Every finding on record at Magnolia Manor of Columbus Nursing Center - West

Based on review of facility policy, record review, and interview, the facility failed to ensure three Residents (R) R24, R61 and R97 out of five residents reviewed for abuse/neglect were protected from potential sexual abuse. The facility failed to ensure R61 was protected from potential sexual abuse by a staff member/staff members after she made an allegation of potential sexual assault and failed to ensure R24 and R97 were protected from potential sexual abuse after the two residents, who were not interviewable, were observed together in R24's room with their pants down. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be, or to continue to be, sexually abused by staff or other residents leading to serious physical and/or psychological harm for each resident. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility failed to ensure R24 and R97 were protected from further potential abuse after an incident of potential resident to resident sexual abuse was observed between the two residents. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F600, Abuse. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. The noncompliance remained at a scope and severity level of D (isolated with the with the potential for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of the facility's undated Abuse Prohibition, Reporting and Investigation Policy read, in pertinent part, Definitions: 1. Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology; and Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; and It is the intent of Magnolia Manor facilities to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. We believe each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 1. Review of R61's Admission Record, dated 09/06/24 and found in the Electronic Medical Record (EMR) under the Admissions Tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes, depression, and anxiety. Review of R61's annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/07/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be completed for the resident due to her refusal to participate in the interview. The assessment indicated the resident had both short and long-term memory deficits. The MDS indicated R61 did not display any behaviors during the assessment reference period. Review of R61's comprehensive Care Plan most recently dated 08/16/24 and found in the EMR under the Care Plan tab, indicated the resident exhibited behaviors including refusal of care and sometimes had delusions and/or hallucinations. The Care Plan also indicated the resident exhibited signs and symptoms of depression, including little interest or pleasure in doing things, feeling down, depressed, or hopeless, poor appetite and being short tempered at times. Review of the Complaint Form, dated 08/06/24 provided by the facility and completed by the MDS Coordinator (MDSC) on behalf of R61, read, in pertinent part, I spoke with (R61) asking her if she had any complaints. She said yes. She said the CNAs (Certified Nursing Assistants) let her lay in urine and she is only changed once a shift. She said they are sometimes rough with her when giving care. She said she wondered if the females that work here are Lesies (sic) because they put their fingers up her. She said they put stuff in her drinks and are trying to poison her. Review of R61's EMR indicated nothing related to the resident's report of potential abuse by staff and nothing to indicate the resident was physically assessed and or sent to the local Emergency Department (ED) for evaluation related to the above referenced potential abuse. Nothing could be found in the facility's documentation or in the resident's EMR to indicate any attempt was made to determine what specific staff R61 was referring to related to the allegation of potential abuse or that R61 was protected from further potential abuse by staff after her allegation of potential abuse was made on 08/06/24. During an interview with the MDSC on 09/03/24 at 2:36 PM, she confirmed R61 reported the potential abuse to her on 08/06/24. The MDSC stated R61 alleged female staff put their fingers in her. She stated (R61) looked right at me wide eyed, held my hand, and said she wondered if the females were lezzies (lesbians) because they put their fingers up me. The MDSC stated she reported the allegation to Registered Nurse (RN)1 (the Unit Manager responsible for R61's care), the Administrator, and the Director of Nursing (DON) immediately after the report of potential abuse. The MDSC stated RN1 told her the resident had recently been impacted (with hard stool in her colon) and that R61 had a history of refusing cares. The MDSC indicated she was not aware of how R61's allegation of potential abuse was addressed after it was reported. During an interview with RN1 on 09/03/24 at 3:01 PM, she confirmed the MDSC reported R61's allegation of potential abuse to her on 08/06/24 and confirmed R61's allegations were related to staff poisoning her drinks and her perception that (female) staff in the facility were lesbians and were fingering her (placing their fingers in her vagina). RN1 stated she and the Administrator spoke to R61 related to the allegation of potential abuse two days after the allegation was made and the resident stated she didn't want the CNAs to change her (provide peri-care/incontinence care) because the staff was all lesbians and were going to finger her. RN1 confirmed no physical assessment was completed for R61 nor did staff attempt to send the resident to the local ED for evaluation related to the report of potential abuse. She confirmed nothing was done, after the resident's report of potential abuse, to ensure the resident was protected from further potential abuse by staff as far as she was aware. During an interview with the Social Services Director (SSD) on 09/03/24 at 3:32 PM, she stated she was aware of R61's allegation of potential abuse. She stated the MDSC brought the resident's Complaint Form related to the allegation to her on the day of the report, and that she read the complaint form over and then gave the form to the DON and the Administrator the same day. The SSD stated she and RN1 attempted to interview R61 about the report of potential abuse on the day of the report, but R61 refused to speak with them. The SSD stated she was not involved in/aware of any measures put into place related to the resident's allegation to ensure the resident's protection from further potential abuse. During an interview with the DON on 09/03/24 at 3:42 PM, she confirmed she was the facility's Abuse Coordinator and stated she was aware of R61's allegation of potential abuse, but stated she was not involved in facility follow-up related to the allegation to ensure R61's protection from further potential abuse. The DON stated she had heard a little bit about the resident's allegation from staff, but stated R61 could be a little bit delusional. The DON confirmed R61 had never been physically assessed related to the allegation of potential abuse and stated she did not think any attempt had been made to send the resident to the ED for evaluation. She confirmed nothing had been done related to the resident's allegation of potential abuse to ensure R61 was protected from further potential abuse by staff. She stated her expectation was any resident who reported potential abuse was to be assessed for potential injury and measures were to be taken to ensure the resident was protected from further potential abuse. During an interview with the Administrator and DON on 09/04/24 at 11:16 AM, the Administrator confirmed the DON was the facility's Abuse Coordinator and stated he and the DON were both responsible for ensuring residents were protected from potential abuse. The Administrator stated he was aware of R61's allegation of potential abuse on 08/06/24, but stated he did not interpret the report as potential abuse since the resident often refused care, had a history of kicking a CNA during care, and had a history of urinary tract infections (UTIs) and potential bowel obstruction requiring staff to potentially remove stool digitally from the resident's rectum. The Administrator stated his expectation was that any resident who reported potential abuse should be protected from further potential abuse while an investigation into the alleged abuse was conducted. He confirmed this had not been done related to R61's allegation of potential abuse. During an interview on 09/06/24 at 2:00 PM, R61 confirmed her report of potential abuse to the MDSC on 08/06/24. 27375 2. Review of R24's Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified and dementia in other diseases classified elsewhere without behavioral disturbance. Review of R24's quarterly MDS with an (ARD) of 07/09/24 revealed the facility assessed the resident to have a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. 3. Review of R97's Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified, with other behavioral disturbance, and unspecified psychosis not due to a substance or known physiological condition. Review of R97's quarterly MDS with an (ARD) of 02/15/24 revealed the facility assessed the resident's BIMS score was blank, there was no score to assess resident's cognitive status. Record review of R97's Progress Note dated 01/25/24 located in the EMR under the Progress Note tab revealed resident was noted at 4:05 PM by CNA's doing rounds to be in R24's room with the door closed. R24 was lying in her bed on a towel with her pants half-way down and R97 was coming out of R24's bathroom with his shirt up and his pants half-way down. Review of a Witness Statement provided by the facility dated 01/25/24 written by Certified Nurse Aide (CNA) 8 revealed CNA8 went into R24's room to change R24's brief. CNA8 opened R24's bathroom and R97 was in the bathroom barefoot and pulling up his shirt. CNA8's witness statement also stated R24 was sitting on her bed, the covers were pulled back and a towel was spread out on the bed. Review of a Witness Statement dated 01/25/24 written by CNA7 revealed CNA7 entered R24's room, she saw R24's pants down and R97 was in R24's bathroom with his shoes off and his and his shirt up. The statement also revealed there was a large towel laid across R24's bed. Review of a Witness Statement provided by the facility dated 01/25/24 written by Licensed Practical Nurse (LPN) 13 revealed on 01/25/24 approximately 6:00 PM CNA's reported to her that R24's bedroom door was closed and when they entered they witnessed, R24 laying on her bed on a towel with her pants halfway down. The statement also revealed R97 was coming out of R24's bathroom with his shoes off, shirt up and his pants half-way down. The residents could not explain what happened. During an interview on 09/03/24 at 11:15 AM the Administrator stated he was aware of the potential abuse incident between R24 and R97. However, he felt the incident did not need to be investigated or reported to the state, because staff did not witness R24 and R97 doing anything. During an interview on 09/03/24 at 4:04 PM with the DON who read the three witness statements and confirmed the incident between R24 and R97 was potential abuse. She said she did not know if it was an allegation of sexual abuse, because staff did not see R24 and R97 doing anything. During an interview on 09/04/24 at 4:57 PM, CNA7 stated she remembered R97 was in R24's bathroom with his shoes off and his shirt up, while R24's pants were down with a large towel laid on R24's bed. 29015

