data sheets dated 06/14/2024 - 06/16/2024. She confirmed the staffing data sheets should include actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides, and it did not. An interview was conducted on 06/17/2024 at 8:30 a.m. with S1ADM. He reviewed the nurse staffing data sheets dated 06/14/2024 - 06/16/2024. He confirmed the staffing data sheets should include actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides, and it did not.

Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 141 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled Food Storage Labeling revealed in part, the following: Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. d. Product Placement Food is stored in containers that are durable, leak proof and can be tightly sealed or covered. An observation was made on 01/17/2024 at 12:12 p.m. of the facility's walk-in pantry with S2FNS which included: -One opened, unsealed, 1/4 full, 42 ounce box of quick oats, with no open date; -One opened, unsealed, 1/2 full, 42 ounce box of quick oats, with no open date; and -One opened, 3/4 full, 128 ounce container of lemon juice with a label, which read, refrigerate after opening. An observation was made on 01/17/2024 at 12:20 p.m. of the facility's walk-in refrigerator with S2FNS which included, one opened, unsealed, 1/4 used, 5 pound block of sliced Swiss cheese. An interview was conducted on 01/17/2024 at 12:21 p.m. with S2FNS. She confirmed the above observations. She confirmed all food items should have been sealed and labeled with the opened date. She confirmed food items which required refrigeration after opening should have been stored in the refrigerator. An interview was conducted on 01/23/2024 at 10:00 a.m. with S1ADM. He stated all food items which required refrigeration after opening should have been stored in the refrigerator. He confirmed all opened food items should have a label with the opened date.

Based on observations, interviews and record review, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1(#26) of 4 (#26, #27, #103 and #105) residents reviewed for falls. Findings: Review of the clinical record for Resident #26 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Displaced Fracture of Lesser Trochanter of Right Femur, Muscle Weakness, and Lack of Coordination. Review of Resident #26's Yearly MDS revealed an ARD of 12/22/2023 and a BIMS of 15, which indicated he was cognitively intact. Review of the most current Care Plan revealed the following: Problem: 07/23/2022- Potential for further falls r/t history of falls. Intervention: 10/13/2023- non-skid tape to floor in front of recliner. On 01/22/24 at 8:48 a.m., an observation was made of Resident #26's room. There was no non-skid tape to floor in front of recliner. On 01/22/24 at 8:58 a.m., an interview and observation was conducted with S7CNA. She said she was not aware that Resident #26 required non-skid tape in front of his recliner and verified no non-skip tape was present on the floor in front of his recliner at this time. On 01/22/24 at 9:04 a.m., an interview was conducted with S6LPN. She said Resident #26 was considered high risk for falls and had a recent history of falls. She reviewed his care plan and verified his intervention of non-skid tape in front of his recliner. On 01/22/24 at 9:10 a.m., an observation was made of Resident #26's room with S6LPN, she verified there were no non-skid tape on Resident #26's floor in front of his recliner. She verified it should've been there. 01/22/24 at 9:10 a.m., an interview was conducted with S4ADON. She verified there was no non-skid tape in front of Resident #26's recliner and should have been. On 01/23/24 at10:53 a.m., an interview was conducted with S3DON. She reviewed Resident #26's care plan and confirmed Resident #26 should have non-skid tape in front of his recliner. She confirmed staff should ensure all care plan interventions are in place.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 2 (#80 and #86) of 32 residents reviewed for MDS. Findings: Resident #80 Review of Resident #80's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Anemia in Chronic Kidney Disease, Urinary Tract Infection (UTI), and Acute Cystitis without Hematuria. Review of Resident #80's Diagnosis Sheet revealed UTI's on 01/12/2023, 02/23/2023, 09/27/2023, and 12/08/2023. Review of Resident #80's Urinalysis dated 11/28/2023 revealed a positive culture for Citrobacter freundii. Review of Resident #80's Medical Records revealed she was admitted to a long term acute hospital on 12/01/2023 for Multi Drug Resistant Organism Urine, UTI, and Acute Kidney Injury. Review of Resident #80's Quarterly MDS with an ARD of 12/14/2023 revealed a BIMS of 15, which indicated she was cognitively intact. Further review revealed UTI's were not coded as active diagnosis in Section I. On 01/17/24 at 2:55 p.m., an interview was conducted with Resident #80. She stated she had frequent UTI's. She stated she was admitted to the hospital recently several times for UTIs. On 01/23/2024 at 9:15 a.m., an interview was conducted with S4ADON. S4ADON verified Resident #80 complained of pain and had a positive urine culture. S4ADON confirmed UTI's should have been coded as an active diagnosis on Resident #80's Quarterly MDS. Resident #86 Review of Resident #86's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Post-Traumatic Stress Disorder (PTSD). Review of Resident #86's Diagnosis Sheet revealed an active diagnosis of PTSD with an onset date of 07/27/2018. Review of Resident #86's Quarterly MDS with an ARD of 12/07/2023 revealed a BIMS of 15, which indicated he was cognitively intact. Further review revealed Resident #86's Quarterly MDS with an ARD of 08/25/2023 and his Quarterly MDS with an ARD of 11/14/2023 revealed PTSD was not coded as an active diagnosis in Section I. On 01/18/2024 at 1:00 p.m., an interview was conducted with Resident #86. He stated he had a history of PTSD from being abused as a child. On 01/23/2024 at 4:15 p.m., an interview was conducted with S5AN. She stated she was responsible for the MDS Assessments for Resident #86. She stated she was aware Resident #86 had a diagnosis of PTSD. She reviewed Resident #86's Quarterly MDS dated [DATE] and his Quarterly MDS 11/14/2023. After review, S5AN confirmed PTSD was not coded as an active diagnosis for Resident #86 and should have been. On 01/23/2024 at 4:25 p.m., an interview was conducted with S3DON. She reviewed the MDS assessments mentioned above for Resident #80 and #86. She verified if a resident had an active diagnosis, the MDS should be coded correctly with those diagnoses. She confirmed Resident #80's MDS should have reflected an active diagnosis of UTIs, and Resident #86's MDS's should have reflected an active diagnosis of PTSD, and they did not. 46975

Based on record review and interviews the facility failed to ensure it was free of significant medication errors for 2 (#9, #32) of 7 (#5, #8, #9, #32, #64, #118, #125) residents reviewed for medications. The deficient practice had the potential to effect the 145 residents residing in the facility receiving medications. Resident #9 A review of Resident #9's clinical record revealed she was admitted on [DATE] with a diagnosis of Congestive Heart Failure. A review of Resident's #9's Quarterly MDS with ARD of 01/17/2023 revealed a BIMS of 9, which indicated she had moderate cognitive impairment. A review of Resident #9's Physician Orders dated February 2023 included, in part: 02/11/2022 Document edema using scale as follows: 0=none, 1=trace, 2=minimal edema, 3=moderate edema, 4=severe edema. A review of Resident #9's MAR dated February 2023 revealed the following: Lasix 20mg tablet by mouth daily for chronic diastolic (congestive) heart failure with a start date of 02/11/2022. A further review of Resident #9's MAR revealed Lasix 20mg was not administered on 02/02/2023, 02/03/2023, 02/05/2023, 02/06/2023, and 02/07/2023. A review of Resident #9's most recent Care Plan revealed the appropriate identification of problems, goals and approaches pertinent to the resident's condition and diagnosis. Approaches included, in part, the following: Problem: Resident has a diagnosis of heart failure and hypertension. Approaches: Vital signs as ordered, instruct resident to notify nurse of any chest pains, headaches, or other changes, diet as ordered, administer medication as ordered, observe for effectiveness of medications, notify MD of any complications, weights as ordered. A review of the facility's Medication Reorder binder dated February 1, 2023-February 9, 2023 revealed the reorder for Resident #9's Lasix was requested from pharmacy once on February 6, 2023. A review of the facility's Emergency Kit List revealed Lasix was available for use in the emergency kit. On 02/06/2023 at 8:55 a.m., an observation was made of Resident #9. She was sitting in her wheelchair with legs hanging down. Edema noted to bilateral ankles and lower legs. On 02/06/2023 at 12:30 p.m., an observation was made of Resident #9. She was sitting in her wheelchair with legs hanging down. Edema noted to bilateral ankles and lower legs. On 02/07/2023 at 10:50 a.m., an observation was made of Resident #9. She was sitting in her wheelchair with legs hanging down. Edema noted to bilateral ankles and lower legs. On 02/08/2023 at 9:47 a.m., an interview was conducted with S6CNA. She stated she was taking care of Resident #9. She stated since she had been a CNA at the facility, she had observed swelling to Resident #9's legs and ankles. On 02/08/2023 at 10:30 a.m., an interview was conducted with S3LPN. She stated she worked the 6 a.m. to 2 p.m. shift. She stated she was aware of Resident #9's edema, and when she first started working at the facility it was one of her biggest concerns. She stated Resident #9 had Lasix ordered at 5:00 a.m. She confirmed Resident #9's Lasix was not given several times since the beginning of February and stated she did not see the reason why it was not given documented. On 02/08/2023 at 11:50 a.m., a telephone interview was conducted with S4LPN. She stated she was working the night shift on Saturday 02/04/2023 and Sunday 02/05/2023. She verified she took care of Resident #9 on those shifts. She stated she did not give the 5:00 a.m. dosages of Lasix on the mornings of Sunday 02/05/2023 and Monday 02/06/2023 because Resident #9's Lasix was not available. On 02/08/2023 at 12:37 p.m., a telephone interview was conducted with S2LPN. She stated she was working the night shift on Wednesday 02/01/2023 and Monday 02/06/2023. She verified she took care of Resident #9 on those shifts. She stated she did not give the 5:00 a.m. dosages of Lasix on the mornings of Thursday 02/02/2023 and on Tuesday 02/07/2023. She stated on the morning of Thursday 02/02/2023 she could not find Resident #9's Lasix on the medication cart or in Resident #9's bin in the medication room. She stated she did not notify anyone Resident #9's Lasix was unavailable on the morning of Thursday 02/02/2023. She said Resident #9 had Lasix ordered because she had fluid retention in her legs from sitting in her wheelchair during the day. She said Lasix helped decrease the swelling in her legs. She said on the morning of Tuesday 02/07/2023 she did not give Resident #9's Lasix because it was still unavailable. She said she could not remember if she faxed a request to pharmacy on Tuesday 02/07/2023 when she realized Lasix was still unavailable. She said she did not notify anyone at the facility Resident #9 was out of Lasix. She said there was an emergency kit at the facility which contained certain medications in the event a resident ran out of an important medication. She said when she looked at the list of drugs in the emergency kit, she overlooked Lasix on the list. She confirmed she should have administered the Lasix from the emergency kit to Resident #9. On 02/08/2023 at 2:18 p.m., an interview was conducted with S1DON. She stated when a resident's medication got low, the nurse should peel off the sticker on the medication card, which contained the name of the medication and the name of the resident. The nurse should fax it to the pharmacy to reorder. She stated if a medication was not available, the facility had an emergency medication kit. She stated this kit contained certain medications that could be administered to residents if their medication was unavailable. She said Lasix was one of the medications included in the emergency kit. She reviewed Resident #9's MAR and confirmed Lasix had not been given on 02/02/2023, 02/03/2023, 02/05/2023, 02/06/2023, or 02/07/2023. She stated staff should have notified her if Lasix was unavailable for Resident #9. She stated she had not been notified on 02/02/2023, 02/03/2023, 02/05/2023, 02/06/2023, or 02/07/2023 related to Lasix not being available. She confirmed if Lasix was not available in Resident #9's bin or in the medication cart, Lasix should have been pulled from the emergency kit and administered. Resident #32 A review of Resident #32's clinical record revealed he was admitted on [DATE] with a diagnosis that included left femur fracture. A review of Resident's #32's Quarterly MDS with ARD of 01/23/2023 revealed a BIMS of 12, which indicated he had moderate cognitive impairment. A review of Resident #32's Physician Orders dated February 2023 included, in part: 01/17/2023 Enoxaparin 30mg/0.3mL syringe, inject 0.3mLs into the skin every 12 hours X 4 weeks. A review of Resident #32's MAR dated February 2023 revealed the following: Enoxaparin 30mg/0.3mL syringe, inject 0.3mLs into the skin every 12 hours X 4 weeks for prevention of blood clots with a start date of 01/17/2023. A further review of Resident #32's MAR revealed Enoxaparin 30mg/0.3mL was not administered as ordered on 02/03/2023, 02/04/2023, 02/05/2023, and 02/06/2023. A review of Resident #32's most recent Care Plan revealed the appropriate identification of problems, goals and approaches pertinent to the resident's condition and diagnosis. Approaches included, in part, the following: Problem: Potential for injury related to anticoagulant. Approaches: Medications as ordered. A review of the facility's Medication Reorder binder dated 02/03/2023 through 02/06/2023 revealed the reorder for Resident #32's Enoxaparin was not requested from pharmacy. A review of Nurse's Notes revealed no entries for reason Resident #32 was not given Enoxaparin on 02/03/2023 through 02/06/2023. On 02/08/2023 at 11:49 a.m., an interview was conducted with Resident #32. He stated he was not given his Enoxaparin injection for 4 days in a row. He stated the nurses told him Enoxaparin was out of stock in the facility. On 02/08/2023 at 11:51 a.m., a telephone interview was conducted with S4LPN. She stated she performed care for Resident #32 on 02/03/2023. She stated Resident #32 received Enoxaparin due to his recent procedure to reduce the chance of blood clots, and he should have received Enoxaparin as ordered every 12 hours. She stated Enoxaparin was used to prevent blood clots in post-operative residents. She stated at 7 a.m. on 02/03/2023 Enoxaparin was not available. She stated she did not call S1DON or pharmacy to try to locate the medication. She stated she understood by Resident #32 not receiving Enoxaparin injections, he could have thrown a blood clot. On 02/08/2023 at 2:18 p.m., an interview was conducted with S1DON. She stated Resident #32's Enoxaparin was misplaced when the medication was placed in the wrong resident's medication bin. She stated she was made aware of the medication issue with Resident #32 on 02/06/2023 when day shift's S8LPN notified her Enoxaparin was not located in the resident's medication bin for his 02/06/2023 7 a.m. dose. She confirmed the nurses working on 02/03/2023 through 02/05/2023 should have notified her or the on call supervisor if they could not locate Resident #32's Enoxaparin. She stated Enoxaparin was a very important medication, especially for a post-operative resident. On 02/08/2023 at 2:46 p.m., a telephone interview was conducted with S9LPN. She stated she performed care for Resident #32 on 02/04/2023 and 02/05/2023. She stated Resident #32 received Enoxaparin due to his recent procedure to reduce the chance of blood clots, and he should have received this medication as ordered twice daily. She stated during her shift on 02/04/2023 she did not see Enoxaparin available in Resident #32's medication bin. She stated she should have called S1DON and did not. She stated she was not sure if any other staff notified S1DON. 46981

