Every finding on record at Mccomb Community Care Center

Based on interview and record review, the facility failed to obtain physician-ordered hemoglobin A1C laboratory tests for two (2) of (21) sampled Residents.Findings include: In an interview with the Director of Nursing (DON) on 8/5/26 at 2:15 PM, she acknowledged that Resident #105 has a doctor's order for Hemoglobin A1C labs scheduled for April, July, and October, but the July lab was not completed. She added that with the change to the new company, there were no staff members specifically assigned to ensure the labs were completed as ordered. The DON stated it is important to ensure labs are completed timely in order to identify if a resident has had a change in condition. When asked whose role it is to ensure labs are completed as scheduled, the DON indicates that nursing leadership is responsible for assigning and overseeing completion of ordered labs.In an interview with the Medical Records Licensed Practical Nurse (LPN) #1 on 8/5/26 at 2:40 PM, she acknowledged that it has been part of her role to run a monthly report at the end of each month to identify labs needed for the previous month. She states she did not run the July report because she was on vacation, and her workload was very full when she returned. She added that she did not consider it that important since the labs involved were only Hemoglobin A1C labs. The Medical Records LPN explained that it is important to ensure labs are completed timely and in accordance with the physician's orders because the results allow the provider to determine whether the resident's blood sugar is being regulated. She states that not completing the labs could cause all sorts of problems for the residents.In an interview with the DON on 8/5/26 at 3:37 PM, she acknowledged that the Hemoglobin A1C labs for Resident #43 were also not drawn as ordered and confirms that this resident's A1C was due in July as well.During an interview with the Administrator at 12:44 PM on 8/6/26, she explained that she expects her staff to ensure labs are completed as per the physician's orders, as this can help aid in the prevention of negative outcomes in the health of the residents. Resident #105 A record review of the admission Record revealed the facility admitted Resident #105 on 4/7/26 with diagnoses including type 2 diabetes mellitus without complications and end stage renal disease.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/26 revealed a Brief Interview Mental Score (BIMS) of (12), indicating the resident is cognitively intact.A record review of the Order Summary Report revealed an order dated 4/8/26 for Hemoglobin A1C labs every three (3) months (January, April, July, October). Resident #43A record review of the admission Record revealed the facility admitted Resident #105 on 7/16/24 with diagnoses including type 2 diabetes mellitus without complications, and chronic kidney disease, stage (3).A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/15/26 reveals a Brief Interview Mental Score (BIMS) of fifteen (15), indicating the resident is cognitively intact.A record review of the physician orders revealed Hemoglobin A1C labs every three (3) months (July, October, January, Apri).

Based on interview, record review, and facility policy review, the facility failed to follow the comprehensive care plan for obtaining the physician-ordered Hemoglobin A1C laboratory test for two (2) of (21) sampled residents. Resident #43 and Resident #105.Findings include: A record review of the facility policy, Care Plans, Comprehensive Person-Centered, revised March 2022, reveals, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Resident #105 A review of Resident #105's Care Plan Report initiated on 4/10/26, directed staff to monitor laboratory results, report results to the physician as needed, and obtain a hemoglobin A1C every three months during January, April, July, and October. A review of Resident #105's Order Summary Report revealed an order dated 4/8/26 to obtain a hemoglobin A1C every three months during January, April, July, and October. A review of Resident #105's admission Record revealed the facility admitted the resident on 4/7/26 with diagnoses that included type 2 diabetes mellitus without complications and end-stage renal disease. a A review of Resident #105's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/08/26, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A review of Resident #105's laboratory records revealed the hemoglobin A1C care planned for July 2026 was not completed. Resident #43 A review of Resident #43's Care Plan Report, initiated on 7/16/24, directed staff to obtain laboratory tests as ordered. During an interview on 8/5/26 at 3:37 PM, the Director of Nursing (DON) acknowledged Resident #43's hemoglobin A1C was due in July 2026 and confirmed it was not completed as ordered and care planned. A review of Resident #43's admission Record revealed the facility admitted the resident on 7/16/24 with diagnoses that included type 2 diabetes mellitus without complications, stage 3 chronic kidney disease, and paroxysmal atrial fibrillation. A review of Resident #43's Minimum Data Set assessment (MDS), with an Assessment Reference Date (ARD) of 5/15/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #43's physician orders revealed an order to obtain a complete blood count (CBC), comprehensive metabolic panel (CMP), and hemoglobin A1C every three months during January, April, July, and October. A review of Resident #43's laboratory records revealed the CBC, CMP and hemoglobin A1C care planned for July 2026 were not completed. During an interview on 8/5/26 at 2:15 PM, the DON acknowledged Resident #105's hemoglobin A1C was due in July 2026 but was not completed. The DON stated the facility did not have a staff member specifically assigned to ensure laboratory tests were completed following a change to a new company. The DON stated nursing leadership was responsible for assigning and overseeing the completion of ordered laboratory tests. During an interview on 8/5/26 at 2:40 PM, Medical Records Licensed Practical Nurse (LPN) #1 stated her assigned duties included running a monthly report to identify laboratory tests due during the previous month. LPN #1 acknowledged she did not run the July report because she had been on vacation and had a heavy workload when she returned. LPN #1 stated timely completion of hemoglobin A1C testing allowed the provider to determine whether a resident's blood glucose was controlled. During an interview on 8/6/26 at 9:11 AM, LPN #2, the Care Plan Coordinator, stated the comprehensive care plan provided structure for how staff should meet each resident's care needs. LPN #2 stated the care plan included instructions for monitoring ordered laboratory tests and that staff should ensure the tests were completed as scheduled. LPN #2 stated failure to implement a resident's care plan could result in adverse outcomes and prevent staff from identifying changes in the resident's condition. During an interview on 8/6/26 at 12:44 PM, the Administrator stated she expected staff to complete laboratory tests according to physician orders because timely testing assisted with preventing negative health outcomes.