Based on review of facility policy, record review, and interviews, the facility failed to ensure allegations of potential abuse related to three (Residents (R) R24, R61 and R97) out of five residents reviewed for abuse/neglect were appropriately reported to the State Agency and other required agencies. The facility failed to report an allegation of sexual abuse by staff members by R61 and failed to report potential sexual abuse between R97 and R24 witnessed by staff members to the State Agency, the local Ombudsman, and local law enforcement. The facility's failure to ensure the alleged potential sexual abuse was reported to appropriate agencies created the potential for residents to continue to be sexually abused by staff or other residents leading to serious physical and/or psychological harm for each resident. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility failed to report potential sexual abuse between R24 and R97 to appropriate outside agencies, including the State Agency. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F609, Reporting of Potential Abuse. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. Findings include: Review of the facility's undated Abuse Prohibition, Reporting and Investigation Policy read, in pertinent part, Definitions: 1. Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and D. Reporting: 1) Once a complaint or situation is identified involving alleged mistreatment, neglect or abuse including injuries of unknown source/origin and misappropriation of resident property the incident will be immediately reported. a. The Administrator or designee will immediately notify (the State Agency) and resident representative of the incident and pending investigation. The Ombudsman will also be notified as appropriate. The Administrator will direct the investigation. b. If indicated and/or directed notification to the local Police Department should be made Obtain the badge number of the investigation officer. Submit the badge number with the facility report to (the State Agency). 1.Review of R61's Admission Record, dated 09/06/24 and found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes, depression, and anxiety. Review of R61's annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/07/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be completed for the resident due to her refusal to participate in the interview. The assessment indicated the resident had both short and long-term memory deficits. Review of a Complaint Form, provided by the facility dated 08/06/24 and completed by the MDS Coordinator (MDSC) on behalf of R61, read, in pertinent part, I spoke with (R61) asking her if she had any complaints. She said yes. She said the CNAs (Certified Nursing Assistants) let her lay in urine and she is only changed once a shift. She said they are sometimes rough with her when giving care. She said she wondered if the females that work here are Lesies (sic) because they put their fingers up her. She said they put stuff in her drinks and are trying to poison her. Nothing could be found in the facility's documentation or in the resident's EMR to indicate the allegation of potential sexual abuse was reported to the State Agency, the Ombudsman, or the local Police Department. During an interview with the MDSC on 09/03/24 at 2:36 PM, she confirmed R61 reported the potential abuse to her on 08/06/24. The MDSC stated R61 alleged female staff put their fingers in her. She stated (R61) looked right at me wide eyed, held my hand, and said she wondered if the females were lezzies (lesbians) because they put their fingers up me. The MDSC stated she reported the allegation to Registered Nurse (RN)1 (the Unit Manager responsible for R61's care), the Administrator, and the Director of Nursing (DON) immediately after the report of potential abuse. During an interview with RN1 on 09/03/24 at 3:01 PM, she confirmed the MDSC reported R61's allegation of potential abuse to her on 08/06/24 and confirmed the allegation of potential abuse was also reported to the DON and Administrator immediately after the resident's allegation of potential abuse. RN1 stated the DON and Administrator were responsible for reporting allegations of potential abuse to outside agencies. During an interview with the Social Services Director (SSD) on 09/03/24 at 3:32 PM, she stated she was aware of R61's allegation of potential abuse. She stated the MDSC brought the resident's Complaint Form related to the allegation to her on the day of the report, and that she read the complaint form over and then gave the form to the DON and the Administrator the same day. She stated she did not know if the allegation was reported to the State Agency, Ombudsman or Local Law Enforcement. During an interview with the DON on 09/03/24 at 3:42 PM, she confirmed she was the facility's Abuse Coordinator and stated she was aware of R61's allegation of potential abuse, but confirmed the allegation was never reported to the State Agency, Ombudsman or Local Police Department. The DON stated upon reflection of the report, R61's 08/06/24 allegation of potential sexual abuse should have been reported to the appropriate outside agencies, including the State Agency, the Ombudsman, and Local Law Enforcement. During an interview with the Medical Director on 09/04/24 at 11:11 AM, he stated he was not aware of R61's allegation of potential sexual abuse. He stated the allegation should have been reported to himself, the State Agency, the Local Ombudsman and Local Law Enforcement immediately and no later than 24 hours after the allegation was made. During an interview with the Administrator and DON on 09/04/24 at 11:16 AM, the Administrator stated he and the DON were responsible for reporting allegations of potential abuse to local outside agencies and confirmed R61's allegation of potential sexual abuse had never been reported to the appropriate outside agencies, including the State Agency, local Ombudsman, and the Local Police Department. The Administrator stated he was aware of R61's allegation of potential abuse on 08/06/24, but stated he did not interpret the report as potential abuse since the resident often refused care, had a history of kicking a CNA during care, and had a history of urinary tract infections (UTIs) and potential bowel obstruction requiring staff to potentially remove stool digitally from the resident's rectum. The Administrator stated because he did not interpret R61's report as an allegation of potential abuse, the allegation was not reported to relevant outside agencies. During an interview on 09/06/24 at 2:00 PM, R61 confirmed her report of potential abuse to the MDSC on 08/06/24. 27375 2. Review of R24's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified and dementia in other diseases classified elsewhere without behavioral disturbance. Review of R24's quarterly MDS with an ARD of 07/09/24 revealed the facility assessed the resident to have a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. 3. Review of R97's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified, unspecified psychosis not due to a substance or known physiological condition, and dementia. Review of R97's quarterly MDS with an ARD of 02/15/24 revealed the resident's BIMS was blank which indicated there is no score to assess resident's cognitive status. Review of R97's Progress Note dated 01/25/24 located in the EMR under the Progress Note tab revealed Resident was noted at 4:05 PM by CNA's doing rounds to be in R24's room with the door closed. R24 was lying in her bed on a towel with her pants half-way down and R97 was coming out of R24's bathroom with his shirt up and his pants half-way down. There was no evidence in the EMR that the potential sexual abuse was reported to the State Agency. During an interview on 09/03/24 at 11:15 AM the Administrator stated he felt the incident did not need to be investigated or reported to the state, because staff did not witness R24 and R97 doing anything. During an interview on 09/03/24 at 4:04 PM with the DON confirmed the incident witnessed between R24 and R97 should have been reported to the State Agency. 29015