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and preventing and controlling COVID-19 infections as evidenced by the following: 1. The facility failed to ensure staff appropriately changed gloves and performed hand hygiene for 3 (#1, #53, and #66) of 3 (#1, #53, and #66) residents observed for perineal care; and 2. The facility failed to ensure staff were appropriately wearing mask during a COVID-19 outbreak on Hall a. Findings: Review of the facility's policy entitled Hand Hygiene revealed the following, in part: Purpose Statement To cleanse hands to prevent transmission of infection or other conditions. To provide clean, health environment for residents, staff, and visitors. Procedure Indications for Hand Washing 2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room. 3. Before and after procedures 4. Before and after applying gloves 9. Wearing gloves does not replace the need to perform hand hygiene Selecting Hand Washing Method 1. When to use alcohol-based hand rub b. After contact with a resident's intact skin; c. After contact with inanimate objects (including medical equipment) e. Before entering a resident's room f. Before exiting a resident's room Review of the facility's policy entitled Coronavirus (COVID-19) Policy Widespread COVID-19 Outbreak is 3 or more COVID-19 cases in HCP. Review of the facility's policy entitled Coronavirus (COVID-19)-Section(s): Outbreak Prevention and Investigation revealed the following: Prevent the spread of respiratory germs WITHIN your facility: Hand hygiene before and after visits and as needed when touching surfaces or people (use of alcohol-based hand rub is preferred). Well-fitted face mask that covers mouth and nose when community transmission levels are high. 1. Resident #1 On 02/08/2023 at 10:37 a.m., an observation was made of S7CNA performing incontinent care on Resident #1. S7CNA donned gloves, unclasped the soiled brief, tucked it between Resident #1's legs, and cleaned urine from Resident #1's perineal area using wipes. She then, without removing her soiled gloves or performing hand hygiene, turned Resident #1 on his side, removed the draw pad from Resident #1, and touched the bottle of spray cleanser on the bed side table. Using her soiled gloves, she placed a clean brief under the resident, moved Resident # 1's peg feeding tubing, straightened his gown, touched Resident #1 and his draw sheet. S7CNA proceeded to roll Resident #1 on his side, place a wedge pillow under him, assist the resident in rolling back over, and adjusted his sheets, peg feeding tubing, bed controls, pillow, sheets, and blanket. S7CNA failed to change gloves or perform hand hygiene until after she completed perineal care for Resident #1. On 02/08/2023 at 10:45 a.m., an interview was conducted with S7CNA. The above observation was reviewed with S7CNA. S7CNA stated she should have changed gloves and applied hand sanitizer after cleaning the urine from Resident #1 and before touching anything else in the resident's room. She confirmed she did not change her gloves or performed hand hygiene during incontinent care for Resident #1 and should have. Resident #66 On 02/07/2023 at 5:10 a.m., an observation was made of S5CNA performing incontinent care for Resident #66. S5CNA donned gloves, unclasped Resident #66's soiled brief, turned the resident on her left side, removed the soiled brief, touched the dresser drawer handle and retrieved a wipe packet from the drawer. S5CNA cleaned urine from Resident #66 using one wipe. Without removing her soiled gloves or performing hand hygiene, S5CNA placed a clean brief under the resident, touched Resident #66's sheet and blanket, bed pillow, and bed control. S5CNA then removed and discarded the left hand glove into the trash. S5CNA proceeded to pick up the trash bag with the right soiled gloved hand, touched the resident's hallway door handle and exited the room. S5CNA touched the gray barrel lid in the hallway with the soiled glove on her right hand, closed the barrel lid with the left ungloved hand S5CNA failed to perform hand hygiene during incontinent care for Resident #66. Resident #53 On 02/07/2023 at 5:15 a.m., an observation was made of S5CNA performing incontinent care for Resident #53. S5CNA donned gloves, unclasped the Resident #53's soiled brief, turned her on her right side, removed the soiled brief, touched the dresser drawer handle and retrieved a wipe packet from the bed side dresser. She then cleaned urine and feces from Resident #53 using one wipe. Without changing her soiled gloves or performing hand hygiene, she placed a clean brief under the resident, straightened Resident #53's gown, touched Resident #53 and her sheet. She adjusted the resident's blanket, bed controls, and pillow. S5CNA removed the soiled glove from left hand, picked up the trash bag with her right soiled gloved hand, and touched the resident's hallway door handle and exited the room. S5CNA touched the gray barrel lid in the hallway with the soiled glove on her right hand, closed the barrel lid with the ungloved left hand S5CNA then proceeded to enter Resident #53's room. She entered Resident #66's room without performing hand hygiene. On 02/07/2023 at 5:18 a.m., an interview was conducted with S5CNA. The above observations were reviewed with S5CNA. She confirmed she did not perform hand hygiene prior to applying gloves during incontinent care on Resident #53 and Resident #66. S5CNA confirmed she did not change gloves after soiled or prior to touching clean items in Resident #53 and Resident #66's rooms. She confirmed she did not perform hand hygiene after soiled gloves were removed. S5CNA stated if the resident is heavily soiled with feces she would change her gloves before she touched any clean items in the resident's room, but if not, she wouldn't change her gloves. She stated she only washed her hands every 3-4 rooms unless visibly soiled. On 02/07/2023 at 5:25 a.m., an interview was conducted with S2LPN. She stated she expected CNAs to perform hand hygiene prior to applying clean gloves, after soiling gloves during incontinent care, and to apply clean gloves prior to touching anything clean in the resident's room. She confirmed the CNAs should have performed hand hygiene before and after donning and doffing gloves. She confirmed gloves should be changed between soiled and clean items touched in the resident's rooms, and prior to entering another residents room. On 02/09/2023 at 8:40 a.m., an interview was conducted with S1DON. She stated she expected all staff to perform hand hygiene prior to placing clean gloves on to provide incontinent care. She confirmed staff should remove soiled gloves and perform hand hygiene prior to touching any clean items in a resident's room. She confirmed staff should perform hand hygiene before exiting a room and before entering another resident's room. She confirmed the CNAs should have performed hand hygiene or glove changes during incontinent care from soiled to clean resident contact. 2. Review of the facility's policy entitled Coronavirus (COVID-19) Policy revealed the following, in part: Widespread COVID-19 Outbreak is 3 or more COVID-19 cases in HCP. Review of the facility's policy entitled Coronavirus (COVID-19)-Section(s): Outbreak Prevention and Investigation revealed the following: Prevent the spread of respiratory germs WITHIN your facility: Hand hygiene before and after visits and as needed when touching surfaces or people (use of alcohol-based hand rub is preferred). Well-fitted face mask that covers mouth and nose when community transmission levels are high. On 02/07/2023 at 5:05 a.m., an observation of the facility revealed all staff wearing a face mask except S5CNA on Hall a. Signage posted at the front entrance screening station revealed a Red sign stating the facility's Transmission rate was HIGH and face mask required. On 02/07/2023 at 5:18 a.m., an interview was conducted with S5CNA. S5CNA stated she hadn't worn a facemask during any of her shifts since she started working at the facility full-time in January 2023. She stated the facility does not have COVID positive residents on Hall a, so she didn't have to mask. On 02/07/2023 at 5:25 a.m., an interview was conducted with S2LPN. She stated staff were expected to wear a facemask during a COVID outbreak. S5LPN confirmed S5CNA was not wearing a face mask while providing care to residents on Hall a and should have been. On 02/09/2023 at 8:40 a.m., an interview was conducted with S1DON. She reported Ten (10) COVID-19 positive residents were on Droplet Precautions in the facility as of 02/09/2023. She stated since the parish transmission rate is high and the facility is currently in a COVID outbreak, all staff are to wear a face mask during their shift. She confirmed S5CNA should have worn a face mask during her shift. 46642

Based on observation and interviews the facility failed to ensure food was palatable and appetizing for 1(#98) of 5 (#98, #112, #446, and #447) residents reviewed for food. Findings: On 02/06/23 at11:42 a.m., an interview was conducted with Resident #98. He stated he doesn't like the food and has issues with food being cold, and not appealing. On 02/07/23 at 10:20 a.m., an interview was conducted with S11LPN. She stated Resident #98 complained often regarding his food. On 02/09/2023 at 8:45 a.m., an interview was conducted with Resident #98. He stated he was served cold food for breakfast. He stated he was told that the microwave on the food cart on his hall was broken, and stated the CNA did not offer to reheat his food, so he refused to eat. On 02/09/2023 at 8:50 a.m., an observation/interview was conducted with S10CNA. She stated the microwave had been dropped from the cart and was not working. Observation of the microwave on the hall cart revealed the microwave electric cord only had 2 out of 3 prongs and couldn't be used. She confirmed she had not offered to reheat Resident #98's food or reported the broken microwave to anyone. On 02/09/2023 at 8:55 a.m., an interview was conducted with S12DM. She stated the CNA's are expected to reheat any resident's food tray on their assigned halls if they complained their food was cold. She stated the hall carts are equipped with microwaves for use when residents do not come to the dining room for meals. She stated all staff should notify her of any broken microwaves as soon as possible, so she can replace it. She stated no staff had reported any broken microwaves. On 02/09/2023 at 11:20 a.m., an interview was conducted with S1DON. She stated it was expected any CNA or nursing staff reheat a resident's food tray at the residents request if their food is cold. She stated staff should use an alternate microwave or bring the tray back to dietary to have it reheated if a microwave was broken on a hall dining cart. She stated staff should report any non-working equipment so it could be replaced. She was informed of the interviews of a resident being served cold food, and a CNA not offering to reheat the resident's breakfast tray. She confirmed if a resident requested their food tray to be reheated, the CNA should have reheated it.

Based on observations, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced by the following: 1. Presence of undated food items in the walk-in refrigerator of the facility's kitchen; 2. Presence of improperly sealed, undated food items in the walk-in freezer of the facility's kitchen; and 3. No thermometer located in the facility's walk-in refrigerator or the walk-in freezer. The facility census was 134. Findings: Review of the facility policy titled Food Storage Labeling revealed the following: Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the food Date of storage 4. Monitoring storage temperatures a. A thermometer is kept in all storage areas. On 01/31/2022 at 9:00 a.m., an observation of the facility's walk-in refrigerator and walk-in freezer was performed with S6PM. The following foods were observed to be undated in the walk-in refrigerator: Margarine 30 lb box of individual serving portions Whipped spread 9.92 lb box of stick butter Yogurt box of 48 containers of 4 oz strawberry, with green fuzzy substance on the outside of the box Shredded American cheese x2- 5 lb bags Shaved parmesan cheese x3- 5 lb bags Chopped lettuce x3 bags Yellow cheese x2 packages of 120 slices Chopped cabbage 20 lbs Scrambled egg bags x61 packages of 5 lbs each Hickory smoked turkey breast x6 packages of 32 oz each Hardwood smoked Buffet Ham x5 packages of 48 oz each Roast Beef x7 packages of 32 oz each Shredded chicken package 5 lbs Single serving jell-o packages x96 containers Single serving yogurt packages of 288 containers (144 strawberry, 48 blueberry, 48 raspberry, and 48 vanilla) Sweet Baby Ray's BBQ sauce x160 oz Mustard potato salad x2 containers of 12 lbs each Creamy cole slaw x2 containers of 11 lbs each Heads of lettuce x6 Tomatoes x9 Swiss cheese slices package 5 lbs There was no thermometer located inside the facility walk-in refrigerator. The following foods were observed to be improperly sealed and undated in the walk-in freezer: One package turnip greens, unsealed and undated One package hush puppies, unsealed One package dinner rolls, unsealed and undated One package cheese omelet, unsealed and undated There was no thermometer located inside the facility walk-in freezer. On 02/01/2022 at 1:50 p.m., interview was conducted with S5DM. She verified there was no thermometer located in the facility walk-in refrigerator and in the walk-in freezer. She said all items in the kitchen should be dated and sealed at all times. She verified the observations made of uncovered and undated food and stated they were not following facility policy on food storage.