Based on observation, interview, record review, and facility policy review the facility failed to follow hand hygiene and infection prevention practices for two (2) of three (3) care observations. Resident #3 and #95.Findings include:Record review of the facility policy Handwashing/ Hand Hygiene with a revision date of 08/2015 revealed, The facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors .Resident #3On 8/5/26 at 10:05 AM, Certified Nursing Assistant (CNA) #2 was observed providing urinary catheter care to Resident #3. CNA #2 gathered supplies, donned a gown, and entered the resident's room. CNA #2 filled a basin with warm water and applied gloves. While wearing the gloves, CNA #2 pulled back the resident's bed covers, adjusted the bed, and touched the privacy curtain before beginning catheter care. Resident #3 had feces in the brief. During care, CNA #2 removed her gloves and applied clean gloves on two occasions without performing hand hygiene. CNA #2 did not perform hand hygiene before beginning care, between glove changes, or after completing care.During an interview on 8/5/26 at 10:38 AM, CNA #2 confirmed she did not perform hand hygiene before, during, or after Resident #3's catheter care. CNA #2 stated she forgot. CNA #2 acknowledged that failing to perform hand hygiene while providing catheter care could cause the resident to develop an infection.A review of Resident #3's admission Record revealed an admission date of 3/24/25 with diagnoses that included neuromuscular dysfunction of the bladder and urinary tract infection.A review of Resident #3's Order Summary Report revealed an order dated 7/17/26 for an 18 French, 30 cubic centimeter indwelling urinary catheter and catheter care with soap and warm water every shift.A review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/27/26, revealed the resident was severely cognitively impaired.Resident #95On 8/5/26 at 8:00 AM, Licensed Practical Nurse (LPN) #2 was observed administering medication to Resident #95. LPN #2 gathered supplies and gloves, knocked on the resident's door, and entered the room. LPN #2 applied gloves and administered one drop of latanoprost ophthalmic solution into each of the resident's eyes. LPN #2 did not perform hand hygiene upon entering the room or before applying gloves and administering the medication.During an interview on 8/5/26 at 8:30 AM, LPN #2 acknowledged she made a mistake and failed to perform hand hygiene before administering Resident #95's ophthalmic medication. LPN #2 stated she usually performed hand hygiene before administering medication. LPN #2 acknowledged that failing to perform hand hygiene could cause the resident to develop an eye infection.A review of Resident #95's admission Record revealed an admission date of 5/20/25 with a diagnosis that included unspecified glaucoma.A review of Resident #95's Order Summary Report revealed an order dated 3/16/26 for latanoprost ophthalmic solution 0.005 percent, one drop in each eye once daily for glaucoma.A review of Resident #95's MDS with an ARD of 5/1/26, revealed a Brief Interview for Mental Status score of 9, which indicated moderate cognitive impairment.During an interview on 8/6/26 at 12:58 PM, the Infection Preventionist stated LPN #2 should have performed hand hygiene upon entering the resident's room and before administering the ophthalmic medication and CNA #2 should have performed hand hygiene upon entering the resident's room and between glove changes. The Infection Preventionist stated the failure created cross-contamination and the possibility of spreading infection. She stated she expected staff to follow the facility's infection prevention policies and procedures.During an interview on 8/6/26 at 1:37 PM, the Director of Nursing (DON) stated CNA #2 should have performed hand hygiene before beginning care and each time she changed gloves, and she expected LPN #2 to perform hand hygiene upon entering the resident's room and before applying gloves and administering medications or treatments. The DON stated she expected staff to provide care according to facility procedures and their training.