Based on review of facility policy, record review, and interview, the facility failed to ensure allegations of potential abuse related to three Residents (R ) R24, R61 and R97 out of five residents reviewed for abuse/neglect were thoroughly investigated. The facility failed to thoroughly investigate an allegation of sexual abuse by staff members by R61 and potential sexual abuse between R97 and R24 which was witnessed by staff members. The facility's failure to ensure the alleged potential sexual abuse was thoroughly investigated created the potential for residents to continue to be sexually abused by staff or other residents leading to serious physical and/or psychological harm for each resident. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility failed to thoroughly investigate potential sexual abuse between R24 and R97. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F610, Investigation of Potential Abuse. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. Findings include: The facility's undated Abuse Prohibition, Reporting and Investigation Policy read, in pertinent part, Definitions: 1. Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and E. Investigation: 1) Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source/origin and misappropriation of resident property, the following investigation and reporting procedures will be followed: a. The description of the alleged complaint is written on the investigation form. Any physical evidence and description of emotional state will be documented. b. Information gathering - The following information will be gathered: What allegedly occurred? Who is the alleged victim? Who allegedly did it (Who is the suspect or physical description)? Who did they do it to (Who is the resident)? What happened (Be specific about the event that occurred)? When did it happen (The resident's room, bathroom, dining room, etc.)? Why? Include cognitive status of victims and residents who are witnesses. a. Document the description of the injury. Describe size, color, appearance, and location of any injuries and what treatment was rendered, if any. b. Interview will be conducted of all pertinent parties. Written signed statements from any involved should be obtained if possible. Statements will be gathered from the suspect, person making the accusations, resident involved, reliable residents who may have witnessed the incident, and any other persons who may have some information. Identify any possible conflicts between witnesses. c. Past performance and/or previous incidents of involved parties will be evaluated. Review schedules and assignments showing when and where suspect was working at time of the alleged incident. d. All investigative information will be kept on file in a secured location. All information is confidential in nature. 1. Review of R61's Admission Record, dated 09/06/24 and found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes, depression, and anxiety. Review of R61's annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/07/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be completed for the resident due to her refusal to participate in the interview. The assessment indicated the resident had both short and long-term memory deficits. Review of a Complaint Form, provided by the facility dated 08/06/24 and completed by the MDS Coordinator (MDSC) on behalf of R61, read, in pertinent part, I spoke with (R61) asking her if she had any complaints. She said yes. She said the CNAs (Certified Nursing Assistants) let her lay in urine and she is only changed once a shift. She said they are sometimes rough with her when giving care. She said she wondered if the females that work here are Lesies (sic) because they put their fingers up her. She said they put stuff in her drinks and are trying to poison her. A statement related to R61's allegation of potential abuse and attached to the Complaint Form, dated 08/08/24 (two days after the resident's initial report of potential abuse) and signed by the Administrator and Registered Nurse (RN)1 (the Unit Manager responsible for R61's care) read, Writer and Unit Manager met with resident as an additional follow-up to her recent grievance. Resident voiced that things are going well. She stated that she has not been refusing care and that her mind is good, and she knows when she needs care. Writer recommended that she allow the staff to provide her some nail care. She stated that she would allow (staff) to do it. The writer also encouraged the resident to attend activities, and a TV and radio was offered but she declined. Resident requested more snacks and beverages. Follow-up was conducted with food service. The statement did not address the investigation of resident's allegation of potential sexual abuse. Review of the Findings From Investigation document, attached to R61's 08/06/24 Complaint Form dated 08/08/24, and signed by the Administrator, read, After several attempts to speak with (R61), I met with she and the Social Services Director. We spoke with the resident regarding her concerns, and we spoke with staff members regarding the concern. The staff on both rotations denied her allegations. I also checked the documentation in her records and it indicates that she frequently refuses care. (R61) has a history of having thoughts and making comments that are outside of reality. There was not evidence to support the claims that she made. She accused the staff of placing things in her beverages yet there is no report or finding of poisoning. The document did not specifically address R61's allegation of potential sexual abuse. The facility was not able to provide any additional documentation related to an investigation done in response to R61's 08/06/24 allegation of potential sexual abuse by staff including written and signed statements obtained from residents or staff potentially knowledgeable about the alleged incident, evidence of any attempt to assess R61 physically and psychosocially related to the reported incident, or the facility's attempt to identify potential perpetrators of the alleged abuse, exact circumstances of the alleged abuse, or time/date of the alleged abuse. During an interview with the MDSC on 09/03/24 at 2:36 PM, she confirmed R61 reported the potential abuse to her on 08/06/24. The MDSC stated she was not involved in an investigation related to R61's report of potential abuse nor was she asked to provide a written statement related to R61's allegation of potential abuse. During an interview with the DON on 09/03/24 at 3:42 PM, she confirmed she was the facility's Abuse Coordinator and stated she was aware of R61's allegation of potential abuse, but confirmed a full investigation into the resident's allegation had never been done. The DON stated upon reflection of the report, R61's 08/06/24 allegation of potential sexual abuse should have been thoroughly investigated; however, the allegation was not interpreted as potential abuse at the time of the report due to R61's history of behaviors and delusional thinking. During an interview with the Administrator and DON on 09/04/24 at 11:16 AM, the Administrator stated he and the DON were responsible for investigating allegations of potential abuse. He confirmed R61's allegation of potential sexual abuse had not been thoroughly investigated and that he was unable to locate any additional documentation related to an investigation into the resident's allegation of sexual abuse. The Administrator stated he did not interpret R61's report as potential abuse since the resident often refused care, had a history of kicking a CNA during care, and had a history of urinary tract infections (UTIs) and potential bowel obstruction requiring staff to potentially digitally remove stool from the resident's rectum. The Administrator stated because he did not interpret R61's report as an allegation of potential abuse, the allegation was not investigated as though it was an allegation of potential abuse. 27375 2. Review of R24's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified, and dementia in other diseases classified elsewhere without behavioral disturbance. Review of R24's quarterly MDS with an ARD of 07/09/24 revealed the facility assessed the resident to have a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. 3. Review of R97's Face Sheet, located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unspecified psychosis not due to a substance or known physiological condition, and dementia. Review of R97's quarterly MDS with an ARD of 02/15/24 revealed the resident's BIMS was blank which indicated there is no score to assess resident's cognitive status. Record review of R97's Progress Notes dated 01/25/24 located in the resident's EMR under the Progress Note tab revealed resident was noted at 4:05 PM by CNA's doing rounds to be in R24's room with the door closed. R24 was lying in her bed on a towel with her pants half-way down and R97 was coming out of R24's bathroom with his shirt up and his pants half-way down. There was no evidence in the EMR that the incident between R27 and R97 had been thoroughly investigated. During an interview on 09/03/24 at 11:15 AM the Administrator stated he felt the incident did not need to be investigated, because staff did not witness R24 and R97 doing anything. During an interview on 09/03/24 at 4:04 PM the DON confirmed the incident between R24 and R97 was not thoroughly investigated because staff did not see the residents doing anything. 29015

Based on record review, review of job descriptions, interview, and facility policy review, the facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently. The facility failed to maintain an abuse free environment, failed to timely report allegations of abuse, failed to thoroughly investigate allegations of abuse for three residents (Residents (R) 24, R61, and R97) of five reviewed for abuse out of a sample of 25. Immediate Jeopardy related to this failure was identified on 09/04/24 at 4:51 PM and was determined to exist since 01/25/24, when the facility's Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently related to potential abuse, reporting abuse, and completing thorough investigations of abuse. On 09/04/24 at 4:51 PM, the facility's Administrator was notified of the Immediate Jeopardy at F835, Administration. The facility Administrator was notified that the Immediate Jeopardy was removed on 09/06/24 at 4:00 PM. Findings include: Review of the Facility Administrator job description undated indicated, .The primary purpose of your job description is to manage operations in accordance with current applicable federal, state, and local standards, guidelines, and regulations.to assure that the organization is operating effectively and efficiently. As the Facility Administrator, you are delegated the administrative authority, responsibility, and accountability for carrying out your assigned duties. Review of the Director of Nursing (DON) job description undated indicated, .The primary purpose of the position is to plan, organize, develop and direct the overall operations of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Review of the Social Services Director undated job description indicated, .The primary purpose of the position is to provide interventions that meet the psychosocial needs of residents and families in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Administrator. Review of the RN (Registered Nurse) Supervisor job description indicated, .The primary purpose of the position is to direct and supervise resident care in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility and as may be required by the Director of Nursing to ensure that the highest quality of care is maintained at all times. Review of a facility policy titled Abuse Prohibition/Reporting and Investigation dated 04/17 indicated .It is the intent of [named facility] facilities to actively preserve each resident's right to be free from mistreatment, neglect, abuse.We believe each resident has the right to be free from verbal, sexual, physical, and mental abuse.Any person who hearing a complaint of abuse.must immediately report it to the Administrator or their designee.It will be the responsibility of any department head and/or supervisor receiving the complaint of alleged abuse.must immediately report it to the Administrator and/or their designee.Once a complaint or situation is identified involving alleged.abuse.the incident will be immediately reported.The initial report of the incident will be faxed or emailed within 2 hours abuse.to the Complaint Investigation Intake and Referral Unit.A written report of investigation will be submitted to the .Long Term Care Section Complaint Coordinator, within 5 days of the incident.Details of the incident.Signed statements from pertinent parties.Cognitive status of .resident.Information gathered from the investigation.Action taken by the facility-safeguarding the resident and preventing reoccurrence.Final action/conclusion made by the facility.Through the Quality Assurance Performance Improvement Committee, the facility will analyze the occurrences to determine what changes are needed, if needed, to policies and procedural guidelines to prevent further occurrences. 1. Failure to ensure residents are free from potential Abuse Cross Reference F600: The facility failed to ensure two residents were free from potential sexual abuse. Resident (R61) alleged potential sexual abuse by unknown female staff members on 08/06/24. Staff witnessed R97 potentially sexually assaulting R24 on 01/25/24. 2. Report Alleged Violations of Abuse/Neglect Cross Reference F609: The facility failed to report allegations of potential staff to resident (R61) sexual abuse. Additionally, the facility failed to report allegations of resident (R97) to resident (R24) potential sexual abuse. 3. Investigate Alleged Violations of Abuse/Neglect Cross Reference F610: The facility failed to investigate an allegation of staff to resident (R61) potential sexual abuse. The facility further failed to investigate alleged resident to resident sexual abuse by R97 to R24. During an interview on 09/04/24 at 11:15 AM, the Administrator confirmed his responsibility was to oversee the functions of the facility. The Administrator stated that the DON was the facility's designated abuse coordinator. The Administrator stated that it was his and DON's responsibility to report allegations of abuse to the State Agency and to complete a thorough investigation. 29015