Based on record review, observations, and interview, the facility failed to provide care and services to meet quality professional standards. The facility failed to ensure: 1. Medications were administered safely and timely by leaving the medications at the bedside for 1 (#63) of 6 (#22, #26, #50, #63, #73, and #87) observed during initial screening of residents upon facility entrance; and 2. A resident consumed medicines at the time of administration for 1 of 1 (#63) residents observed taking medications. Findings: Review of the facility policy titled Administration of Medications revealed the following: Purpose To administer medications in accordance with best practice. Procedure General: 3. Drugs and biologicals are administered no more than one hour before or no more than one hour after the dosage time on the order. 7. Stay with the resident until the resident takes all medications. Oral Medication Administration Procedure 12. Administer the medication to the resident. Observe that the resident had ingested the medication. Review of the clinical record for Resident #63 revealed she was admitted to the facility on [DATE] with diagnoses, which included Primary Generalized [CONDITION(S)], Major Depressive Disorder, Unspecified Dementia without Behavioral Disturbance, Essential Primary Hypertension, GERD, History of Falling, and Abnormal Weight Loss. Review of the MDS with an ARD of 12/08/2021 revealed her BIMS score was 7 indicating she was severely cognitively impaired. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 1 mg PO daily [MEDICATION(S)] 10 mEq PO daily [MEDICATION(S)] 40 mg PO BID [MEDICATION(S)] 100 mg, 2 tablets PO TID [MEDICATION(S)] 10 mg PO daily 1. On 01/31/2022 at 10:45 a.m., an observation was made of Resident #63 in bed with her eyes closed and the lights were off in the room. There was a clear medicine cup, which contained 6 tablets on her bedside table in her room. On 01/31/2022 at 10:49 a.m., an interview was conducted with S2LPN. She said she was the nurse for Resident #63. She verified there was a medication cup at Resident #63's bedside with 6 pills in the cup. She said she thought resident had taken her medications this morning but apparently she had set the cup down and not taken the pills when she gave them to her. She was asked if she should leave the cup or medications at the bedside of a resident and she said she should not leave medications unattended. She was asked if she should verify a resident had taken the medications and not pocketed them and she verified she should ensure the medications were taken at the time she brought them to the resident for administration. S2LPN said, She just didn't take them. 2. On 01/31/2022 at 10:49 a.m., an interview was conducted with S2LPN. She said she was the nurse for Resident #63. She verified there was a medication cup at Resident #63's bedside with 6 pills in the cup. S2LPN then administered the 6 pills in the cup on Resident #63's bedside table at 10:49 a.m. She verified the 6 pills were Resident #63's 8:00 a.m. medications and said resident should have taken the 6 pills at 8:00 a.m. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observation, and interviews, the facility failed to ensure adequate supervision to prevent accidents for 1 (#73) of 3 (#38, #61, and #73) residents who were identified as unsafe smokers and who needed supervision with smoking. Findings: Resident #73 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], Major Depressive Disorder, Neuromuscular Dysfunction of Bladder, [CONDITION(S)], Protein Calorie Malnutrition, Anxiety, Cachexia, Hypertension, GERD, and Irritable Bowel Syndrome. Review of the facility's Smoking Policies and Regulations revealed: The decision with regard to smoking is a personal matter and should be treated as such. However, the administration of this facility realizes that smoking is a source of possible fires and, therefore, have developed these policies and procedures to ensure the safety of the residents, employees, and visitors. Residents are not permitted to smoke in their rooms. Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurses station. The facility will provide matches and will light cigarettes upon request in designated areas set aside for smoking. These areas will be monitored by designated staff. Family or visitors may be allowed to monitor a resident with nursing approval. Visitors are not permitted to give or leave smoking paraphernalia with any resident. Adherence to these policies and procedures will be strictly enforced. Review of Resident #73's care plan revealed the following: Problem onset 12/07/2020: Resident uses tobacco Approaches: Cigarettes and lighters are kept at nursing station, Resident needs a smoking apron, and Resident needs assist with smoking. Review of Admission Agreement dated and signed by RP on 12/07/2020 revealed: C. The resident and/or resident representative agree: 7. The resident and/or resident representative further agree (i) the facility is absolutely smoke free and that smoking and smoking materials are permitted only in designated smoking areas. Review of the MDS with an ARD of 12/10/2021 revealed Resident #73 had a BIMS of 10 indicating she had a moderate cognitive impairment. On 02/03/2022 at 11:22 a.m., an observation was made of Resident #73 in her room and in her bed. The room smelled of cigarette smoke and there were 2 open windows observed. There were 2 packs of cigarettes, one open, and a lighter on the bedside table There was a cup with liquid in it and 2 fully smoked cigarettes in the cup of liquid. Resident #73 was interviewed and she said she asked a CNA about getting up to go outside to smoke and the CNA said she did not have to get up. She said the CNA opened the windows and said Go ahead and smoke. Resident #73 refused to identify the CNA. On 02/03/2022 at 12:14 p.m., an interview was conducted with S3CNA. She verified she had just come out of Resident #73's room and she said the room smelled like smoke. She said Resident #73 told her a CNA told her to smoke in the room. On 02/03/2022 at 1:25 p.m., interview was conducted with S2LPN. She said Resident #73 was not supposed to smoke in her room. She said Resident #73 had a visitor today. She said she did not know if the visitor brought the cigarettes to the resident. She said cigarettes and lighters are supposed to be on the cart and not supposed to be in a residents room. S2LPN verified it was not okay for resident to smoke in her room and she could catch the bed on fire. On 02/03/2022 at 2:56 p.m., an interview was conducted with Resident #73's brother. He said he did bring the cigarettes to Resident #73 today when he visited. He said while he was in the room for a visit, a CNA came in and resident asked to go out to smoke. He said the CNA went over, opened the windows, and said, just go ahead and smoke. He said the CNA left the room and Resident #73 lit up and smoked two cigarettes. He said he knew Resident #73 should not be smoking in the room but he did not say anything to her. On 02/03/2022 at 3:18 p.m., an interview was conducted with S4CNA. She said she was the one who opened the window in Resident #73's room. She said the resident did not ask to get up to go smoke and she never told the resident to smoke in the room. She said she did not see the cigarettes in the room and she had no idea the resident was going to smoke in the room. On 02/03/2022 at 4:00 p.m., interview was conducted with S1ADMIN. He said Resident #73 did admit to smoking in her room. He verified Resident #73 was not supposed to smoke in her room and there were designated smoking areas for residents to smoke. He said the smoking rules were to protect the safety of all residents in the facility.

Based on interviews and record review, the facility failed to ensure staff reported an allegation of mental and verbal abuse to the administrator within 2 hours of the allegation being made for 1 (R1) of 6 (#1, #2, #3, #4, #5, R1) residents reviewed for abuse. Findings: A review of the facility's policy Incident Investigation and Reporting revealed, in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to the state survey agency, law enforcement, and others as required by state and federal requirements. 2. Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Mental Abuse: This includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. 3. Abuse, neglect, misappropriation of resident property and exploitation are crimes and shall be reported to proper authorities as such. In the event of any incident involving an allegation or suspicion of mistreatment, exploitation, neglect, abuse, misappropriation or other crime, as well as injuries of unknown origin, elopement, and/or adverse events, each occurrence will be reported immediately to the Administrator of the facility, who will immediately notify the Corporate Compliance Officer and Regional Supervisor. A review of the medical record revealed Resident R1 was admitted to the facility on [DATE]. Resident R1's quarterly MDS with an ARD of 04/13/2021 revealed the resident had a BIMS of 12. On 06/15/2021 at 10:39 a.m., an interview was conducted with S3CNA. She stated Resident R1 told her a CNA that worked on the night shift or evening shift refused to give her snacks. Resident R1 further stated the CNA told her she was too fat to have snacks. S3CNA stated Resident R1 did not know the name of the CNA. S3CNA stated she felt the incident was verbal abuse. She stated Resident R1 told her about these incidents multiple times in the past month but she had not reported it to any other staff member. She stated the most recent time Resident R1 told her about this incident was 06/08/2021. On 06/15/2021 at 11:23 a.m., an interview was conducted with Resident R1. She stated a night shift CNA refused to give her snacks and told her You are too fat. She stated this happened on multiple occasions. She stated the last time it happened was either on 06/11/2021 or 06/12/2021. She stated she reported these incidents to a staff member 3 or 4 times. She stated these incidents made her feel bad and stupid and she was intimidated by the staff member. On 06/15/2021 at 3:44 p.m. an interview was conducted with S1ADM. He stated if a staff member was withholding snacks and calling a resident fat he would consider that abuse. He stated he would open a SIMS report and conduct an investigation. He stated if a staff member was made aware of this incident by a resident, he would expect them to immediately notify him or their immediate supervisor. He confirmed no staff member had reported to him that Resident R1 had made allegations that a CNA was withholding snacks and calling the resident fat.

Based on observations and interviews, the facility failed to implement appropriate infection control practices during the provision of resident care as evidenced by failing to ensure staff appropriately changed gloves and performed hand hygiene for 1 (#1) of 3 (#1, #4, #5) residents observed during incontinent care. Findings: On 06/14/2021 at 10:00 a.m., an observation was made of incontinent care provided to Resident #1 by S3CNA and S4CNA. S3CNA and S4CNA entered Resident #1's room and applied clean gloves. S3CNA and S4CNA unfastened the resident's soiled brief and the resident had a bowel movement. S3CNA cleaned the resident's buttocks and removed the resident's soiled brief. S3CNA held the soiled brief in her hand and opened the resident's bathroom door with the soiled gloves. S3CNA removed the trash can from the bathroom, placed it at the resident's bedside, and discarded the soiled brief. S3CNA did not remove her soiled gloves or use hand sanitizer. While wearing the same gloves she used during incontinent care, S3CNA proceeded to apply the resident's clean brief and pants. S3CNA removed the resident's shirt, applied a clean shirt and proceeded to move the resident's wheelchair closer to the bed. S3CNA put the total lift sling underneath Resident #1, then opened the door and moved the total lift machine into the room from the hallway. S3CNA pushed the total lift machine to the resident's bedside, applied the loops of the sling to the mechanical lift and used the remote to transfer the resident into the wheelchair. Once Resident #1 was in the wheelchair, S3CNA then unhooked the loops of the total lift, adjusted the resident in the wheelchair, and grabbed the footrests of the wheelchair. She then removed the soiled gloves. On 06/14/2021 at 10:19 a.m. an interview was conducted with S3CNA. She confirmed she did not remove her soiled gloves or performed hand hygiene after assisting Resident #1 with incontinent care. She confirmed she should have removed her gloves and performed hand hygiene before proceeding to assist the resident with getting dressed and using the mechanical lift to transfer the resident. On 06/16/2021 at 11:14 a.m. an interview was conducted with S2DON. She stated when staff were performing incontinent care, she expected them to wash or sanitize their hands before they enter the room, don gloves, perform incontinent care, then remove gloves and sanitize their hands after they perform incontinent care. She stated staff did not have to change their gloves or sanitize their hands after they wiped a resident's buttocks even if the resident had a bowel movement unless their gloves were visibly soiled. She confirmed S3CNA should have changed her gloves and sanitized her hands after providing incontinent care and before dressing the resident and transferring the resident with the mechanical lift.