Based on interview, record review, and facility policy review, the facility failed to develop, implement, and maintain effective corrective actions and monitoring for two (2) of (2) previously identified quality-of-care concerns reviewed, oral care and hand hygiene. The facility was cited for these practices during its September 2024 recertification survey, and the same deficient practices recurred during the August 2026 recertification survey. Findings include:A record review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Program, no date, reveals, . Implementation: The QAPI Committee oversees the QAPI Plan, which details the program's structure and activities. the committee tracks performance, establishes goals, identifies deficiencies, analyzes causes, implement corrective actions, and monitor improvements .A review of the recertification survey conducted in September 2024 revealed that the facility was cited under F677 for not providing adequate oral care and under F880 for failing to ensure proper hand hygiene before administering care to residents. Resident #18 and Resident #73.A review of the current recertification survey August 2026 revealed the facility was again cited under F677 for not providing adequate oral care and under F880 for failing to ensure proper hand hygiene before administering care to residents. Resident #3 and Resident #95.In an interview with the Administrator at 12:26 PM, on 8/6/26, she explained that it is a practice of the facility to monitor their Quality Assurance and Performance Improvement Program (QAPI) Plan, adding that continued monitoring is necessary as it helps identify care concerns to ensure there is no break in the quality-of-care residents receive. At 1:51 PM on 8/6/26, in an interview with the Director of Nursing (DON), she acknowledged that the facility was cited during the annual recertification in 2024 for not providing proper oral care and for not adhering to correct handwashing techniques prior to providing care. She explained that additional education is needed for Certified Nursing Assistants (CNAs) who provide Activities of Daily Living (ADL) that includes oral care, because inadequate oral hygiene can lead to cavities, pain, or infection. The DON further stated that the same level of attention is needed for handwashing practices, noting that CNAs require better monitoring and reinforcement of proper hand hygiene to prevent cross-contamination and reduce the risk of infection when providing care.

Based on observation, interview, facility policy review, and record review, the facility failed to provide oral care in accordance with physician's orders for one (1) of three (3) residents reviewed for Activities of Daily Living (ADL) care. Resident #52. Findings Include: Record review of the facility policy Mouth Care revised February 2018 revealed, The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection . Record review of the facility policy Resident Rights revised December 2016 revealed, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . a dignified existence; b. be treated with .dignity .On 8/3/26 at 2:30 PM, Resident #52 was observed with visibly unclean teeth. Dried secretions, dried skin, and a thick white film were observed on the resident's teeth.On 8/5/26 at 9:22 AM, Resident #52's mouth was again observed to be visibly unclean. The resident had unclean teeth, thick oral secretions, and visible plaque on the teethDuring an interview on 8/5/26 at 9:45 AM, Licensed Practical Nurse (LPN) #3 stated she had applied lip balm to Resident #52's lips that morning. LPN #3 stated staff cleaned the resident's mouth daily but acknowledged the resident's mouth had appeared this way since admission.During an interview on 8/5/26 at 11:07 AM, Certified Nursing Assistant (CNA) #1 stated CNAs were responsible for cleaning Resident #52's mouth daily. CNA #1 stated she completed the resident's oral care at approximately 10:00 AM that morning. CNA #1 stated she was unsure whether the night-shift staff consistently provided oral care because she worked the 3:00 PM to 11:00 PM shift.During an interview on 8/5/26 at 12:50 PM, the Director of Nursing (DON) confirmed Resident #52's mouth appeared visibly unclean that morning. The DON stated the resident's mouth was chronically covered with plaque, although the amount varied and improved when staff cleaned the resident's mouth. The DON confirmed oral care was not documented as completed on 7/26/26, 8/2/26, and 8/4/26. The DON stated CNAs were responsible for providing oral care twice daily. The DON stated she did not know why staff failed to provide the care on the identified dates. The DON stated failing to provide oral care could result in plaque buildup, cavities, and an increased risk of infection. The DON stated she expected CNAs to provide oral care twice daily and licensed nurses to intervene when CNAs did not provide the required care. The DON also stated the facility sent Resident #52 to a dentist during September 2025, but the dentist did not evaluate the resident because of an insurance or payment dispute.A review of the Oral Care Task Record for Resident #52 revealed oral care was not completed on 7/26/26, 8/2/26, and 8/4/26.A review of resident # 52's admission Record revealed she was admitted on [DATE] with diagnoses that included aphasia following cerebral infarction. A review of resident #52's Order Summary Report revealed an order for Enteral Feed Order every shift Nasal/Oral Care completed dated 6/27/26. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/19/26 revealed a Brief Interview of Mental Status (BIMS) score of three (3) indicating cognitive skills were severely impaired.