Based on observation, interview, policy review, product label and/or instruction review, and a review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure one of three Housekeepers (Hskpr) used cleaning and disinfecting products according to manufacturer's instructions for use (MIFU) to ensure bacteria [MEDICAL CONDITION] were removed so as to prevent the potential for spread of disease, including COVID-19. Findings include: Review of the facility policy titled Housekeeping Services, copyright date 2012, showed: Purpose: To promote a safe and sanitary environment which is maintained by a contracted service, by employees of the facility, or a combination of both. Policy: I. Frictional Cleaning A. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident areas IV. Choice of Cleaning Agents for Use in Patient Care Areas A. A hospital-grade disinfectant/detergent registered by the federal EPA (Environmental Protection Agency) shall be used. B. Except for alcohol (70 to 90%), antiseptic agents intended for use on skin will not be used for surface cleaning VI. Infection Prevention A. Housekeeping Services play a large role in maintaining a clean healthcare environment. B. Personnel will be oriented and trained in proper technique Review of the Centers for Disease Control (CDC) Coronavirus page for long term care facilities (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html ) showed: .Environmental Cleaning and Disinfection: Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas. Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Use an EPA-registered disinfectant from List Nexternal icon on the EPA website to disinfect surfaces that might be contaminated with [DIAGNOSES REDACTED]-CoV-2. Ensure HCP are appropriately trained on its use Review of the bleach label copy provided by the facility showed: Directions for use: It is a violation of Federal Law to use this product in a manner inconsistent with its labeling. DO NOT use this product full strength for cleaning surfaces. Always dilute strictly in accordance with the directions. For prolonged use, wear gloves. For Hospital Use: Hospital Disinfection ½ Cup Bleach 1 Gallon Water Pre-wash surface, then apply bleach solution. Let stand 5 minutes. Rinse and air dry Review of the Sani-Kleen Broad-Cide 128 instruction sheet showed: .See product label for complete mixing and use instructions. Dilution is 1oz./gal. (1:128) .Viruses: This product kills the following viruses in 10 minutes at 1 oz. per gal. of water and 5% soil on hard non-porous surfaces: . Human Coronavirus . Review of a copy of the PDI Super Sani-Cloth wipes canister label from the facility showed .Virucidal in 2 minutes. Review of a copy of the Dispatch wipes canister label from the facility showed Cleaner disinfectant towels with bleach. Kills [DIAGNOSES REDACTED]icile spores in 3 minutes. (While human coronavirus was not shown on the label, Dispatch is on the EPA list for disinfectants effective against coronavirus.) Review of the CDC page regarding building disinfection (https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html) showed: Disinfect with a disinfectant on EPA List N: Disinfectants for Coronavirus (COVID-19) external icon. Follow the instructions on the label to ensure safe and effective use of the product. Many products recommend: Keeping surface wet with disinfectant for a period of time (see product label). Precautions such as wearing gloves and making sure you have good ventilation while using the product If products on EPA List N: Disinfectants for Coronavirus (COVID-19) are not available, bleach solutions can be used if appropriate for the surface and will be effective against coronaviruses when properly diluted. Most household bleach contains 5%-9% sodium hypochlorite. Do not use a bleach product if the percentage is not in this range or is not specified, such as some types of laundry bleach or splash-less bleach as these are not appropriate for disinfection. Follow the directions on the bleach bottle for preparing a diluted bleach solution. If your bottle does not have directions, you can make a bleach solution for disinfecting by mixing: 5 tablespoons (1/3 cup) of bleach per gallon of room temperature water OR 4 teaspoons of bleach per quart of room temperature water. Follow the manufacturer's application instructions for the surface. If instructions are not available, leave the diluted bleach solution on the surface for at least 1 minute before removing or wiping. This is known as the contact time for disinfection. The surface should remain visibly wet during the contact time. Ensure proper ventilation during and after application (for example, open windows). Never mix household bleach (or any disinfectants) with any other cleaners or disinfectants. This can cause vapors that may be very dangerous to breathe in. Make a new diluted bleach solution daily. Bleach solutions will not be as effective after being mixed with water for over 24 hours. In an interview on 2/11/21 at 11:05 a.m. regarding the product(s) used on high touch areas of the facility (e.g., handrails, doorknobs, light switches), Hskpr GG stated she used PDI Sani Cloths (purple top canister), Dispatch wipes, bleach solution and Sani Chem Broad-Cide spray bottle. At this time, Hskpr GG showed the products on the housekeeping cart. When asked how long the product was used on the high touch areas (contact time), Hskpr GG stated, Really no time I'm certain of. I wipe it down and may go back and dry it. Hskpr GG then picked up a dry white cloth to show. When asked about the concentration of the bleach solution, Hskpr GG did not know a specific percentage. Hskpr GG picked up the spray bottle and pointed to the 350 milliliter (ml) line stating, I mix about half and half, up to here with bleach and the rest water. Bleach is used in the bathrooms, I let it sit for like two - three seconds. Observation of Hskpr GG cleaning the bathroom for room [ROOM NUMBER] on 2/11/21 at 11:10 a.m. showed her spraying the toilet rim, and seat bottom with both the bleach solution and Broad-Cide products simultaneously, with one spray bottle in each hand. Hskpr GG then went to the cart at the room doorway to retrieve a bowl brush and white cloths, used the bowl brush around the bowl for six rounds, then took the white cloths and wiped down the top, then bottom of the toilet seat, and then the bowl rim with the dry cloths at 11:11 a.m. At 11:13 a.m., Hskpr GG pulled two PDI Sani-Cloths from the canister and cleaned the room door doorknob, then the bathroom door doorknob, then the overbed table at 11:13:15 a.m. And although the surface should have remained wet for two minutes to ensure the effectiveness of the cleaner, at 11:14:00 (45 seconds later) the overbed table was observed to be drying. Hskpr GG failed to rewet the table to ensure that it remained wet for the required two minutes. In an interview on 2/11/21 at 5:34 p.m., the Environmental Services Director (EVSD) revealed that the contact time depended on the product and could be anywhere from two to ten minutes for each product. She stated, The Broad-Cide comes premixed, the only thing mixed is the bleach and it should not be too strong. I try to mix that myself, ½ cup bleach to one gallon of water according to the directions on the label, and I am mixing a solution that should have a 5-minute contact time. Broad-Cide is a five to seven-minute dwell time, and I mainly want them (staff) to use that on the floors, it can be dispensed right into the buckets. When asked if the practice observed at 11:10 a.m. met expectations for disinfection, the EVSD stated, Well, no, not on that one. I expect staff should follow manufacturer's dwell time.

Based on staff and resident interviews and record review the facility failed to ensure that treatment was obtained in a timely manner following a [MEDICAL CONDITION] for one Resident (R) (A) from a total sample of six residents. Actual harm was identified when R A fell on [DATE] and suffered a left [MEDICAL CONDITION] that was not recognized until 11/22/20 when the resident was sent to the ER (emergency room ) and had to undergo surgery for [REDACTED]. Findings include: Resident (R) A was assessed on the quarterly Minimum Data Set (MDS) assessment as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. She was also assessed as utilizing a wheelchair for mobility. R A sustained a fall on 11/19/20. A review of the clinical record revealed an 11/19/20 2:55 p.m. nurse's note entry that documented the resident was found lying on her left side on the floor (in her room), and stated she was trying to pick up some paper off the floor and slid out of her wheelchair. The nurse's note also documented that the resident complained of pain to the left hip; The Nurse Practitioner was notified and ordered x-rays of the resident's left hip, left thigh (femur), and left knee. During an interview on 12/4/20 at 10:45 a.m., RA confirmed her fall from 11/19/20, stating that she fell out of her wheelchair when she reached over too far to throw something away. Review of the two-page Radiology Report dated 11/19/20 documented x-ray results as follows: page 1 of 2: documented x-ray results for the left hip to be: There is a [MEDICAL CONDITION] neck with angulation. Conclusion: Acute femoral neck fracture. X-ray results for the left thigh (femur) was also documented on page 1 and included the following: There is [MEDICAL CONDITION] neck with angulation. Conclusion: [MEDICAL CONDITION] femoral neck. At the lower one-quarter of page 1 documentation for the results for the resident's left knee begin and with the x-ray results of the left knee being continued on page 2 (of 2) that document the following: Conclusion: 1. [MEDICAL CONDITION] changes of the knee with no acute fracture identified. 2. If there is concern for meniscal or ligamentous injury, consider MRI evaluation. Review of the X-ray report revealed that the pages were numbered: 1 of 2, and 2 of 2. During an interview on 12/7/20 at 1:20 p.m. Licensed Practical Nurse (LPN) CC stated that the order for the x-rays was completed on 11/19/20, the report was sent to the facility, and she took it off the facsimile machine and read the conclusion that there was no fracture. LPN CC stated that there was only one page (of the report) that came off of the facsimile machine. During an interview on 12/7/20 at 4:03 p.m. radiology company staff EE stated that the radiology report for RA was faxed to the facility on [DATE] at 18:27 (6:27 p.m.), and that it had faxed seven times. Following the fall on 11/19/20, a review of the November 2020 Medication Administration Record (MAR) revealed that RA complained of a pain level of 10 (on a pain scale of zero to 10) at 9:00 a.m. on 11/20/20, 11/21/20 and 11/22/20, and 650 milligrams (mg) of Tylenol was administered. Follow up entries on the MAR for 11/20/20 and 11/21/20 document the medication being somewhat effective an hour later with a pain level of 8 out of 10. However, the follow up entry on the MAR for 11/22/20 documented that the Tylenol was not effective. On 11/22/20 an 11:57 a.m. nurse's note entry documented that RA complained of severe hip and flank pain to the left side and swelling and warmth were noted to the left hip. The note also documented that x-ray results (the x-ray results from 11/19/20) were positive for a fracture to the left femoral neck; The physician was notified, and RA was transported to the emergency room . A subsequent nurse's note on 11/22/20 documented that RA was admitted to the hospital and was scheduled to have left hip surgery the following day. Review of a Physician order [REDACTED]. Review of a History and Physical for R A for an acute care hospital dated 11/22/20 documented R A to the ER with complaint of left hip pain after falling from a wheelchair three days ago. Physical exam revealed that R A had a deformity of the left hip and externally rotated leg. Assessment/Plan documented the following: Closed impacted fracture of left hip. Presented to ER status [REDACTED]. Surgeon has been consulted and plans to take patient for surgery tomorrow. Review of a PAR (Patients at Risk) note dated 12/1/20 at 12:33 p.m. documented the following: Resident readmitted to facility on 11/27/20 status [REDACTED]. During interviews on 12/4/20 at 1:00 p.m. and on 12/9/20 at 10:45 a.m. Registered Nurse (RN) AA stated that she worked day shift on 11/20/20, 11/21/20 and 11/22/20. When she came to work on Friday (11/20/20), she was made aware of RA's fall from the day before (11/19/20). RN AA stated that they usually follow-up on a fall for three days and that she would ask the resident in the mornings how she was doing and if she needed anything for pain. RN AA stated that after Tylenol administration on 11/20/20 and 11/21/20, R A did not stay at a pain level of 8 (as initially documented on the MAR following the pain medication administration), the pain eased off more and R A did not ask for anything else for pain. RN AA stated that after RA's left hip pain was not relieved with pain medication on 11/22/20 (as it had been on 11/20/20 and 11/21/20), and the left hip area was swollen, that she had the x-ray results (from 11/19/20) pulled up in the computer, and the x-ray results showed a fracture, so she called the doctor. During an interview on 12/7/20 at 3:50 p.m., R A commented that the three days after her fall, before she went out to the hospital were pain-filled days.