Based on record reviews and interviews, the facility failed to ensure direct care staff provided basic life support, including CPR, to a resident requiring emergency care according to the resident's advance directive and physician's orders [REDACTED].#1) of 5 (Residents #1, #2, #R7, #R8, #R9) residents reviewed for death in the facility. On [DATE] at 7:20 p.m., an Immediate Jeopardy occurred for Resident #1 when the resident, who was a full code, did not receive CPR upon being found unresponsive. The hospice nurse was notified at the time the resident was found unresponsive by S5LPN. At approximately 9:00 p.m., the hospice RN arrived at the facility and Resident #1 was pronounced deceased by the Coroner. At approximately 11:15 p.m., S5LPN realized the resident's code status was a full code and that CPR should have been initiated when the resident was found unresponsive. The facility implemented corrective actions prior to the State Agency's investigation on [DATE]; thus, it was determined to be a Past Noncompliance citation. Findings: Review of Resident #1's clinical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Louisiana Physician order [REDACTED]. Full treatment was checked. No artificial nutrition by tube was checked. This form was dated [DATE] and signed by the resident's daughter. Review of MDS with ARD of [DATE] included the following: Entered from acute care hospital. Services of hospice. BIMS- resident unable to perform. Functional status - extensive assist. State Specific- Completed LaPost- yes. Review of Resident #1's care plan included the following: [DATE]- Resident is on Hospice Services. Resident will have wishes honored, comfort measures provided, and effective management of pain through next review [DATE]. Staff will provide resident and family support as needed through next review. Approaches: Appropriate for resident's need and end of life care. [DATE]- Review advance directive with resident/family on admission. Honor Residents Wishes /Honors [DATE]. Approaches: Re-review code status quarterly. Honor resident/family advance directive request. Maintain appropriate resident code status identification. Resident is a full code. [DATE]- Resident is on Hospice. Comfort measures will be provided through next review [DATE] Approaches: Staff will provide comfort measures. Assess for verbal and nonverbal pain. Reposition for comfort as needed. Notify MD and Hospice if interventions are ineffective. Respect and Honor resident wishes. Hospice Chaplain to visit periodically. [DATE]-Resident has an advanced directive. Resident remains full code while on Hospice. Review of Physician order [REDACTED]. admitted to Hospice services [DATE]. D/C all labs, appointments and procedures. Do not call 911, call Hospice Services first. DX: [MEDICAL CONDITION] [DATE]- D/C Do not call 911. Pt. is a full code. Code Status: Full code. Physician order [REDACTED]. Resident is a full code. Review of Hospice Physician's Plan of Care revealed Medical Treatment Orders: Order Clarification: code status remains Full Code, HA frequency change to 2x weekly, per facility request. Resuscitation Code Status: Full Resuscitation. Review of Resident #1's Hospice Interim Plan of Care dated [DATE] revealed the code status was a Full Code. CPR was checked-yes. Review of IDG Reports dated from [DATE]- [DATE] revealed no documentation that resident's code status was changed. On [DATE] at 9:35 a.m., an interview was conducted with S6LPN. She was asked if code status could be identified when in the resident's room or on the door way entering the room. She stated, No- not in the room or on the door. She was asked if a CNA found a resident not breathing what should they do. She stated they would call the nurse on the call light and wait for the nurse to come with the crash cart and chart to let them know if they needed to start CPR. She further stated the code status was to be verified by a second nurse before CPR was started. On [DATE] at 9:47 a.m., an interview was conducted with S3SS. She was asked when the code status determined on a resident was. She stated on admission the family completed the LaPost regarding code status. The LaPost was in the admission packet. She stated, if for some reason they changed their mind, they would come back into social services and complete an updated form. She was asked if Resident #1's family had ever changed her code status. She stated they had not, that the daughter was waiting on her father to decide. She verified Resident #1 was a full code at the time of her death. On [DATE] at 9:55 a.m., an interview was conducted with S4MR. S4MR verified Resident #1 did not have a code status change, the resident was a full code. On [DATE] at 3:45 p.m., an interview was conducted with S5LPN. She was asked if she was the nurse that discovered Resident #1 unresponsive. She stated, Yes and explained on [DATE] at 7:20 p.m. she walked into the residents' room to check vitals. She stated she found the resident unresponsive and cold when touched. S5LPN stated she asked the CNA what time she had last seen the resident and the CNA said around 6:30 p.m. and the resident was ok. S5LPN was asked what action she took when she discovered the resident unresponsive. She stated she called hospice first and then called family. The family arrived first and then the hospice nurse arrived at 9:00 p.m. S5LPN stated the hospice nurse verified that the resident was deceased , contacted the funeral home and the coroner. S5LPN was asked when she realized the resident's code status was a Full Code. She stated she was looking through the chart getting her paperwork together and she realized Resident #1 was a Full Code. She stated at that time she went outside, called the DON and informed her that Resident #1 was a Full Code and she had not performed CPR on the resident. On [DATE] at 1:00 p.m., an interview was conducted with S1DON. She was asked if a resident was found unresponsive what procedure was to be followed. She stated who ever found the resident was to press the call light and call a Code Blue. She further stated Code Blue was announced over the intercom system and someone would come with the crash cart and the residents' chart. She explained 2 nurses were to check the LaPost to verify the code status; then CPR would be started if they were a Full Code. S1DON was asked to explain what happened on [DATE] at 7:20 p.m. with Resident #1. She stated S5LPN called the S1DON at approximately 11:15 p.m. S5LPN told the DON that she had messed up because she had found Resident #1 unresponsive and called the hospice nurse. S5LPN told S1DON she had not checked the chart to determine code status when she found the resident unresponsive. S5LPN explained to S1DON, the resident was a Full Code, she assumed she was a DNR and had not performed CPR. Throughout the survey on dates [DATE] - [DATE], 16 staff were interviewed on how to locate the code status in the chart and the proper procedure when you find a resident unresponsive. Observations were made of staff showing surveyors where in the clinical record they would find the code status of the resident and interviews were conducted with these staff members and they were knowledgeable of the facility's CPR policy. Throughout the survey dates of [DATE] - [DATE], 14 resident records were reviewed; 5 of which were deceased , 12 of which received hospice services, and there were no concerns. The facility implemented the following actions to correct the deficient practice on [DATE]. 1- S5LPN was suspended in order to conduct a full investigation. 2- A full CPR staff in-service was conducted by the DON on [DATE] at 8:30 a.m., DON or designee continued to in-service staff on each shift until all nursing staff were trained on La Post/DNR status, substantial compliance achieved [DATE]. 3- DON and/or designee reviewed nurse's notes daily to ensure compliance as it pertains to La post/DNR/Initiation of Code Blue. 4- All current resident's code status was identified and verified for accuracy. 5- Social Services will review LaPost monthly until compliance met. 6- Facility initiated an emergency QA. 7- DON maintains monitoring by conducting a CPR-Code Drill on various shifts weekly, then monthly to ensure staff compliance with facility policy and quarterly thereafter. QAPI was implemented beginning [DATE]. A Root Cause Analysis was conducted and a plan of correction implemented. The facility identified the problem- identified was CPR not being initiated on a full code resident. The Plan of Correction projected completion date of [DATE] included: 1- Change in facility policy for two nurses to verify resident code status during an emergency/ code situation. 2- Both nurses will document the resident's code status in the nurse's notes. 3- Nursing staff were in-serviced immediately on LaPost and location of DNR status in resident's chart. 4- Facility will review LaPost/Code status monthly until substantial compliance is achieved. 5- The facility will monitor for compliance by the DON or designee will perform random code blue drills on alternating shifts monthly to ensure staff compliance with facility policy and quarterly thereafter.

Based on observation, interviews, and record reviews, the facility failed to ensure a resident's right to be free from sexual abuse for 1 (#79) of 2 (#2 and #79) sampled residents reviewed for abuse. This was evidenced by the facility's failure to: 1. Protect a resident who was incapable of making decisions for herself from (Resident #79) from a resident who was able to make decisions for himself (Resident #2), 2. Provide evidence of ongoing monitoring, training and staff knowledge/comprehension of interventions, and 3. Implement the facility's policies and procedures as related to resident abuse, sexual assault and incident investigation/reporting. The failed practice resulted in an Immediate Jeopardy situation for Resident #79 on 12/8/18 at 10:30 a.m. when the resident, who was not capable of making decisions for herself, was being inappropriately touched in the abdominal and vaginal area by Resident #2. At 10:40 a.m., this observation was made by S30HSK who then notified S11LPN. Prior to removing Resident #79 from the situation, S11LPN observed resident #2 to remove his right hand from resident #79's waistband of her pants and to smell his hand. The Immediate Jeopardy ended for resident #79 on 12/20/2018 at 6:00 p.m. when the facility implemented the necessary interventions/measures to protect the resident from further sexual abuse. S1REG and S2ADMIN were notified of the Immediate Jeopardy on 12/20/18 at 4:05 p.m. The Immediate Jeopardy was removed on 12/21/2018 at 2:17 p.m. when the facility submitted an Immediate Jeopardy Plan of Removal which included: 1. The resident found to have been affected by the deficient practice Resident #79, has been placed on Q 1 hour monitoring to ensure she is protected from any further sexual advances. Resident was assessed for physical or psychological harm with no findings of harm. 2. Resident #2, the accused was placed on one on one supervision at approximately 6:00 p.m. until such time as his discharge on 12/21/18. Immediate plans have been made for the following: a. Interview Resident #2 POA was conducted 12/20/18 at 5:45 p.m. to review the finding of the investigation. Resident's POA asked could she discharge her son on 12/21/18 after receiving [MEDICAL TREATMENT]. The facility initiated the proper discharge procedures and resident will be leaving from [MEDICAL TREATMENT] on 12/21/18 with no expected return to the facility. 3. The facility has conducted interviews with all interviewable residents (beginning on 12/20/18 at 6:00 p.m. and completed on 12/21/18 by 8:00 a.m. by the facility assessment team) to ensure no inappropriate sexual contact has been experienced and to also determine the resident's current sexual status. The facility interviewed 133 residents from the facility census on 12/20/18. Of those residents interviewed 129, answered no to all questions with 4 responding inappropriately due to cognition. An additional 5 were non-interviewable and 4 residents were in the hospital for a total census review of 142 4. The facility will include, in all resident's smart chart care plans, behaviors to be monitored by staff. The results of these behaviors will be reviewed daily by the Director of Nursing or Designee. 5. All facility staff is having immediate in-servicing on how to report suspicion of inappropriate sexual conduct and who to report the suspicion if noted. Staff will not be allowed to perform their duties until they have been properly in-serviced by the abuse coordinator or properly trained designee. This in-servicing began 12/20/18 at 6:00 p.m. by the Director of Nursing Services and will continue prior to any staff reporting to work. Competency will be monitored using a posttest with the opportunity for further education if deemed necessary by the Abuse Coordinator or his trained designee. The facility Abuse Coordinator plans to monitor staff competency by direct observation, continued in-servicing, and resident and staff interview no less than 5 times per week and documenting said efforts on a facility QA tool. These audits will be continued until substantial compliance is achieved and no less than monthly thereafter. 6. The Regional Supervisor conducted and in-service on 12/21/18 at 1:00 p.m. with the Department head staff to include the Abuse Coordinator/Administrator on Abuse and Neglect, Elder Justice Act, Review of Corporate training video's on Abuse and Neglect, State Agency and Law Enforcement Flow sheet. A posttest was administered to ensure competency. These department heads will conduct further training of staff. 7. The facility has conducted an emergency QA with the facility Medical Director to outline the aforementioned protocol with no further recommendations. The QA will be on-going until substantial compliance is achieved. 8. Any residents that exhibited inappropriate sexual behavior will have an individualized person centered care plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. The deficient practice continued at a potential for more than minimal harm for the other 97 female residents in the facility who were incapable of sexual consent. Findings: Review of the facility's policy titled Resident Abuse revealed in part the following: Procedures: A. Resident abuse is considered a critical offense and will be treated as such in the discipline process. B. An employee who knows about abuse or neglect or exploitation and fails to report it to his/her supervisor or member of management also face immediate termination and/or fines and imprisonment or all three. The same consequences apply if the employee gives a false report. C. Any charge of resident abuse shall be investigated by the administrator or is his designee. D. In cases involving resident abuse, where required by law, the facility administrator shall notify the proper authorities. Review of the facility's policy titled Sexual Assault/Rape Investigation: revealed in part the following: Policy All allegations of sexual assault or rape or attempted rape of a resident will be investigated thoroughly by the facility following facility abuse investigation policies and procedures with the following additional steps: 1. Notify family, physician, and law enforcement personnel, as well as state officials as stated in abuse investigation policy and procedure. 8. Report to the State (Licensure and Certification) as per Abuse Investigation policy. Review of the policy titled Incident Investigation and Reporting revealed in part the following: 1. Each resident residing in this facility has the right to be free from any type of abuse. Abuse: Instances of all abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse: Is nonconsensual sexual contact of any type with a resident. 3. Abuse shall be reported to proper authorities as such. The administrator will begin an investigation. The administrator shall report to State Survey Agency and local enforcement entities any reasonable suspicion of a crime against a resident. The administrator shall report no later than 2 hours after forming the suspicion, if the suspicions involve abuse. Continue Emergency QA meetings and processes as needed. 6. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. In case of resident-to-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed. A review of the Client Incident Report (OTIS) revealed in part the following: Incident ID: 3 Occurred - 12/8/18 at 10:30 a.m. Discovered - 12/8/18 at 10:40 a.m. Reported in facility - 12/8/18 at 10:41 a.m. Accused/Allegation: Resident #2 Abuse: Sexual Victims: Resident #79 Description: NFA was notified that Resident #2 was observed to be touching another female resident, Resident #79. Both residents were removed from the living room area where the incident was observed. NFA was able to watch video surveillance that revealed Resident #2 did touch Resident #79 on her legs, breast, and abdomen area. Both residents were interviewed in regards to the incident by professional nursing staff. Resident #79 agreed when asked that she knew Resident #2 and that he touched top of her left, abdomen, and sides of abdomen. Resident #79 also mentioned Resident #2 was her boyfriend. Resident #79 Review of clinical record for Resident #79 revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of MDS with ARD of 11/6/18 revealed Resident #79 had a BIMS score of 3 which indicated a severe cognitive impairment. Review of Resident #79's Social History that was provided by the facility revealed the following: Emotional mental status: confused and friendly Review of care plan with a problem on set date of 8/23/17 revealed the following: Problem/Need: Resident has altered thought process related to severely impaired cognition. 