Based on policy review, record review and interviews the facility failed to provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to a resident requiring such care or initiate the emergency response system in accordance with related physician's orders and the resident's advance directives for one (1) of four (4) sampled residents. Resident #1 The facility's failure to review and implement the code status according to the advance directives resulted in Resident #1 not receiving CPR and emergency services. The resident subsequently expired at the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] and existed at: 42 CFR(s): 483.24 (a)(3) -Cardiopulmonary Resuscitation (F678) Scope and Severity J.This situation placed Resident #1 and all other residents who were full code status at risk for serious injury, serious harm, serious impairment, or death.The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 1:45 PM and provided the IJ template. The facility provided an acceptable corrective action plan on [DATE] in which they alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed on [DATE].Based on the facility's implementation of corrective actions on [DATE], the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on [DATE] prior to the SA's entrance on [DATE]. Findings Included:Record review of the facility policy titled, Emergency Procedure-Cardiopulmonary Resuscitation version date [DATE], revealed, . If an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or b. There are obvious signs of irreversible death (e.g., rigor mortis) .Emergency Procedure-. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing.b. Instruct a staff member to activate the emergency response system (code) and call 911.c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events.chest compressions, airway, breathing.Record review of the RESIDENT/FAMILY CONSENT FOR CARDIOPULMONARY RESUSCITATION dated [DATE] for Resident #1 and signed by Resident #1's Resident Representative (RR) revealed the document indicated by initials of the RR stated, I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in care of extreme emergency. Record review of the Progress Notes for Resident #1 dated [DATE] at 5:47 AM, revealed Licensed Practical Nurse (LPN) #1 documented on [DATE] she observed the resident was not breathing and she was unable to obtain any vital signs and documented that in response she notified a hospice nurse, the resident's primary healthcare provider and Resident Representative (RR), the Director of Nurses (DON) and the Executive Director (ED), with no mention of initiation of cardiopulmonary resuscitation.Record review of the incident Report dated [DATE] revealed that on [DATE], Resident was found unresponsive at approximately 5:20 am by the CNA. The CNA reported to the nurse resident condition. The nurse went to the Resident room and found the resident in his bed unresponsive. She attempted to obtain a pulse and blood pressure without success and did not observe any rise or fall of his chest.Record review of the Facility Investigation revealed LPN #1 observed Resident #1 was not responsive at 5:20 AM on [DATE] and did not verify the resident's code status and did not initiate the emergency response system or CPR. On [DATE] at 1:20 PM, during a telephone interview LPN #1 revealed that at approximately 5:20 AM on [DATE] she observed Resident #1 was not responsive. She said she left his room, gathered equipment to measure vital signs, returned and was unable to attain any detectable pulse and Resident #1 had no chest rise or fall and she was unable to auscultate any breath sounds with stethoscope. She stated that she left him again and grabbed his binder at the nurses' station to locate the telephone number for his hospice service and notified the on-call hospice nurse that he had died. She stated that she was notified by the DON on [DATE] that Resident #1 had a code status of Full Code. LPN #1 stated, I didn't run a code due to him being hospice. I always worked with hospice patients that were DNR code status. She confirmed that when she grabbed the resident's binder (or chart) she did not look for his code status. She confirmed that she did not look on Point Click Care (PCC) software for the resident's code status and that she got his binder (chart) to look for the telephone number for his hospice service.On [DATE] at 1:25 PM, during an interview the ED said she was notified on [DATE] by the night shift (11:00 PM to 7:00 AM) Nurse Supervisor of an allegation that proper emergency procedure for an unresponsive resident was not initiated when Resident #1 was determined to be unresponsive by LPN #1 on [DATE]. She confirmed that she notified the DON of the allegation on [DATE] at 7:28 AM. She said an investigation was immediately initiated, beginning with record review of the medical record for Resident #1 and subsequent interview with LPN #1. The ED confirmed that the facility investigation determined that LPN #1 had failed to follow the correct protocol for an incidence of an unresponsive resident on [DATE] because she failed to check Resident #1's code status after determining he was nonresponsive and pulseless and failed to initiate the proper emergency procedure for an unresponsive resident. She confirmed that facility policy was that any incident of a resident being nonresponsive should result in their nurse checking, or having another staff check, the resident's code status. She confirmed that failure to check a resident's code