Based on staff interviews, record review, and review of the facility policy titled, Laboratory, Radiology, and Other Diagnostic Services the facility failed to ensure that the physician was notified timely of abnormal radiology test results for one resident (A) from a total sample of six residents. Actual harm was identified when Resident (R) A fell on [DATE] and suffered a left [MEDICAL CONDITION] that was not recognized until 11/22/20 when the resident was sent to the ER (emergency room ) and had to undergo surgery for [REDACTED]. Findings include: The facility had a Laboratory, Radiology, and Other Diagnostic Services policy. The policy included that the facility assumed responsibility for the timeliness and quality of laboratory, radiology, and other diagnostic services. Resident (R) A sustained a fall on 11/19/20. A review of the clinical record revealed an 11/19/20 2:55 p.m. nurse's note entry that documented the resident was found lying on her left side on the floor (in her room), and stated she was trying to pick up some paper off the floor and slid out of her wheelchair. X-rays were ordered and obtained on 11/19/20, and the report was faxed to the facility on [DATE]. Review of the two-page Radiology Report dated 11/19/20 documented x-ray results as follows: page 1 of 2: documented x-ray results for the left hip to be: There is a [MEDICAL CONDITION] neck with angulation. Conclusion: Acute femoral neck fracture. X-ray results for the left thigh (femur) was also on page 1 and documented the following: There is [MEDICAL CONDITION] neck with angulation. Conclusion: [MEDICAL CONDITION] femoral neck. At the lower one-quarter of page 1 documentation for the results for the resident's left knee begin and with the x-ray results of the left knee continuing on page 2 of 2 that document the following: Conclusion: 1. [MEDICAL CONDITION] changes of the knee with no acute fracture identified. 2. If there is concern for meniscal or ligamentous injury, consider MRI evaluation. Review of the X-ray report revealed that the pages were numbered: 1 of 2, and 2 of 2. During an interview on 12/7/20 at 1:20 p.m. Licensed Practical Nurse (LPN) CC stated that the order for the x-rays was completed on 11/19/20, the report was sent to the facility, and she took it off the facsimile machine and read the conclusion that there was no fracture. LPN CC stated that there was only one page (of the report) that came off of the facsimile machine. During interviews on 12/4/20 at 1:00 p.m. and on 12/9/20 at 10:45 a.m. Registered Nurse (RN) AA stated that when RA's left hip pain was not relieved with pain medication on 11/22/20 (as it had been on 11/20 and 11/21/20), and the left hip area was swollen, she had the x-ray results (x-ray results from 11/19/20) pulled up in the computer, which showed a fracture, so she called the doctor. Record review revealed that R A did not receive treatment for [REDACTED]. Cross refer to F684.

Based on record review, staff interview and review of the facility policy titled Bed Holds the facility failed to ensure that two of four residents (R) (R#220, R#62) were provided a bed hold notice at the time of transfer to a hospital. Findings include: 1. Review of the medical record for R#220 revealed resident was transferred from the facility to the hospital on the following dates: 7/4/19, 7/8/19, 8/12/19, 9/11/19, 10/16/19. Review of the hospitalization s since (MONTH) 2019 did not reveal that a bed hold notice was provided to R#220. During interview on 10/31/19 at 3:39 p.m. with the Admissions Director who revealed that the bed hold policy is discussed upon admission but, nursing is responsible for sending out bed hold notices when residents transfer to the hospital. During interview on 10/31/19 at 3:43 p.m. with Unit Manager Licensed Practical Nurse (LPN) HH who reported that a packet is sent to the hospital with residents upon transfer. This packet included the face sheet, Physicians Order for Life-Sustaining Treatment (POLST), advance directives, transfer sheet, immunizations, current physicians' orders, last progress note, and the most current labs. Unit Manager further reported that bed hold notices are not a part of the packet that is sent to the hospital. Unit Manager LPN HH further reported that Admissions or someone in the financial department would be responsible for the bed hold notification. During interview on 10/31/19 at 4:00 p.m. with the Administrator, it was reported that Admissions and Reimbursements are responsible for notifying residents of bed hold upon transfer. Reimbursements would only do so as a secondary resource. It was further reported that bed hold notices should be sent with the other hospital documents at the time of transfer. The Administrator confirmed the Medicaid Status for R#220 for each date that resident was transferred to the hospital. During interview on 10/31/19 at 6:32 p.m. with the Administrator it was reported that bed hold notification was provided but there is no evidence to show that the bed hold notice was provided to R#220 at this time. Review of the facility's policy titled Bed Holds with a revision date of (MONTH) (YEAR), Procedural Guidelines for Medicaid residents: [NAME] Medicaid will pay for a resident's bed for a total of seven days. General Procedural Guidelines: [NAME] As part of the admission process, the Admission Director (or person responsible for admissions) should review the Policy on Bed Holds during Hospital Stays and Therapeutic Leave found in the Resident Handbook. B. In addition, at the time of transfer of a resident for hospitalization or therapeutic leave, written notice regarding the bed hold policy should be given to the resident or resident representative which specifies the duration of the bed hold policy. C. In cases of emergency transfer, notice at time of transfer means that the family or resident representative are provided with written notification within 24-hours of the transfer. This should be done by sending the resident's copy of the notice with the other paperwork sent with the resident to the hospital. 2. A review of patient transfer forms revealed that resident #62 was transferred on 2/8/19, 3/15/19 and 8/16/19 to an acute care hospital. There were transfers forms on the chart but no bed-hold forms found for any of the transfers.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for hospice for three resident's (R) R#75, R#43, and R#114 of 16 hospice residents. Findings include: 1. Record review revealed that R#75 was admitted to the facility on [DATE] on Hospice. Review of the Quarterly MDS assessment dated [DATE] for Section O: Special treatments and Programs revealed that Hospice was not triggered for R#75. Record review of the facility care plan for R#75 with an onset date of 3/29/19 with a problem area of hospice due to [MEDICAL CONDITIONS] and nutritional marasmus. Approaches: Coordinate care with hospice team, coordinate care with hospice to assure the resident has little pain as possible, provide resident and family with grief and spiritual counseling if desired, hospice to visit as ordered/indicated. Review of the hospice care plan from the hospice company dated 9/19/19 revealed R#75 had a current care plan with hospice. 2. Review of the medical record revealed that R#43 was admitted to the facility on [DATE] and was a hospice resident. Review of the Annual MDS dated [DATE] and the Quarterly MDS assessment dated [DATE] revealed that on Section O, the resident was not triggered for receiving hospice. Review of the facility care plan dated with a problem onset of 6/22/19 revealed R#43 was on hospice due to a terminal [DIAGNOSES REDACTED]. 3. Record review revealed that R#114 resident is a hospice resident. Review of the Re-Admission MDS assessment dated [DATE] revealed R#114 was readmitted to the facility and continued on hospice although hospice did not trigger on the re-admission MDS assessment. Review of the facility care plan with a problem onset of 10/18/19 revealed the resident was admitted to the facility on hospice. Coordination of care for the facility and hospice were in place on the care plan. An interview on 10/31/19 at 5:23 p.m. with Registered Nurse (RN/MDS) DD stated there is a process she follows to complete the MDS assessment. She revealed using the MDS tracking log to track all transmittals. RN/MDS DD verified R#75, R#43 and R#114 were not triggered for hospice although the residents were care planned for hospice. An interview on 10/31/19 at 5:26 p.m. with RN/MDS BB revealed that R#43 is hospice resident and when completing the Quarterly MDS assessment she clicked on the wrong area.