8/27/18 BIMS score of 3. Goals/Target Date: Resident will have all needs met through next review period, 12/31/18 Approaches: Provide reorientation to resident as needed, explain each activity/procedure prior to beginning it, and provide activities that require only short attention span for completion, refocus conversation when resident loses focus. Resident #2 Review of the medical record for Resident #2 revealed he was a [AGE] year old male and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of MDS with ARD of 8/21/18 revealed Resident #2 had a BIMS score of 13 which indicated he was cognitively intact. Review of Resident #2's Social History provided by the facility revealed clear distinguishable speech, is able to make self understood, understands clear comprehension of others, and no behaviors noted. Other Social notes section revealed Resident #2 ambulated throughout the facility with a walker. Review of care plan with onset date of 12/1/17 revealed: Problem/Need: Noncompliance, Resident has refusal of care at times, resident will attempt to exit facility without informing staff of signing himself out after repeated education and verbalizing understanding. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] Order/Start Date: 5/14/18 EMAR-Behaviors: Monitor for targeted behaviors, Withdrawn Order/Start Date: 12/17/18 at 6:00 p.m. Every Hour Checks for monitoring to be documented by nurses A review of the Police Report dated 12/17/18 at 4:18 p.m. revealed in part: S32OFC responded to take a report of a possible sexual battery that occurred at a nursing home on 12/8/18 at approximately 10:20 a.m. Upon arrival, S32OFC met with the complainant, S2ADMIN, who advised one of his male residents at the facility, Resident #2, had acted inappropriately with another resident, Resident #79. S32OFC viewed the surveillance video that showed Resident #2 touch Resident #79 in her upper inner thigh near her genitals, and lift up her shirt, and touched areas of her upper chest near her breast. S1ADMIN stated, Resident #79's family had power of attorney and wished to not pursue charges, nor did Resident #79. The facility did want to have a police report made as per the state's request during an audit at the facility. A review of S30HSK written statement dated 12/8/18 revealed I seen Resident #2 digging in Resident #79 brief and this was like an hour before lunch and when he pulled his hand out of her brief he smelled his hand. A review of Resident #79's statement revealed in part: Asked her if she was in any relationship with Resident #2 and she replied No Asked her if Resident #2 was her boyfriend and she replied yes. Review of a Departmental Note written by S13LPN dated 12/8/18 at 9:28 p.m. revealed in part: I clarified to Resident #2 that Resident #79 was not with it mentally and that he cannot do that to her. Educated Resident #2 that he cannot touch Resident #79 inappropriately again and to stay away from her from now on. An interview was conducted with S10SSD on 12/17/18 at 2:23 p.m. She reported the facility used the BIMS score as a tool to confirm the resident's capacity to consent to sexual activity. S10SSD verified a BIMS score of 3 was a severe cognitive impairment and the resident was unable to knowingly consent to sexual activity. When asked if Resident #79 could consent to a sexual relationship she stated In my opinion she was not cognitively able to make that decision. When asked if Resident #2 was aware of his actions with Resident #79 she stated he is mentally aware. When asked what interventions were put into place to protect Resident #79 she reported she spoke with Resident #2 and monitored Resident #79 for 1 day. An observation was made of Resident #79 on 12/17/18 at 2:40 p.m. Resident #79 was sitting in the living area of Hall B and was noted to be unsupervised by staff. She was sitting in a Geri chair with her head tilted to the left side and eyes closed. Resident #79 did not respond to verbal stimuli. An interview was conducted with S28ACTDIR, on 12/17/18 at 2:59 p.m. She reported Resident #2 showed some physical tendencies towards Resident #79, and she had begun to separate them when she saw them near each other. She stated Resident #79 did not have the mental capacity for that type of relationship, and Resident #2 had a much higher mental capacity than Resident #79. An interview was conducted with S3DON on 12/17/18 at 3:03 p.m. When asked what interventions were put into place after the abuse on 12/8/18 she replied she spoke with staff and instructed them to keep Resident #2 and Resident #79 apart. She also reported acute charting was implemented for a few days (12/8/18-12/12/18) to watch for behaviors and ensure Resident #2 and Resident #79 were separated. She explained acute charting consisted of a note being made of the resident's locations once a shift. When asked whose responsibility it was to monitor the residents, she reported it was no one's specific duty. She explained the whole staff was made aware and should be keeping an eye on it. When asked if Resident #79 was able to consent she stated no then immediately stated I can't answer that question because I don't know. She verified the facility used the BIMS score to determine the capacity to consent sexual activity. A telephone interview was conducted with Resident #79's responsible party on 12/18/18 at 9:20 a.m. She reported she was notified about the alleged abuse on 12/8/18 involving Resident #2 and Resident #79. She reported she was told Resident #2 was the perpetrator, and he was mentally above her aunt's status but was not completely with it. She revealed her only concern was whether Resident #2 knew what he was doing when her aunt did not. When asked to clarify what the mental orientation of Resident #2 was she replied it was presented to me Resident #2 was not completely with it. When asked what was reported to her she responded a staff member thought they may have seen Resident #2's hand in Resident #79's pants, but with the video footage the facility was unsure if that actually happened. She reported Resident #79 could not consent to an intimate sexual relationship, and Resident #79 would not have understood. Resident #79's responsible party did not report she had been informed Resident #2 had touched Resident #79 on the legs, breast, and abdomen area. An interview was conducted with S9RN on 12/18/18 at 9:43 a.m. When asked if Resident #79 could consent to a sexual relationship, she replied it would be more of a school girl crush and not a woman knowingly wanting an intimate relationship. On 12/18/18 at 1:55 p.m. Resident #79 was observed sitting in her Gerichair in the living area of Hall B, and no staff supervision was noted. Resident #79 had her eyes closed and she was leaning to her left side. When her name was called she was able to look up and reply ok, but could not carry on a meaningful conversation. An interview was conducted with Resident #2 on 12/19/18 at 8:43 a.m. He admitted he had touched Resident #79's abdomen, thigh, and leg when he was trying to wake her up. He reported Resident #79 was his girlfriend. An interview was conducted with S28ACTDIR on 12/19/18 at 12:28 p.m. When asked to clarify what she had meant when she reported physical tendencies in our interview earlier in the week she reported she had a gut feeling about Resident #2. When asked to clarify the gut feeling she reported Resident #2 had started becoming closer to Resident #79. She explained further it was a change for Resident #2 to start seeking to sit next to Resident #79 and talk with her because he did not normally socialize with residents outside of the smoker's porch. She reported she began separating the 2 residents at that point out of concern. She reported her assistant S29ACT, noticed the change in behavior first and reported it to her. S28ACTDIR stated she observed and noticed the same behavior. She reported she notified S10SSD 3-4 days prior to the abuse occurring on 12/8/18. An interview was conducted with S29ACT on 12/19/18 at 12:28 p.m. She verified she had noticed Resident #2 becoming closer with Resident #79 and this concerned her due to Resident #79's mental status. She verified she began separating the 2 residents and notified S28ACTDIR. An interview was conducted with S10SSD, on 12/19/18 at 2:45 p.m. When asked if she was made aware of S29ACTDIR's concerns regarding Resident #79 and Resident #2 she replied yes. She reported she was told Resident #2 was getting too close to Resident #79. She reported she made an observation, prior to the abuse on 12/8/18, of Resident #2 and Resident #79 sitting in the day area, holding hands, talking, and engaging. She denied notifying anyone of the observation or documenting it. She verified she made the one observation of the 2 residents and since she did not see any red flags she let it go. She stated in hind sight I should have reported it. When asked if Resident #2 and Resident #79 were noted to be friends prior to the abuse she replied they were not friends before so it was a change because the 2 residents were holding hands and talking and being together more. She explained she had known Resident #2 since his admission and his normal routine consisted of going to [MEDICAL TREATMENT] and going to the smoking area. She reported he did not normally socialize with other residents unless they were smoking. When asked if Resident #2 had ever expressed or shown interest in having a girlfriend or socializing with female residents she stated, No. She again verified Resident # 2 was able to make rational judgment calls with no cognitive impairment and Resident #79 was not able to consent to a sexual relationship. She reported she had a conversation with Resident #2 after the incident. She reported Resident #2 admitted to putting his hand down Resident #79's pants. She explained Resident #2 did not show any remorse for the behavior and had no issues when he was told he could not go around Resident #79 any longer. When asked if she reported the interview to anyone she replied no. When asked why she did not report it she replied They already knew about it. When asked if Resident #2 was capable of sexually abusing another resident again she stated yes. A telephone interview was conducted with S11LPN on 12/19/18 at 2:27 p.m. She reported she was sitting at the nurses desk when a housekeeper came to her and told her Resident #2 had his hand down Resident #79's pants. She reported she saw Resident #2 messing with the waste line of Resident #79's pants, and it looked as if he was withdrawing his hand from her pants and smelled his hands. She reported it was disgusting. When asked if Resident #79 was able to consent to a sexual relationship she stated, No ma'am she cannot consent to a sexual relationship. An interview was conducted with S22CNA on 12/19/18 at 3:20 p.m. She denied being aware of any resident on Hall A that she was supposed to keep a close watch on for his recent behaviors. An interview was conducted with S19CNASUP, on 12/19/18 at 5:49 p.m. She confirmed she reported S22CNA had not been present for the in-service, and she had worked since the abuse occurred. She reported Resident #2 stayed to himself, and it was unusual for him to be around Resident #79 or any other female. She reported the closeness with Resident #79 was a new behavior for him. She stated she had noticed the change in behavior prior to the abuse occurring on 12/8/18. She denied reporting the change to anyone. She stated Resident #79 was mentally retarded. She verified Resident #79 was unable to consent to a sexual relationship and she felt Resident #2 was aware of what he was doing. An interview was conducted with S22CNA, on 12/19/18 at 6:06 p.m. She reported she had worked shifts in the facility after 12/8/18 and was not made aware of the abuse. She further explained she was unaware of the need to increase monitoring for Resident #2 prior to today, 12/19/18. When asked about what time she was informed she responded it was after she had taken over responsibility of her patients today. An interview was conducted with S2ADMIN on 12/19/18 at 6:50 p.m. He reported after the incident on 12/8/18 the staff were in-serviced, acute charting was implemented, and staff were instructed to keep Resident #2 and Resident #79 separated. When asked how he made sure all staff were in-serviced he replied it was on-going. When asked if all staff were educated about the abuse and interventions he restated it is an ongoing in-service. He verbalized there was a new in-service at each shift change. When asked if he was aware that not all staff were educated about the abuse and interventions he replied We educate our staff and I am sorry if they did not retain the information. I can tell them something and 20 minutes later they forget. When asked if he was aware staff had noticed a behavior change in Resident #2 prior to the incident on 12/8/2018, he replied S28ACTDIR embellished on information that she did not understand and that a gut feeling was not enough for him to act on. When asked if he was aware 4 staff members had noticed a behavior change in Resident #2 he replied no. When asked why the information in the OTIS report was different than the information in the facility incident report and investigation documentation he replied that he saw the video and reported what actually happened. He reported he had better information based off the video than the eye witness staff had. When asked what he considered sexual abuse to be he stated any act that is not consensual by both parties. When asked what the police report detailed he verbalized the officer said it was sexual battery. When asked if rubbing over the legs and breast area is sexual abuse he stated yes and verified this was visible on the video. An interview was conducted with S1REG on 12/19/18 at 7:34 p.m. He reported the only thing the facility could have done differently was to report the alleged abuse to the State Agency in 2 hours instead of 24 hours. An interview was conducted with S5ADON on 12/20/18 at 11:30 a.m. When asked if S22CNA should have been educated about the abuse and interventions she replied yes. She verbalized the staff were told to keep the 2 residents apart and do1 hour charting on Resident #2. When asked who was responsible for documenting the 1 hour charting she replied all staff. When asked who verified the hourly charting was being done she reported she would have to find out because it should be all of their responsibilities. When asked for the documentation verifying the 1 hour charting was done from 12/8/18 when the intervention was put into place to present she replied she was unsure how to find it. S5ADON was unable to verify who was responsible for the ongoing education, continued monitoring, and reevaluation of the effectiveness of education and interventions. On 12/20/18 at 12:07 p.m. S1REG provided documentation of the cover sheet of Resident #2's care plan showing 1 hour charting had been implemented and it was the CNA's responsibility to complete it. There was no date to reflect when the intervention was put into place. The smart charting screen was reviewed with S5ADON on 12/20/18 at 12:16 p.m. She reported this was how the task was made to trigger on the CNA's charting. During the review a pop up screen revealed the 1 hour charting intervention was started on 12/17/18 at 5:10 pm. When asked if that was accurate S5ADON replied she did not know what that screen meant. On 12/20/18 at 12:40 p.m. S5ADON attempted to access smart charting for the CNA's to view the completed 1 hour documentation from 12/8/18 to present. She was unable to pull up the information to show the documentation. An interview was conducted with S3DON on 12/20/18 at 12:50 p.m. When asked when the 1 hour charting was implemented for the CNAs she replied 12/16/18. When asked how it was monitored to make sure it was being done she responded, how do I know if it's being done? She then reported we are verbally monitoring the situation. She verified there was no documentation on evaluating and monitoring for effectiveness of the interventions. An interview was conducted with S2ADMIN on 12/20/18 at 12:55 p.m. He denied having any documentation or a formal QA being done. He also denied having documentation on how the staff was monitored and evaluated to determine the effectiveness of the education and interventions that were put into place. He verified there was no hard documentation to show it was being monitored. He stated I have provided all the information and documentation that was requested and I do not have anymore. When asked to clarify he reported there was no further documentation from the angle of abuse. S3DON provided documentation on 12/20/18 at 1:00 p.m. of an in-service dated 12/10/18 titled Corrective Action Plan. The problem identified was no follow up documentation following an incident. Plan of action revealed an immediate action to in-service staff on proper documentation, and audit of acute charting, and an in-service about proper documentation following an incident. The Monitoring section reported DON or designees will monitor nurse's notes on a daily basis for review. The follow up for effectiveness section was left blank. S3DON verified this was all the physical documentation she had. An interview was conducted with S1REG and S2ADMIN on 12/20/18 at 1:14 pm. S2ADMIN verified the abuse occurred on 12/8/18. S2ADMIN stated the police were notified of the abuse on Monday. He further clarified Monday, 12/17/18. When asked why there was a discrepancy between the facility investigation and the police report he stated the police reported inaccurate information and that never happened. When asked why the incident was not reported sooner to the police he reported the families did not want law enforcement involved. When asked to provide the facility's policy on determining capacity to consent for sexual relationships, documentation of every hour monitoring from 12/8/18 to present, and a list of residents able to consent to sexual activity S1REG responded we provided everything and there was nothing else to provide.

Based on interviews and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to prevent sexual abuse of 1 (#79) of 2 (#2 and #79) residents sampled for abuse as evidenced by failure to: 1. Protect a resident (Resident #79), who was not capable of making decisions for herself, from sexual abuse; 2. Ensure that all staff were properly trained to protect Resident #79 from further abuse; 3. Conduct a thorough and complete investigation of sexual abuse; 4. To report sexual abuse to the State Agency within 2 hours; 5. To report the sexual abuse to local law enforcement within the mandated 2 hour time frame; 6. To follow policies and procedures for reporting and investigating sexual abuse; and 7. To implement a monitoring system to ensure staff knowledge/comprehension and documentation of the interventions to prevent further abuse. The failed practice resulted in an Immediate Jeopardy situation for Resident #79 on 12/8/18 at 10:30 a.m. when the resident, who was not capable of making decisions for herself, was inappropriately touched in the abdominal and vaginal area by Resident #2. At 10:40 a.m., this incident was discovered by S30HSK who then notified S11LPN. Prior to removing Resident #79 from the situation, S11LPN observed resident #2 to remove his right hand from resident #79's waistband of her pants and to smell his hand. The Immediate Jeopardy ended for resident #79 on 12/20/2018 at 6:00 p.m. when the facility implemented the necessary interventions/measures to protect the resident from further sexual abuse. S1REG and S2ADMIN were notified of the Immediate Jeopardy on 12/20/18 at 4:05 p.m. The Immediate Jeopardy was removed on 12-21-2018 at 2:17 p.m., when the facility submitted an Immediate Jeopardy Plan of Removal which included: 1. The resident found to have been affected by the deficient practice Resident #79, has been placed on Q 1 hour monitoring to ensure she is protected from any further sexual advances. Resident was assessed for physical or psychological harm with no findings of harm. 2. Resident #2, the accused was placed on one on one supervision approximately 6:00 p.m. until such time as his discharge on 12/21/18. Immediate plans have been made for the following: a. Interview Resident #2's POA was conducted 12/20/18 at 5:45 p.m. to review the finding of the investigation. Resident's POA asked could she discharge her son on 12/21/18 after receiving [MEDICAL TREATMENT]. The facility initiated the proper discharge procedures and resident will be leaving from [MEDICAL TREATMENT] on 12/21/18 with no expected return to the facility. 3. The facility has conducted interviews with all interviewable residents (beginning on 12/20/18 at 6:00 p.m. and completed on 12/21/18 by 8:00 a.m. by the facility assessment team) to ensure no inappropriate sexual contact has been experienced and to also determine the resident's current sexual status. The facility interviewed 133 residents from the facility census on 12/20/18. Of those residents interviewed 129, answered no to all questions with 4 responding inappropriately due to cognition. An additional 5 were non-interviewable and 4 residents were in the hospital for a total census review of 142 4. The facility will include, in all resident's smart chart care plans, behaviors to be monitored by staff. The results of these behaviors will be reviewed daily by the Director of Nursing or Designee. 5. All facility staff is having immediate in-servicing on how to report suspicion of inappropriate sexual conduct and who to report the suspicion if noted. Staff will not be allowed to perform their duties until they have been properly in-serviced by the abuse coordinator or properly trained designee. This in-servicing began 12/20/18 at 6:00 p.m. by the Director of Nursing Services and will continue prior to any staff reporting to work. Competency will be monitored using a posttest with the opportunity for further education if deemed necessary by the Abuse Coordinator or his trained designee. The facility Abuse Coordinator plans to monitor staff competency by direct observation, continued in-servicing, and resident and staff interview no less than 5 times per week and documenting said efforts on a facility QA tool. These audits will be continued until substantial compliance is achieved and no less than monthly thereafter. 6. The Regional Supervisor conducted and in-service on 12/21/18 at 1:00 p.m. with the Department head staff to include the Abuse Coordinator/Administrator on Abuse and Neglect, Elder Justice Act, Review of Corporate training video's on Abuse and Neglect, State Agency and Law Enforcement Flow sheet. A posttest was administered to ensure competency. These department heads will conduct further training of staff. 7. The facility has conducted an emergency QA with the facility Medical Director to outline the aforementioned protocol with no further recommendations. The QA will be on-going until substantial compliance is achieved. 8. Any residents that exhibit inappropriate sexual behavior will have an individualized person centered care plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. The deficient practice continued at a potential for more than minimal harm for the other 97 female residents in the facility who were incapable of sexual consent. Findings: Cross Refer to F600. A review of the facility's policy entitled Resident Abuse revealed in part: I. Policy Conduct detrimental to resident care that results in neglect or abuse of any resident is strictly prohibited. Refer to Administrative Manual. II. Procedures A. Resident abuse is considered a critical offense and will be treated as such in the discipline process. C. Any charge of resident abuse will be investigated by the Administrator or his designee. D. In cases involving resident abuse, where required by law, the facility administrator shall notify the proper authorities. A review of the facility's policy entitled, Sexual Assault/Rape Investigation revealed in part: Policy All allegations of sexual assault or rape or attempted rape of a resident will be investigated thoroughly by the facility following facility abuse investigation policies and procedures with the following additional steps: 1. Notify family, physician, and law enforcement personnel, as well as, state officials as stated in Abuse Investigation policy and procedure 8. Report to the State (Licensure & Certification) as per Abuse Investigation policy. A review of the facility's policy entitled Incident Investigation & Reporting (LA Only) revealed in part: Purpose To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH, Health Standards Section, law enforcement, and others as required by state and federal requirements. 1. Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property. 3. Abuse, Neglect, Misappropriation of Resident Property and Exploitation are crimes and shall be reported to proper authorities as such. The administrator will begin an investigation. The administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any reasonable suspicion of a crime against a resident. The administrator shall report no later than two hours after forming the suspicion, if the event involves abuse .facility administrator shall ensure that any incident involving an allegation of or suspicion of abuse .are reported not later than 2 hours after allegation is made to law enforcement and the state agency, if the events that cause the allegation involve abuse .in accordance with State Law. 6. The facility will thoroughly investigation all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse .Consider Emergency QA meeting and processes as needed. 7. During and after investigation, the residents will be protected from harm through frequent supervision by staff. In the case of resident-to-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed. The result of the investigation is to be reported to .appropriate officials in accordance with state law. For in-house recording of findings of the investigation, the Incident Investigation in AHT/QA should be utilized Immediate attempts to notify authorities, agencies or other parties must be carried out and documented. Immediate notification is made to appropriate law enforcement authority whenever warranted. The final results of the investigation must be reported to Health Standards Section within five (5) working days of the incident through the use of OTIS .must indicate if the allegation is valid or not. A review of the Client Incident Report (OTIS) revealed in part the following: Incident ID: 3 Occurred - 12/8/18 at 10:30 a.m. Discovered - 12/8/18 at 10:40 a.m. Reported in facility - 12/8/18 at 10:41 a.m. Accused/Allegation: Resident #2 Abuse: Sexual Victims: Resident #79 Description: NFA was notified that Resident #2 was observed to be touching another female resident, Resident #79. Both residents were removed from the living room area where the incident was observed. NFA was able to watch video surveillance that revealed Resident #2 did touch Resident #79 on her legs, breast, and abdomen area. Both residents were interviewed in regards to the incident by professional nursing staff. Resident #79 agreed when asked that she knew Resident #2 and that he touched top of her left, abdomen, and sides of abdomen. Resident #79 also mentioned Resident #2 was her boyfriend. A review of a copy of a handwritten document titled S32OFC was reviewed. It was provided by the Administrator on 12/19/18 at 10:09 a.m. It revealed: Resident #2 Trying to wake her up to talk She was my Girlfriend She didn't seem to mind Didn't believe she was cognitively impaired Never done this before Never do this again The police report number and officer contact information was written at the bottom of the page in a different handwriting. A review of the handwritten eyewitness statement created by S30HSK on 12/08/18 revealed that she saw Resident #2 digging in Resident #79's brief an hour before lunch. When he pulled his hand out of her brief he smelled his hand. The document was signed by S30HSK. A review of the Police Report dated 12/17/18 at 4:18 p.m. revealed: S32OFC responded to take a report of a possible sexual battery that occurred at a nursing home on 12/8/18 at approximately 10:20 a.m. Upon arrival, S32OFC met with the complainant, S2ADMIN, who advised one of his male residents at the facility, Resident #2, had acted inappropriately with another resident, Resident #79. S32OFC viewed the surveillance video that showed Resident #2 touch Resident #79 in her upper inner thigh near her genitals, and lift up her shirt, and touched areas of her upper chest near her breast. S1ADMIN stated, Resident #79's family had power of attorney and wished to not pursue charges, nor did Resident #79. The facility did want to have a police report made as per the state's request during an audit at the facility. An interview was conducted with S3DON on 12/17/18 at 3:03 p.m. When asked what interventions were put into place after the abuse on 12/8/18 she replied she spoke with staff and instructed them to keep Resident #2 and Resident #79 apart. Acute charting was implemented for a few days (12/8/18-12/12/18) to watch for behaviors and ensure that Resident #2 and Resident #79 were separated. She explained acute charting consisted of a note being made of the resident's locations once a shift. When asked whose responsibility it was to monitor the residents, she reported it was no one's specifics duty. She explained the whole staff was made aware and should be keeping an eye on it. An interview was conducted with Resident #2 on 12/19/18 at 8:43 a.m. He admitted he had touched Resident #79's abdomen, thigh, and leg when he was trying to wake her up. He reported Resident #79 was his girlfriend. Resident #2 stated he was told by S2Admin that the incident was reported to the police department and that they would come to interview him. Resident #2 stated that so far no one has come to talk with him. An interview was conducted with S2ADMIN on 12/19/18 at 6:50 p.m. He reported after the incident the staff were in-serviced, acute charting was implemented, and staff were instructed to keep Resident #2 and Resident #79 separated. When asked how he made sure all staff were in-serviced, he replied it was on-going. He reported he reviewed the video and could clearly see Resident #2 did not put his hand in Resident #79's pants. He reported he ultimately determined the allegation was unsubstantiated based off of what he saw in the video. He reported he contacted the police, and they came out to the facility. He reported S30HSK walked past the incident and Resident #2 did not have his hands in Resident #79's pants. He reported he had better information based off the video than the eye witness staff. When asked if all staff were educated about the abuse and interventions he restated it is an ongoing in-service. He verbalized there was a new in-service at each shift change. When asked if he was aware that not all staff were educated about the abuse and interventions, he replied We educate our staff and I am sorry if they did not retain the information. I can tell them something and 20 minutes later they forgot. When asked if he was aware staff had noticed a behavior change in Resident # 2 prior to the incident on 12/8/2018, he replied S28ACTDIR embellished on information that she did not understand and that a gut feeling was not enough for him to act on. When asked if he was aware 4 staff members had noticed a behavior change in Resident #2 he replied no. When asked why the information on the OTIS report was different than the information on the facility incident report and investigation documentation he replied that he saw the video and reported what actually happened. When asked why the allegation was unsubstantiated he stated the OTIS reported what actually occurred. When asked what he considered sexual abuse to be he stated any act that is not consensual by both parties. When asked what the police report detailed he verbalized the officer said it was sexual battery. When asked if rubbing over the legs and breast area is sexual abuse he stated yes and verified this was visible on the video. He reported on the Monday following the abuse. An interview was conducted with S1REG on 12/19/18 at 7:34 p.m. He reported the only thing the facility could have done differently was to report the alleged abuse within in 2 hours instead of 24 hours. An interview was conducted with S5ADON on 12/20/18 at 11:30 a.m. When asked how the facility ensured all CNAs were trained in regards to the abuse she replied it was an ongoing in-service and all staff were supposed to be trained prior to starting their shift. When asked if S22CNA should have been educated about the abuse and interventions she replied yes. She verbalized the staff were told to keep the 2 residents apart and do1 hour charting on Resident #2. When asked who was responsible for documenting the 1 hour charting she replied all staff. When asked who verified the hourly charting was being done she reported she would have to find out because it should be all of their responsibilities. When asked for the documentation verifying the 1 hour charting was done from 12/8/18 when the intervention was put into place to present she replied she was unsure how to find it. S5ADON was unable to verify who was responsible for the ongoing education, continued monitoring, and reevaluation of the effectiveness of education and interventions. On 12/20/18 at 12:07 p.m. S1REG provided documentation of the cover sheet of Resident #2's care plan showing 1 hour charting had been implemented and it was the CNA's responsibility to complete it. There was no date to reflect when the intervention was put into place. The smart charting screen was reviewed with S5ADON on 12/20/18 at 12:16 p.m. She reported this was how the task was made to trigger on the CNA's charting. During the review a pop up screen revealed the 1 hour charting intervention was started on 12/17/18 at 5:10 pm. When asked if that was accurate S5ADON replied she did not know what that screen meant. On 12/20/18 at 12:40 p.m. S5ADON attempted to access smart charting for the CNA's to view the completed 1 hour documentation from 12/8/18 to present. She was unable to pull up the information to show the documentation. An interview was conducted with S3DON on 12/20/18 at 12:50 p.m. When asked when the 1 hour charting was implemented for the CNA's she replied 12/16/18. When asked how it was monitored to make sure it was being done she responded, how do I know if it's being done? She then reported we are verbally monitoring the situation. She verified there was no documentation on evaluating and monitoring for effectiveness of the interventions. S3DON provided documentation on 12/20/18 at 1:00 p.m. of an in-service dated 12/10/18 titled Corrective Action Plan. The problem identified was no follow up documentation following an incident. Plan of action revealed an immediate action to in-service staff on property documentation, and audit of acute charting, and an in-service about proper documentation following an incident. The Monitoring section reported DON or designees will monitor nurse's notes on a daily basis for review. The follow up for effectiveness section was left blank with. S3DON verified this was all the physical documentation she had. An interview was conducted with S2ADMIN on 12/20/18 at 12:55 p.m. He denied having any documentation or a formal QA being done. He also denied having documentation on how the staff was monitored and evaluated to determine the effectiveness of the education and interventions that were put into place. He verified there was no hard documentation to show it was being monitored. He stated I have provided all the information and documentation that was requested and I do not have anymore. When asked to clarify he reported there was no further documentation from the angle of abuse. An interview was conducted with S1REG and S2ADMIN on 12/20/18 at 1:14 pm. S2ADMIN stated the police were notified of the abuse on Monday. He further clarified Monday, 12/17/18. When asked why there was a discrepancy between his investigation and what was stated on the police report he stated the police reported inaccurate information and that never happened. He further explained S32OFC only viewed the footage for a short period of time and he watched the video longer so he had a more accurate picture of what actually happened. When asked why the incident was not reported sooner to the police he reported the families did not want law enforcement involved. When asked to provide the facility's policy on determining capacity to consent for sexual relationships, documentation of every hour monitoring from 12/8/18 to present, and a list of residents able to consent to sexual activity S1REG responded we provided everything and there was nothing else to provide.