Based on record review, interviews and facility data, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the respiratory status of one Resident (R) (R A). This failure to accurately assess the resident, resulted in a comprehensive care plan that did not reflect the respiratory status of R A. The resident sample size was 24. Findings Include: A resident record review was conducted and reflected R A was readmitted from an acute hospital with a [DIAGNOSES REDACTED]. A review was conducted of the MDS annual assessment, dated 2/14/18 and the quarterly assessment, dated 5/15/18. The annual assessment reflected the following: hearing/vision= hearing impaired, unclear speech, impaired vision; mood=08 depression; behavior=00; the cognitive assessment reflects a Brief Interview for Mental Status (BIMS) was conducted with a cognitive score of 15 indicating no impairment; bowel and bladder= always incontinent of both; functional= 2 person assist with transfers and mobility needed, non-ambulatory/[MEDICAL CONDITION]; health conditions= shortness of breath (SOB)= none, tobacco use= yes; dental= cavities/broken natural teeth, inflamed gums; medications= antidepressant and opioids; skin= (Section M) application of a non-surgical dressing other than to feet; special treatments and programs= Respiratory Treatments (Section O-0100) indicates at letter Z none of the above while a resident. A review of the MDS with an Assessment Reference Date (ARD) of 5/15/18, reflected that in Section O-Special Treatments, Procedures and Programs O- -D-2 that Respiratory Therapy: number of days used was 0 days during the seven (7) day look back period. Review of the Physician orders [REDACTED]. Review of the facility form titled Treatment Record for the months of 5/18 and 6/18 reflected a documentation of treatment orders for: skin assessments (initially ordered 3/10/15) conducted every week by the treatment nurses; and a treatment order to apply daily dry dressing [MEDICAL CONDITION] (initially ordered 4/1/16). On 7/11/18 at 11:15 a.m. an observation was conducted of R A during the 11:00 a. m. smoke break for residents. The resident was observed smoking safely with a safety apron in place, and was observed using a provided ash tray appropriately. A neck dressing (band type soft collar) was observed in place; the dressing was clean and dry. On 7/11/18 at 11:45 a.m. an interview and observation was conducted with R A where she stated she was doing well, that she had [MEDICAL CONDITION] removed 2-3 years ago, but could not remember the details. At that time, the resident lifted the loose neck dressing and shared how the stoma looked; a clean and pink open stoma site was observed, without drainage, covered by a 4x4 inch gauze dressing that was secured by a soft neck band/collar. On 7/11/18 at 11:50 a. m. during a brief interview with staff nurse EE on the West-2 unit, She confirmed the resident does not require oxygen supplement and that the residents stoma site has been open but clean and healed for some time. On 7/11/18 at 1: 30 p. m. during a brief interview with Treatment Nurse BB she confirmed that one of the Treatment Nurses changes the [MEDICAL CONDITION]/stoma dressing daily. She stated the stoma site at one time was red and had issues, but has been pink and clean without issues for some time now. She confirmed that the Treatment Nurses are responsible for skin checks, and all skin treatments. During an interview on 7/12/18 at 8:00 a.m. with MDS Coordinator GG she reviewed the resident's comprehensive care plan with the surveyor and provided a paper copy. She stated she has worked for the facility since 2014. She confirmed that the resident was not assessed or care planned for having an [MEDICAL CONDITION] or for general respiratory care goals and interventions. A review was conducted of the provided facility policy entitled, Care Plans-Comprehensive Person-Centered reviewed and updated (MONTH) (YEAR). In the section under Procedural Guidelines the policy indicates: 1. An interdisciplinary team in co-ordination with other resident care services, develops and implements a care plan for each resident. 2. The care plan is developed from the resident assessment (MDS) and in coordination with the attending physician's regimen of care. The care plan will be reviewed and updated with participation of the resident and resident representative(s) and all personnel involved in the care of the resident as needed but no less than quarterly.

Based on observations, interviews and record reviews, the facility failed to identify a pressure ulcer and failed to obtain a Physician's order for treatment for one Resident (R) (R#55) . The sample size was 24 residents. Findings Include: Observation on 7/10/18 at 2:24 p.m. with Certified Nursing Assistant (CNA) (CC), revealed thtat CNA CC was changing R#55 and a Opti- foam gentle silicone face foam and Broder dressing was observed on the right hip without a nurse's signature. CNA CC called the Unit Manager, Registered Nurse BB, Licensed Practical Nurse AA, Director of Nursing and Administrator the dressing was removed by RN BB wound nurse exudate and dry black blood and odor were observed. Measurements of the wound are 1.5 centimeters (cm) x 1.5 cm. No depth. Interview on 7/10/18 at 2:30 p.m. with R#55 revealed that staff put the dressing on her right hip one month ago. Interview on 7/10/18 at 3:00 p.m. with Certified Nursing Assistant CC related to R#55 right hip stage 4, pressure ulcer wound; CNA CC revealed the dressing was observed one week ago with no date, or signature. Interview on 7/10/18 at 3:10 p.m. with Wound Nurse BB, and Treatment Nurse AA in relation to the right pressure ulcer, both wound nurses revealed that they were unaware of the wound; and Wound Nurse BB said she completed a skin assessment for the resident on 7/6/18 and that there was not a pressure ulcer at that time the residents skin was intact. Interview on 7/10/18 at 3:20 p.m. An interview with Unit Manager, MDS Nurse, DON and Administrator revealed that they were all unaware of this pressure ulcer, however, they observed the old dressing not dated, without a nurse's signature and they observed exudate with dry black blood and odor. Interview on 7/11/18 at 10:40 a.m. with Medical Director reveraled that he was unaware of the pressure ulcer until the Unit Manager called him yesterday, 7/10/18, to obtain a treatment order. The Medical Director revealed that the resident previously had a Stage IV pressure ulcer on her right hip that had resolved on 5/26/18. The Medical Director revealed that he believed this wound was caused from the previous resolved pressure ulcer reopening.

Based on record review and staff interview the facility failed to ensure that one of one resident (R) (R27) who receives nutrition via a [DEVICE] ([DEVICE] a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) has a Physician order related to the amount of the bolus ( administration of a limited volume of enteral formula over brief periods of time) of [MEDICATION NAME] the resident should receive. The sample size was 24 residents. Findings include: Record review revealed that R#27 was admitted to the facility with [DIAGNOSES REDACTED]. Record review Minimum Data Set (MDS) annual assessment dated [DATE]. Section K-Swallowing/Nutritional Status: KO100. Swallowing Disorder signs and symptoms of possible swallowing disorders K- none. K0510 nutritional approach feeding tube. K0710 A. Percent intake by artificial route 51% by artificial route during the entire seven days. B. Average fluid intake per day by IV or tube feeding 501 cc/day or more. Review of the care plan dated 5/10/18 identified the resident has a [DEVICE] for her tube feeding. At risk for complications. Has history of aspiration pneumonia. Requires meds crushed and given in tube. Goal resident will receive tube feeding as ordered without complications over the next 90 days. approaches include but not limited to: give tube feeding as ordered. Observation on 07/10/18 at 7:55 p.m. of the bolus feeding for R27 by Registered Nurse (RN) EE revealed that RN EE flushed the [DEVICE] with 175 cc of water and administered a bolus of [MEDICATION NAME] 1.5 250 milliliters (ml) by gravity. Review of the Physician orders for (MONTH) 1, (YEAR) through (MONTH) 1, (YEAR), revealed an order for [REDACTED]. Further review revealed that the Physician Orders did not contain the amount of [MEDICATION NAME] that the resident was to receive via bolus every four hours. Review of the Physician order dated (MONTH) 17, (YEAR) revealed [MEDICATION NAME] 1.5 1050 cc/day. Review of the physician progress notes [REDACTED]. An interview on 07/12/18 at 9:36 a.m. with Registered Nurse (RN) EE revealed that there was not a volume on the Medication Administration Record [REDACTED]. Further interview with RN EE revealed that a new employee would not have any idea of the volume of [MEDICATION NAME] that was to be administred to the resident based on the residents MAR. An interview on 07/12/18 at 9:44 a.m. with the Director of Nursing (DON) revealed that the enteral feeding order did not contain the volume of [MEDICATION NAME] that was to be bolused. The DON confirmed that this was an oversight and that the Physician orders should contain the amount of the bolus that was to be administered. An Interview on 07/12/18 at 11:52 a.m. via phone with the Registered Dietician for the facility regarding the volume of the bolus feeding for R27. The registered dietician revealed that the charts are reviewed for tube feeding orders and for accuracy and if there is any discrepancy she would talk to the nurse and obtain an order clarification. The Registered Dietician confirmed that the order for the residents [MEDICATION NAME] should include a volume.

Based on observation, interview and record review the facility failed to report initial findings and final investigation findings in a timely manner for three (3) out of three (3) reportable incidents. Findings include: Review of the Abuse Prohibition reporting and investigation Policy stated that the initial report would be filed immediately (within 24 hours of discovery), defined what the investigative report would contain, and that a written report of investigation would be submitted within five (5) working days to the State Office. Review of three (3) reportable incidents for resident #111, #92, and #105 revealed the following: 1) Review of the reportable incident for Resident #92. The date of the Incident was 5/4/16, Wednesday. The Initial Investigation was done on 5/9/16, Monday. The investigation revealed that Resident #92 chased Resident #116 out of her room. The final investigation was faxed to the State Agency on 5/16/16 however, it was due on 5/11/16. 2) Review of the reportable incident for Resident #105. The date of the incident was 4/22/16, Friday. The initial investigation was done on 4/26/16, Tuesday and it was due on 4/25/16. The final investigation was faxed to the State Agency on 5/3/16 however, it was due 4/28/16. 3) Review of the reportable incident for Resident #111. The date of the incident was 3/17/16. The initial investigation was on 3/18/16. The final investigation was faxed to the State Agency on 3/25/16 however, it was due on 3/24/16. Interview on 06/03/2016 at 11:26 a.m. with the Director of Nursing (DON) revealed that she thought she had two hours from the time that an incident was reported to her to report it to the state. The DON revealed that she understood that she had 5 working days from the time of the initial investigation to send in the findings for the final investigation. Interview on 06/02/2016 at 11:30 a.m. with LPN, FF, Unit Manager revealed she would report an incident to the (DON) and Social Services and she then files an incident report. If there was an incident of staff to resident abuse she stated that she would remove the resident from the area, report the incident to the (DON) and Social Services, notify the family, assess for injury and notify the physician. If she had a resident that sustained an injury of unknown origin she would assess the resident, document, notify family, notify the physician, notify the (DON), and she would file an incident report. Interview with the Administrator on 06/03/2016 at 6:55 p.m.,revealed that injuries of unknown origin and known origin are reported within the same timeframe immediately, and an Incident Report form is completed before the shift has ended.