Based on record review and staff interview the facility failed to ensure that care and services were provided in accordance with the written plan of care by failing to ensure that 2 person assist was provided for 1 of 6 sampled residents requiring assistance with bed mobility (Resident #2). Resident #2 required extensive assistance with ADLs and required 2 person assistance with bed mobility. One person assistance only was provided, the resident was left unattended on one side, and sustained a fall from the bed resulting in a fractured right hip. Findings: Resident #2 Review of the resident's record revealed that the resident was admitted to the facility on [DATE]. Review of the record revealed the resident had the following Diagnoses: [REDACTED]. Review of the physician's orders [REDACTED]. Review of the MDS (Minimum Data Set) assessment, dated 10/26/10 and 07/28/10, revealed that the resident was assessed as requiring extensive assistance in bed mobility and needing two person physical assist in bed mobility. On 11/17/10 at 12:30 p.m., S3RN (Registered Nurse) Case Manager provided a copy of the resident's careplan and a form entitled Care Plan, Smart Chart II. S3RN stated that this was the information that was in the kiosk (Computer) on the halls for the CNAs (Certified Nurse Aide). S3RN stated that the kiosk has all the approaches from the care plan for the CNAs. S3RN stated that the CNAs document the care that they provide in the kiosk and the documentation can be printed. Review of the resident's plan of care revealed the following: Problem/Need: Smart Chart II Problem Onset: 06/10/10 Tasks for Smart Charting Approaches: Side rails up X 2 while in bed for bed mobility. 2 Person assist with bed mobility. Mechanical lift for transfers, extra large sling, with 2 person assist...... Problem/Need: Physical mobility, impaired. Problem Onset: 07/17/06 Self care deficit related to inability to self perform ADLS Approaches: Reposition in bed and wheel chair as needed for comfort and pressure relief. Dependence on staff X 2 for bed mobility, transfers, toileting, bathing; Set up and supervision for eating; Hoyer lift with staff assist X 2 for transfers. Review of the Bed Mobility Transfer documentation by the CNAs for the months of October and November 2010, revealed the following: One person physical assist for bed mobility was documented on the following dates: 10/05/10 at 2:39 p.m. 11/03/10 at 2:58 p.m. 10/06/10 at 3:25 p.m. 11/05/10 at 2:07 p.m. 10/07/10 at 2:47 p.m. 11/06/10 at 2:33 p.m. 10/10/10 at 3:04 p.m. 11/07/10 at 8:25 p.m. 10/10/10 at 6:10 p.m. 11/08/10 at 8:37 p.m. 10/13/10 at 2:06 p.m. 11/09/10 at 3:13 p.m. 10/16/10 at 2:50 p.m. 11/10/10 at 2:24 p.m. 10/17/10 at 2:02 p.m. 10/18/10 at 2:07 p.m. 10/19/10 at 2:47 p.m. 10/22/10 at 3:07 p.m. 10/23/10 at 3:08 p.m. 10/24/10 at 10:26 a.m. 10/25/10 at 10:28 a.m. 10/30/10 at 11:27 a.m. 10/31/10 at 9:14 a.m. Review of the nurse's notes revealed the following: 11/10/10 11:05 p.m. Role: Charge Nurse 10:12 p.m. reported via ______ (S5CNA) that Res. rolled onto the floor at her bed side while staff was assisting her with comfort measures with the SR (Side Rail) down. Noted Res. lying on her right side with her head against the bed side table. Neuro checks WNL (Within Normal Limits) skin intact to head no noted discoloration. T (Temperature) 98.2 R (Respiration) 20 P (Pulse) 102 BP (Blood Pressure) 138/61. Staff X 4 assisted with rolling Res. to a supine position on the floor R/T (Related to) Res. C/O (Complaint of) right LE (Lower Extremity) pain no noted skin discoloration or break in skin. Res. has no ability to move her LE therefore an accurate assessment would be X-ray of her LE. 10:30 Res. remain on the floor at her bed side and _____ NP(Nurse Practitioner) was notified of Res.'s condition. T 97.2 P 97 R 20 BP 107/56 with Neuro checks WNL and a weight of greater than 300 lbs. hitting the floor without resistance. T/O (Telephone order) Send Res. to _____ (Local hospital) for X-ray and evaluation per _____ NP. 10:35 p.m. _____ (Ambulance Service) notified of Res.'s need for transport to ______ (Hospital) and present condition. 11:00 p.m. Res. transported via stretcher to ____ (Ambulance Service) for transport to _____ (Hospital). Presently AAO X 3 (Oriented to person, place, and time) and continued C/O right LE pain. Neuro checks WNL. Prepared by: ______ (S4LPN). There was no documented evidence in the nurse's notes that indicated that the CNA staff were providing 2 person assist with bed mobility. Review of the facility's Employee Warning Report for S5CNA revealed the following: Date of violation: 11/10/10 - Did not use 2-person assist when changing resident in _____ (Resident #2's room number). Resident rolled out of bed. Fx'd (Fractured) right hip. Attached to the Warning Report was the following: Describe the incident that occurred with _______ (Resident #2) - Went in the room to change _______ (Resident #2). I put the left side of the rail down turn her over I went to the other side of the bed I was trying to pull the fitting sheet and she fell off the bed I have change her before by myself I did not do this on purpose Was anyone in the room with you - No Do you usually change ________ (Resident #2) by yourself - Yes Did you intend to harm ______ (Resident #2) - No (Answers to above questions hand written, form signed by S5CNA and dated 11/11/10). Review of the resident's hospital records revealed the following: Emergency Department Course: After initial history and physical exam, x-ray of the right femur reveals a femoral neck fracture with displacement.....Patient will be admitted for further treatment..... Patient will be placed in Buck's traction. She was given narcotics for pain. Radiology Report: 11/10/10 Right Femur, 2 views. Impression: Acute subcapital right [MEDICAL CONDITION]. Consultation Request Report: 11/11/10 Chief Complaint: Right hip pain. X-Ray: Right femoral neck fracture, displaced. Recommendation: Would consider conservative treatment, is non-ambulatory. Will discuss with _______ (Primary Care Physician) Radiology Report: 11/17/10 Right hip, 2 views. Clinical information: status [REDACTED]. On 11/17/10 at 12:00 p.m., S3RN Case Manager was interviewed and verified that she did the follow up on the fall for Resident #2. S3 verified that the resident fell out of bed during care by one CNA. S3 verified that the resident was a 2 person assist for bed mobility, but the CNA provided care to the resident alone on 11/10/10. S3RN verified that the resident rolled out of bed to the floor when the CNA left the side rail down during care. On 11/17/10 at 12:05 p.m., S1DON (Director of Nursing) was interviewed. After reviewing the incident report for Resident #2, she stated that it was on the resident's care plan that she needed 2 person assist for bed mobility. When asked if the CNA knew that the resident needed 2 person assist, she stated that aide knew it, she just didn't get assistance. S1 stated that she contacted the hospital and they informed her that the resident had a [MEDICAL CONDITION]. On 11/17/10 at 1:00 p.m., S6CNA was interviewed and verified that she was routinely assigned to Resident #2. When asked which resident's on her assignment required 2 person assist with bed mobility, she stated Resident #2. When asked how long Resident #2 had required 2 person assist in bed mobility, she stated, "Forever". She stated that as long as she had been providing care to the resident she had needed 2 person assist. S6 stated that the resident could not move or assist with turning. On 11/17/10 at 2:30 p.m., S5CNA was interviewed and verified that she was the CNA assigned to Resident #2 on 11/10/10 when she fell out of bed. When asked what had happened, she stated that she turned the resident on her left side and put the side rail down. S5 stated that she then went to the right side of the bed and pulled on the draw sheet and the resident rolled out of bed because she left the side rail down. S5 verified that she had performed the care alone. S5 stated that she had been working with the resident for over 5 years. S5 stated that she usually changed the resident by herself. S5 stated that the other CNAs are busy too. S5 verified that there was a CNA supervisor on duty that night. S5 stated that the facility told the staff that they need to get another CNA to assist. S5 stated that she knew the resident was supposed to have 2 person assist with bed mobility. S5 verified that 2 person assist for bed mobility was in the kiosk prior to this incident. On 11/17/10 at 3:05 p.m. S7CNA Supervisor was interviewed and verified that she was the CNA Supervisor for the 3-11 shift and was working the night Resident #2 fell out of bed. S7 stated that the resident was a 2 person assist for bed mobility and verified that it was in the kiosk. S7 stated that some CNAs just do it themselves and don't ask for help. S7 stated that she was available to assist the CNAs. On 11/17/10 at 3:15 p.m., S2ADM (Administrator) was interviewed. S2 stated that S5CNA had admitted to him that she had been changing and repositioning Resident #2 by herself for years. He stated that S5CNA admitted to him that she knew the resident required 2 person assist and thought she was helping by providing the care alone. S2 stated that the resident was scheduled to have surgery at 4:00 p.m. today to repair her [MEDICAL CONDITION]. On 11/18/10 at 9:45 a.m., S8LPN was interviewed. When asked how the nurse ensured that the CNAs were providing care to the residents in accordance with the plan of care, she stated that they have report at the beginning of the shift and tell them what resident needs. S8 stated, "We have the kiosk to let us know the type of assistance the resident needs. I would like to think our CNAs are following our procedure." S8 stated that she may observe CNA care during medication pass. When asked how she knew if the CNA was following the plan of care, she stated, "We fully rely on training, inservice and the reports of decline." On 11/18/10 at 9:55 a.m., S9LPN was interviewed. When asked how she ensured that the CNA followed the plan of care for residents requiring 2 person assist with bed mobility, she stated, "The aides I work with know that they are supposed to use 2 people, they are written up if they don't." On 11/18/10 at 10:30 a.m., S1DON was interviewed. When asked how the nurses ensure that the CNAs followed the resident's plan of care, she stated that there were just a couple of residents before 11/10/10 that required 2 person mobility and Resident #2 was one of them. She stated that the nurses know to check on this now. After reviewing the ADL records for Resident #2 for October and November, 2010, she verified that the CNAs had documented one person assist on multiple days. S1 stated that the care plan nurse had assessed the resident and care planned the 2 person assist with bed mobility. On 11/18/10 at 12:00 p.m., S4LPN was interviewed by telephone. S4 verified that the she was the nurse assigned to Resident #2 on the evening of 11/10/10 when she fell out of bed. When asked how do you ensure that the CNAs are providing care according to the resident's plan of care, she stated that she instructed the CNA at the beginning of the shift and told them to use 2 people for any personal care. S4 stated, "We have to keep telling her (Resident #2) and the CNAs that it takes 2 people to do any personal care. S4 stated that she told the CNAs and they are supposed to comply. S4 stated that safety for the CNAs and the resident requires that 2 people assist her. S4 stated that the resident's size and limited range of motion made her a 2 person assist. When asked how she knew if the CNAs were using 2 person assist, she stated she instructed the CNA and made sure they knew 2 people were required.