Based on record review, resident, family and staff interviews the facility failed to provide quarterly account statements for five (5) residents from a sample of thirty four (34). Findings include: Interview on 6/1/16 at 8:18 a.m. with resident #59s representative for financial decisions stated that they have never received a statement from the facility. Further interview revealed that he/she have called and they would tell them over the phone how much was in the resident's account. Interview on 6/1/16 at 9:56 a.m. with resident #109s representative for financial decisions stated that they have never received an account statement. Interview on 6/1/16 at 8:17 a.m. with resident #21 stated that the facility does not let her know how much money she has in her account. Interview on 5/31/16 at 3:59 p.m. with resident #99s representative for financial decisions stated that he/she has not seen a statement in six (6) months. Interview on 5/31/16 at 5:13 p.m. with resident #111 stated that the facility does not let him/her know what their account balance is and he/she has never received a statement. Interview on 6/2/16 at 2:18 p.m. with the Resident Trust Book Keeper stated that the filing system was changed in February 2016 and also stated that a balance report is provided to the switch board operator on duty and each resident that has a balance can sign for money if available and that no bank statements mailed out had been returned.

Findings: Observation on 06/02/2016 at 7:58 a.m. and on 6/3/16 at 12:55 p.m. in the dining room on the Secured Unit, resident #10 was observed with his/her chin level with the table. Review of resident #10's medical record listed [DIAGNOSES REDACTED]. The 3/3/16 annual (MDS) coded resident #10 with a Brief Interview for Mental Status (BIMS) summary score of 02 which indicated severe cognitive impairment. Review of the Care plan for resident # 10 did not document an intervention for resident #10 to be seated at chin height at the dining table . Observation on 06/02/2016 at 7:58 a.m. and on 6/3/16 at 12:55 p.m. in the dining room on the Secure Unit, resident #52 was observed with his/her chin level with the table and he/she was holding the left arm with his/her right hand in order to feed his/herself. The resident scooped the food straight into his/her mouth from the plate. Review of resident #52's medical record listed [DIAGNOSES REDACTED]. Review of the 4/4/16 annual Minimum Data Set (MDS) for resident #52 coded a Brief Interview for Mental Status (BIMS) of 00 indicating severe cognitive impairment. Review of the Care plan for resident #52 did not document an intervention for the resident to be seated at chin height at the dining table . Observation and Interview on 06/03/2016 at 5:08 p.m. with the Director of Nursing (DON) confirmed that both resident #10 and #52 were seated at chin height at the dining table. During further interview on 6/3/16 at 5:32 p.m., the DON stated that new tables had recently been purchased and he/she had not realized that the tables were to tall for some of the residents. Based on observation, record review and staff interview, the facility failed to maintain dignity for three (3) residents (#75,#97 and #2 ) by failing to knock and await a response before entering residents rooms and for two (2) residents (#10 and #52) by failing to provide dining tables at appropriate height from a census sample of thirty four (34) residents. Findings include: Observation on 6/1/16 at 6:58 a.m., Certified Nursing Assistant (CNA) JJ entered resident #75's room without knocking or identifying his/herself during delivery of the resident 's breakfast tray. Observation on 6/1/16 at 7:42 a.m., CNA NN was observed to enter room [ROOM NUMBER] without waiting for resident #97 to respond. In addition, on 6/1/16 at 7:42 a.m., CNA JJ was observed to enter room [ROOM NUMBER] without knocking and waiting for response and by not identifying his/herself. Observation on 6/1/16 at 10:21 a.m., CNA MM was observed to open the door to resident 2' s room without knocking or identifying his/herself. CNA MM then closed the door and left the room upon seeing surveyor. Interview on 06/03/2016 at 7:19 a.m. with the Director of Nursing (DON) he/she stated that staff are expected to knock on doors and wait for the resident response before entering a resident's rooms. If there is no response then staff are expected to knock again prior to entering the room. Once in the room the staff are expected to introduce him/herself to the resident. The DON further stated that due to some residents having dementia the resident may never answer and that is why the staff should knock the second time. The DON stated that this information had been relayed to staff. Interview on 06/03/2016 at 8:38 a.m. with CNA NN, he/she stated that the process for entering a resident's room is to knock, enter room, and then state name. CNANN further stated that if he/she knows the resident is not going to respond he/she will just knock and enter the room.

Findings Include Observation of sacral wound care treatment for [REDACTED]. Revealed LPN AA removed scissors from his uniform pocket to cut the foam wound packing that was placed into the resident's sacral wound and then place the scissors back into uniform pocket. LPN AA then removed the scissors again from uniform pocket and cut the adhesive strips that was placed around the sacral wound and then placed scissors back into the uniform pocket. Review of resident # 9 revealed a healing stage four and a physician order [REDACTED]. Review of Wound Care/Treatment guidelines revealed supplies should be placed on a clean surface. Interview with LPN AA on 06/3/16 at 07:35 a.m. stated that the scissors were in their uniform pocket at the beginning of the wound care and throughout the wound care. Then stated that they put the scissors back into my pocket after using for treatment and stated that they always keep the sisscors in their pocket. Interview with the Director of Nurse's (DON) on 06/03/2016 3:52 p.m. revealed that I would expect LPN AA to keep the scissors clean and not put in the uniform pocket. I expect the nurse to keep the scissors clean during the wound care treatment. 2. Review on 06/03/2016 at 5:53 p.m. of Infection Control Surveillance sheets revealed that the different types of infections in the facility were being monitored however, the line listing from 03/2015 through 09/2015 was not available and the break down of infections by units was not available from 03/2015 to 05/2015. Interview on 06/03/2016 at 6:05 p.m. with the Infection Control Nurse revealed that she had documentation of each individual with an infection and how it was treated and the monitoring of the trending on the units. Further interview revealed that the previous Infection Control Nurse left the job due to illness. The current Infection Control Nurse stated that she was hired for the job in December, 2015 and started working on Infection Control in January, 2016. Review of Line Listing of resident was available from 11/2015 to 4/2016, but from 03/2015 through 09/2015 they were not available. The break down of infections by units was only available from 01/2016 to 04/2016 and 03/2015 to 05/2015. Review on 06/03/2016 at 7:00 p.m. of Infection Surveillance Policy revealed that a Line Listing of Resident Infections is to be maintained as well as Infection Surveillance Summary Reports. Based on observations and staff interviews, the facility failed to store resident's personal care items to prevent possible contamination on three (3) of three (3) units; and failed to maintain accurate documentation of the infection control program; and improper storage of scissors. The current facility census was one hundred twenty-three (123) residents. The sample size was thirty four (34). Findings include: 1. During observation on 05/31/2016 at 11:40 a.m. in room [ROOM NUMBER] there was one urine hat on the floor in the shower. 2. During observation on 05/31/2016 at 2:28:25 p.m. in room [ROOM NUMBER] on the secure unit there was a wash basin on floor, under the sink that was not bagged or labeled. 3. During observation on 06/01/2016 at 7:56 a.m. in room [ROOM NUMBER] there was one toothbrush on the sink not covered and a nebulizer mask not bagged by bed C. 4. During observation on 06/01/2016 at 8:45 a.m. in room [ROOM NUMBER] there was one bed pan and one urine hat not bagged in bathroom. 5. During observation on 06/01/2016 at 10:02 a.m. in room [ROOM NUMBER] on the locked unit there was one urinal on the shelf not bagged or labeled and one wash basin not bagged or labeled and sitting on floor under sink in room. 6. During observation on 06/02/2016 at 2:08 p.m. in room [ROOM NUMBER] on the locked unit there was one urinal on shelf not bagged or labeled and one wash basin not bagged or labeled and sitting on floor under sink in room. Environmental tour with Maintenance Director and Director of Nursing began on 6/2/2016 at 3:28 p.m. 7. During observation on 06/02/2016 at 3:40 p.m. in room [ROOM NUMBER] there was one urine hat on the floor by toilet in resident ' s bathroom. 8. During observation on 06/02/2016 at 3:55 p.m. in room [ROOM NUMBER] on the secure unit there was one urinal on shelf not bagged or labeled and one wash basin not bagged or labeled and sitting on floor under sink in room. 9. During observation on 06/02/2016 at 3:57 p.m. in room [ROOM NUMBER] there was one bed pan and one urine hat not bagged in bathroom. 10. During observation on 06/02/2016 at 4:00 p.m. in room [ROOM NUMBER] there was an uncovered toothbrush on the sink in resident ' s room. 11. During observation on 06/02/2016 at 4:04 p.m. in room [ROOM NUMBER] there was a nebulizer not bagged by bed C. Interview with Director of Nursing (DON) on 6/2/2016 at 4:05 p.m. revealed that the personal care items, urinals, bath basins, toothbrushes, and nebulizer's identified should have been bagged and labeled.

Based on record review and staff interviews, the facility failed to ensure clinical records were complete and accurately documented for one resident #9 for Negative Pressure Wound Treatment setting (NPTW). The Census sample size was thirty-four (34) residents. Findings include: Review of resident's #9 clinical record revealed a healing stage four pressure ulcer to the sacrum. Further review of the clinical record revealed a Physician order [REDACTED]. - An observation of the pressure ulcer treatment on resident #9 on 6/2/16 at 09:40 a.m. by two (2) Licensed Practical Nurse's (LPN) AA and BB revealed LPN AA place the setting on the Genadyne XLR8 [DEVICE] System at 125 millimeter of Mercury (mmHg). LPN AA stated this was a general setting that the wound care Physician wanted for his residents and this was the only setting he was aware of and it was a standing order. Interview with the Wound Care Physician by telephone on 6/3/16 at 08:55 a.m. revealed that the [DEVICE] setting was a general communicated rule for a setting at 125 mmHg and would write an addendum for the resident #9 to clarify the order. Interview with the Administrator on 06/03/2016 at 3:27 p.m. revealed the only information on the Genadyne XLR8 [DEVICE] System was printed information from the product's web site. The Administrator revealed that was no policy or procedure regarding the [DEVICE] system. Interview with the Director of Nurse's (DON) on 06/03/2016 6:22 p.m. revealed that we do not have a policy for NPWT and we go by the doctors orders for the [DEVICE] setting. During the interview the DON confirmed that no order or standing order was written for the NPWT setting until surveyor inquired.

Based on review of the facility policy for capillary blood sampling (finger stick blood sugar), medical record review, and staff interview, the facility failed to obtain a physician order for [REDACTED]. Findings Include: The medical record for resident #37 revealed that the resident was admitted to the facility September 2014. Upon admission, the facility started obtaining finger stick blood sugar sample four (4) times a day. A review of the physician's orders revealed that there were no physician orders to collect these finger stick blood samples. Further review of the medical record, revealed that on 11/5/14 and 3/4/15, the pharmacist consultant requested the finger sticks to be evaluated by the Medical Doctor (MD) for discontinuation or change in the frequency of collection. This did not occur until the surveyor made the facility aware of this issue. An interview on 3/25/15 at 2:17 p.m. with Licensed Practical Nurse (LPN) " AA " revealed that he/she was not aware of the resident not having orders for finger stick four (4) times a day and verified that there was not an order for [REDACTED]. An interview on 3/25/15 at 2:53 p.m. with the Director of Nursing (DON) verified that resident #37 did not have an order for [REDACTED].

Based on record review, staff interview and review of the facility "Medication Administration-General Guidelines" the facility failed to maintain accurate clinical record regarding the administration of insulin , antidepressant and antipsychotic medication for one (1), #138, of twenty eight (28) sampled residents. Findings include: Review of resident #138's clinical record revealed a 2/1/2015 physician's orders [REDACTED]. [MEDICATION NAME] 100 units/milliliter vial 8 units subcutaneous three (3) times a day with meals, [MEDICATION NAME] 100 units/milliliter vial 20 units subcutaneous at hour of sleep and [MEDICATION NAME] 30 milligrams by mouth daily for Depression. Review of the Medication Administration Record [REDACTED]. An interview with Licensed Practical Nurse (LPN) "DD" on 3/25/15 at 3:16 p.m. revealed that while he/she had administered the [MEDICATION NAME] as ordered he/she had failed to initial the medication as being administered on 2/14/15 and 2/15/15 at 5;00 p.m. Review of resident #138's clinical record revealed a 3/1/ physician's orders [REDACTED]. Continued review of the MAR for March 2015 revealed no documentation on 3/9/15 that nursing staff had administered the [MEDICATION NAME] 0.25 milligrams every morning as ordered on that day. Review of the facility "Medication Administration-General Guidelines" revealed under Procedural Guidelines, #10. The resident's Medication Administration Record [REDACTED]. Initials on each MAR indicated [REDACTED]. An interview with the Director of Nurses (DON) on 3/25/15 at 2:50 p.m., revealed that the nurses responsible for medication administration on the above dates had failed to document the [MEDICATION NAME] and [MEDICATION NAME] as administered. Interview with the DON further on 3/26/15 at 10:05 a.m. revealed that it was his/her expectation that the nurse initial the MAR indicated [REDACTED].

Based on observation, record review and staff interview, the facility failed to ensure that one (1) resident (#137), with a history of weight loss, was served ice cream, double meats and double desserts as ordered by the physician from a sample of twenty four (24) residents. Findings include: Review of the clinical record for Resident #137 revealed multiple [DIAGNOSES REDACTED]. The resident was admitted to Hospice on 6/7/13. Record review revealed the resident had a physician's orders [REDACTED]. Observation during lunch service on 9/11/13 at 11:40 a.m., revealed the resident was served a regular portion of pureed meat, one (1) serving of dessert and no ice cream. The resident ate 100% of her meal. Observation during dinner service on 9/11/13 at 5:20 p.m. revealed the resident was served a regular portion pureed meat and one (1) serving of dessert. An interview with the charge nurse on 9/12/13 at 8:35 a.m. revealed the resident was to receive double meat with meals and double dessert and ice cream with lunch and supper. An interview with dietary staff ("AA") on 9/12/13 at 8:15 a.m. revealed that in June the facility started a new dietary ticket system. She stated the resident's diet orders did not transition over to the new ticket system. She reviewed the residents chart and confirmed the resident's current diet order and revealed that the dietary staff uses the tickets to know what kind of diet to serve the residents. In review of the residents dietary ticket, it only specified pureed diet and did not list ice cream with lunch and supper, double dessert with lunch and supper, or double meat with meals. Review of the Registered Dietitian recommendations dated 5/16/13 reveal the resident had a significant weight loss since admission of 13.5 % and to start double meat portions with meals and double desserts with lunch and dinner. Further review of the Nutritional Progress assessment dated [DATE] and signed by the Registered Dietitian revealed the resident's diet included ice cream with lunch and dinner, and double meats and double desserts. The resident had no further significant weight loss at this assessment.

Based on observations, staff interview and record review, it was determined that the facility failed to implement interventions to reduce the risk of falls and/or injury for two residents ("K" and #21) of eight residents with a history of falls in a total sample of 25 residents. This failure resulted in actual harm for resident #21. Findings include: 1. Resident #21 had [DIAGNOSES REDACTED]. Licensed staff coded him/her as needing limited assistance with ambulation and supervision with transfers. According to nursing documentation and a review of the facility's incident reports, he/she had a history of [REDACTED]. The facility's 10/24/09 "Incident/Accident Report" documented that the resident was seated on the toilet and fell forward. Nursing staff described the resident as having a one (1) and 1/2 inch laceration to his/her nose. To prevent recurrence, the licensed nurse documented that the certified nursing assistant (CNA) was counseled on not leaving the resident unattended. On the 11/11/09 "Incident/Accident Report", the nurse documented that the CNA stated that she had placed the resident on the toilet and turned on the water in the sink, when the resident jumped up, lost his/her balance, and landed (fell ) on the floor. The resident fractured his/her clavicle. To prevent a recurrence, the nurse documented that staff was to provide hands on contact when toileting the resident. On the 12/18/09 "Incident/Accident Report," the licensed nurse documented that the resident stood up after toileting and fell . To prevent recurrence, the nurse noted that a body alarm was to be used while the resident was in a regular chair. The Director of Nursing stated on 8/26/10 at 10:52 a.m., that the follow up intervention after the resident's fall on 12/18/09 was for him/her to be assisted with toileting by two staff persons, instead of one. However, on the 3/22/10 facility's "Incident/Accident Report" form, licensed nurse noted that the resident was in the shower room with one CNA. The licensed nurse documented that the CNA left the resident to go and get towels and, when she returned, the resident was on the floor. The nurse noted that the resident sustained [REDACTED]. To prevent recurrence, the nurse documented that the CNA was "re-instructed and counseled." Despite the facility's plans to provide supervision by nursing staff and hands on contact with the resident, those interventions were not consistently implemented by nursing staff which resulted in injury to the resident. 2. Resident "K" had [DIAGNOSES REDACTED]. Staff's documentation on the resident's care plan noted that he/she had fallen at least seven times since 12/3/09. Licensed nursing staff documented on the resident's care plan on 6/12/10 that he/she had a history of [REDACTED]. On 7/15/10, staff documented that the resident had removed the Velcro seat belt and turned off the wheelchair seat alarm. During an interview on 8/25/10 at 3:00 p.m., resident "K" stated that he/she was aware of the need to call for assistance with transfers but, if staff did not respond within five minutes, he/she would attempt to transfer without assistance. There was a care plan since at least 11/19/09 to address the resident's risk for injuries related to falls. There were interventions for staff to place the wheelchair seat alarm box behind or under the resident's wheelchair and out of the resident's reach. Following a fall on 6/12/10, there was a care plan intervention for an alarm to be applied to the resident's bathroom door to alert staff if the resident attempted to toilet without assistance. However, during observations on 8/24/10 at 3:15 p.m., on 8/25/10 at 11:00 a.m. and 3:00 p.m., and on 8/26/10 at 8:30 a.m., 10:00 a.m., 11:00 a.m. and 1:10 p.m., the resident was seated in the wheelchair with the alarm box attached to the top of the wheelchair seat back. Observations on 8/26/10 at 8:30 a.m., 10:00 a.m., 11:00 a.m. and 1:10 p.m. revealed that the alarm on the resident's bathroom door was not intact and would not alarm when the door was opened. On 8/26/10 at 1:10 p.m., while licensed nurse "LL" was present in the room, resident "K" was able to reach behind the wheelchair and turn off the wheelchair seat alarm.