Based on record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for 1 of 6 sampled residents requiring assistance with bed mobility (Resident #2) by failing to: 1) Provide necessary care and service to ensure the resident's safety during assistance with ADLs (Activities of Daily Living). 2) Implement the identified approaches in the resident's plan of care for safe bed mobility. 3) Provide supervision of staff to ensure that identified interventions/approaches were implemented in accordance with the plan of care. Resident #2 required extensive assistance with ADLs and required 2 person assistance with bed mobility. One person assistance only was provided, the resident was left unattended on one side, and sustained a fall from the bed resulting in a fractured right hip. Findings: Resident #2 Review of the resident's record revealed that the resident was admitted to the facility on [DATE] and transported to the hospital on [DATE]. Review of the record revealed the resident had the following Diagnoses: [REDACTED]. Review of the physician's orders [REDACTED]. Review of the MDS (Minimum Data Set) assessment, dated 10/26/10 revealed that the resident was assessed as requiring extensive assistance in bed mobility and needing two person physical assist in bed mobility. On 11/17/10 at 12:30 p.m., S3RN (Registered Nurse) Case Manager provided a copy of the resident's careplan and a form entitled Care Plan, Smart Chart II. S3RN stated that this was the information that was in the kiosk (Computer) on the halls for the CNAs (Certified Nurse Aide). S3RN stated that the kiosk has all the approaches from the care plan for the CNAs. S3RN stated that the CNAs document the care that they provide in the kiosk and the documentation can be printed. Review of the resident's plan of care revealed the following: Problem/Need: Smart Chart II Problem Onset: 06/10/10 Tasks for Smart Charting Approaches: Side rails up X 2 while in bed for bed mobility. 2 Person assist with bed mobility. Mechanical lift for transfers, extra large sling, with 2 person assist...... Problem/Need: Physical mobility, impaired. Problem Onset: 07/17/06 Self care deficit related to inability to self perform ADLS Approaches: Reposition in bed and wheel chair as needed for comfort and pressure relief. Dependence on staff X 2 for bed mobility, transfers, toileting, bathing; Set up and supervision for eating; Hoyer lift with staff assist X 2 for transfers. Review of the Bed Mobility Transfer documentation by the CNAs for the months of October and November 2010, revealed the following: One person physical assist for bed mobility was documented on the following dates: 10/05/10 at 2:39 p.m. 11/03/10 at 2:58 p.m. 10/06/10 at 3:25 p.m. 11/05/10 at 2:07 p.m. 10/07/10 at 2:47 p.m. 11/06/10 at 2:33 p.m. 10/10/10 at 3:04 p.m. 11/07/10 at 8:25 p.m. 10/10/10 at 6:10 p.m. 11/08/10 at 8:37 p.m. 10/13/10 at 2:06 p.m. 11/09/10 at 3:13 p.m. 10/16/10 at 2:50 p.m. 11/10/10 at 2:24 p.m. 10/17/10 at 2:02 p.m. 10/18/10 at 2:07 p.m. 10/19/10 at 2:47 p.m. 10/22/10 at 3:07 p.m. 10/23/10 at 3:08 p.m. 10/24/10 at 10:26 a.m. 10/25/10 at 10:28 a.m. 10/30/10 at 11:27 a.m. 10/31/10 at 9:14 a.m. Review of the nurse's notes revealed the following: 11/10/10 10:34 p.m. Role: Charge Nurse fell from bed at a height of approx. 3 feet to the floor with Res. (Resident) weight at greater than 300 lbs. (Pounds) and no resistance to the fall. Res. fell from her bed to the floor with a weight of over 300 lbs. hitting the floor with no resistance. Prepared by: _____ (S4LPN - Licensed Practical Nurse). 11/10/10 11:05 p.m. Role: Charge Nurse 10:12 p.m. reported via ______ (S5CNA) that Res. rolled onto the floor at her bed side while staff was assisting her with comfort measures with the SR (Side Rail) down. Noted Res. lying on her right side with her head against the bed side table. Neuro checks WNL (Within Normal Limits) skin intact to head no noted discoloration. T (Temperature) 98.2 R (Respiration) 20 P (Pulse) 102 BP (Blood Pressure) 138/61. Staff X 4 assisted with rolling Res. to a supine position on the floor R/T (Related to) Res. C/O (Complaint of) right LE (Lower Extremity) pain no noted skin discoloration or break in skin. Res. has no ability to move her LE therefore an accurate assessment would be X-ray of her LE. 10:30 Res. remain on the floor at her bed side and _____ NP(Nurse Practitioner) was notified of Res.'s condition. T 97.2 P 97 R 20 BP 107/56 with Neuro checks WNL and a weight of greater than 300 lbs. hitting the floor without resistance. T/O (Telephone order) Send Res. to _____ (Local hospital) for X-ray and evaluation per _____ NP. 10:35 p.m. _____ (Ambulance Service) notified of Res.'s need for transport to ______ (Hospital) and present condition. 11:00 p.m. Res. transported via stretcher to ____ (Ambulance Service) for transport to _____ (Hospital). Presently AAO X 3 (Oriented to person, place, and time) and continued C/O right LE pain. Neuro checks WNL. Prepared by: ______ (S4LPN). Further review of the nurse's notes for October and November, 2010 revealed that on 10/19/10 and 11/10/10 the nurse documented that the Hoyer lift was used with the assistance of 2 CNAs. There was no documented evidence in the nurse's notes that indicated that the CNA staff were providing 2 person assist with bed mobility. Review of the facility's Resident Incident Report revealed the following: Incident type: Fall w/head injury Type of injury: None apparent Date/Time: 11/10/10 10:11 p.m. Witness: _____ (S5CNA) Report prepared by: _____ (S4LPN) Narrative of incident and description of injuries: Staff states Res. rolled OOB (Out of Bed) to the floor while being assisted with comfort measures and SR down. Res. C/O right LE pain on a scale of 3/10. No apparent injury other than Res.'s complaint. Immediate Post-Incident Action: Keep Res.'s SR up at all times and be assisted via staff X 2. Review of the facility's Employee Warning Report for S5CNA revealed the following: Date of violation: 11/10/10 - Did not use 2-person assist when changing resident in _____ (Resident #2's room number). Resident rolled out of bed. Fx'd (Fractured) right hip. Attached to the Warning Report was the following: Describe the incident that occurred with _______ (Resident #2) - Went in the room to change __ _____ (Resident #2). I put the left side of the rail down turn her over I went to the other side of the bed I was trying to pull the fitting sheet and she fell off the bed I have change her before by myself I did not do this on purpose Was anyone in the room with you - No Do you usually change ________ (Resident #2) by yourself - Yes Did you intend to harm ______ (Resident #2) - No (Answers to above questions hand written, form signed by S5CNA and dated 11/11/10). Review of the resident's hospital records revealed the following: Nursing Triage and Assessment: Patient presents from _____ (Facility) S/P (status [REDACTED]. bed, states fell out of bed while repositioning, C/O pain to RLE (Right Lower Extremity) from knee to hip.... Pain Scale: States pain 8/10. Physician Chart Emergency Department Course: After initial history and physical exam, x-ray of the right femur reveals a femoral neck fracture with displacement.....Patient will be admitted for further treatment..... Patient will be placed in Buck's traction. She was given narcotics for pain. Radiology Report: 11/10/10 Right Femur, 2 views. Impression: Acute subcapital right [MEDICAL CONDITION]. Consultation Request Report: 11/11/10 Chief Complaint: Right hip pain. X-Ray: Right femoral neck fracture, displaced. Recommendation: Would consider conservative treatment, is non-ambulatory. Will discuss with _______ (Primary Care Physician) Radiology Report: 11/17/10 Right hip, 2 views. Clinical information: status [REDACTED]. On 11/17/10 at 11:35 p.m., S10CNA Supervisor was interviewed. S10 stated that the facility has a CNA Supervisor on the 7-3 and 3-11 shifts during the week, and there is a CNA Supervisor on the weekends. S10 stated that they have a book that at the nurse's station that has what lifts, transfer, or assistance each resident needs. S10 stated that the kiosk has all the residents' information in it, or the CNA can ask the nurse. S10 verified that Resident #2 required 2 people to assist her in bed. On 11/17/10 at 12:00 p.m., S3RN Case Manager was interviewed and verified that she did the follow up on the fall for Resident #2. S3 verified that the resident fell out of bed during care by one CNA. S3 verified that the resident was a 2 person assist for bed mobility, but the CNA provided care to the resident alone on 11/10/10. S3RN verified that the resident rolled out of bed to the floor when the CNA left the side rail down during care. On 11/17/10 at 12:05 p.m., S1DON (Director of Nursing) was interviewed. After reviewing the incident report for Resident #2, she stated that it was on the resident's care plan that she needed 2 person assist for bed mobility. When asked if the CNA knew that the resident needed 2 person assist, she stated that aide knew it, she just didn't get assistance. S1 stated that she contacted the hospital and they informed her that the resident had a [MEDICAL CONDITION]. On 11/17/10 at 1:00 p.m., S6CNA was interviewed and verified that she was routinely assigned to Resident #2. When asked which resident's on her assignment required 2 person assist with bed mobility, she stated Resident #2. When asked how long Resident #2 had required 2 person assist in bed mobility, she stated, "Forever". She stated that as long as she had been providing care to the resident she had needed 2 person assist. S6CNA stated that she would never consider trying to turn or provide care to this resident without assistance. S6 stated that the resident could not move or assist with turning. On 11/17/10 at 2:30 p.m., S5CNA was interviewed and verified that she was the CNA assigned to Resident #2 on 11/10/10 when she fell out of bed. When asked what had happened, she stated that she turned the resident on her left side and put the side rail down. S5 stated that she then went to the right side of the bed and pulled on the draw sheet and the resident rolled out of bed because she left the side rail down. S5 verified that she had performed the care alone. S5 stated that she had been working with the resident for over 5 years. S5 stated that she usually changed the resident by herself. S5 stated that the other CNAs are busy too. S5 verified that there was a CNA supervisor on duty that night. S5 stated that the facility told the staff that they need to get another CNA to assist. S5 stated that she knew the resident was supposed to have 2 person assist with bed mobility. S5 verified that 2 person assist for bed mobility was in the kiosk prior to this incident. On 11/17/10 at 3:05 p.m. S7CNA Supervisor was interviewed and verified that she was the CNA Supervisor for the 3-11 shift and was working the night Resident #2 fell out of bed. S7 stated that the resident was a 2 person assist for bed mobility and verified that it was in the kiosk. S7 stated that some CNAs just do it themselves and don't ask for help. S7 stated that she was available to assist the CNAs. On 11/17/10 at 3:15 p.m., S2ADM (Administrator) was interviewed. S2 stated that S5CNA had admitted to him that she had been changing and repositioning Resident #2 by herself for years. He stated that S5CNA admitted to him that she knew the resident required 2 person assist and thought she was helping by providing the care alone. S2 stated that the resident was scheduled to have surgery at 4:00 p.m. today to repair her [MEDICAL CONDITION]. On 11/18/10 at 9:45 a.m., S8LPN was interviewed. When asked how the nurse ensured that the CNAs were providing care to the residents in accordance with the plan of care, she stated that they have report at the beginning of the shift and tell them what resident needs. S8 stated, "We have the kiosk to let us know the type of assistance the resident needs. I would like to think our CNAs are following our procedure." S8 stated that she may observe CNA care during medication pass. When asked how she knew if the CNA was following the plan of care, she stated, "We fully rely on training, inservice and the reports of decline." On 11/18/10 at 9:55 a.m., S9LPN was interviewed. When asked how she ensured that the CNA followed the plan of care for residents requiring 2 person assist with bed mobility, she stated, "The aides I work with know that they are supposed to use 2 people, they are written up if they don't." On 11/18/10 at 10:30 a.m., S1DON was interviewed. When asked how the nurses ensure that the CNAs followed the resident's plan of care, she stated that there were just a couple of residents before 11/10/10 that required 2 person mobility and Resident #2 was one of them. She stated that the nurses know to check on this now. After reviewing the ADL records for Resident #2 for October and November, 2010, she verified that the CNAs had documented one person assist on multiple days. S1 stated that the care plan nurse had assessed the resident and care planned the 2 person assist with bed mobility. On 11/18/10 at 12:00 p.m., S4LPN was interviewed by telephone. S4 verified that the she was the nurse assigned to Resident #2 on the evening of 11/10/10 when she fell out of bed. When asked how do you ensure that the CNAs are providing care according to the resident's plan of care, she stated that she instructs the CNA at the beginning of the shift and told them to use 2 people for any personal care. S4 stated, "We have to keep telling her (Resident #2) and the CNAs that it takes 2 people to do any personal care. S4 stated that she told the CNAs and they are supposed to comply. S4 stated that safety for the CNAs and the resident requires that 2 people assist her. S4 stated that the resident's size and limited range of motion made her a 2 person assist. When asked how she knew if the CNAs were using 2 person assist, she stated she instructed the CNA and made sure they knew 2 are required.