status and that failure to initiate the emergency CPR procedure for a resident with 'Full Code' code status during an unresponsive episode could result in lack of provision of potentially lifesaving interventions. On [DATE] at 1:30 PM, during an interview the Director of Admissions revealed each resident's code status was printed on the admission Record (the first item in each resident's binder/chart) and under the Advanced Directives tab behind the admission Record. She said there would also be a Physician's Order if the resident requested DNR. She confirmed the code status was visible on each resident's Electronic Medication Administration Record (EMAR) available to nurses. She stated that just because the resident received hospice services did not mean they automatically had a DNR code status.Record review of the Order Summary Report revealed an order dated [DATE] for code status Full Code, which indicated the resident had chosen to receive cardiopulmonary resuscitation in case of cardiac arrest or pulselessness.Record review of a handwritten Physician's Telephone Orders dated [DATE] revealed an order to admit to hospice with a code status listed as Full Code.Record review of the admission Record for Resident #1 revealed the facility admitted the resident on [DATE] with diagnoses of severe protein-calorie malnutrition, heart failure and atherosclerotic heart disease.Record review of the Minimum Data Set (MDS) for Resident #1 with Assessment Reference Date (ARD) [DATE] revealed the resident's Brief interview for Mental Status (BIMS) score was listed as 99 with documentation that the resident was unable to complete the interview, with no noted memory problem and was independent with decisions regarding tasks of daily life. Section 0 of the MDS review revealed the resident received hospice care.Corrective Action PlanResident (#1) who was receiving hospice services from Hospice Compassus beginning on [DATE], for unspecified severe protein calorie malnutrition, unspecified systolic congestive heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of malignant neoplasm of the prostate, and dysphasia unspecified. Resident has resided at [NAME] Community Care Center since [DATE], and was listed as a full code per the resident/family request on [DATE]. The resident expired on [DATE], at approximately 5:20am with no CPR initiated. Coroner, RP, DON, Administrator and Hospice were notified of the death.On [DATE] the resident's assigned nurse was suspended pending the results of the investigation.On [DATE] the QA Committee completed a root cause analysis to identify the cause of the failure to initiate CPR.QA Committee has reviewed the Emergency Care, Resident Rights, Abuse-Neglect of Resident and Care Plans, Comprehensive Person-Centered policies, and identified that no updates are required.On [DATE] nursing staff education was initiated regarding the Emergency Care policy prior to working until 100% of nursing staff education has been achieved. Nurses will not be allowed to work without in-servicing on the Emergency Care Policy. Training was initiated on Emergency Care/Code Status utilizing a Mock code with the clinical team beginning on [DATE] by the Director of Nursing (DON). Post training debriefing will be completed by the DON or the Staff Development Nurse to evaluate learning100% of residents' medical records were audited on [DATE] for accuracy of correct code status by the Medical Records Nurse. No residents were affected.DON, ADON or the Staff Development Nurse will continue to conduct mock codes with debriefing to evaluate learning twice a week for 12 weeks. The QA Committee will review results of debriefing and evaluation of learning and make recommendations on any adjustments to the plan of correction.An Emergency QA Meeting was conducted on [DATE] to discuss with the interdisciplinary team members and the Medical Director the results of the findings and the plan of action.The facility alleges all corrective actions were completed on [DATE], and the IJ removed on [DATE].Validation:The SA validated the Corrective Action Plan on [DATE] and determined the IJ was removed on [DATE] prior to SA entrance on [DATE].

Based on observation, interviews, record reviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care, specifically nail care, for a dependent resident for one (1) of four (4) sampled residents, Resident #1. Findings Included: Review of the facility's policy titled, A.M. Care, dated 10/09, revealed, .A.M. (Morning) Care will be given to residents daily .Procedure .10. Provide nail care as needed . Record review of the Admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD).a Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. Further review revealed Resident #1 was dependent upon staff for ADL care. On 4/07/25 at 12:15 PM, an observation revealed Resident #1 had ten fingernails with thick grayish brown substance beneath each nail. On 4/07/25 at 2:30 PM, during an observation and interview, Licensed Practical Nurse (LPN) #1 reviewed the fingernails of Resident #1 and described them as dirty and removed chunks of a grayish brown substance from beneath each of the resident's fingernails with an orange stick. Resident #1 indicated she preferred her fingernails to be their length, but did not like them to be dirty. On 4/07/25 at 3:00 PM, an interview with the Director of Nurses (DON) revealed she expected staff to perform resident nail care for residents. On 4/07/25 at 4:00 PM an interview with CNA #3 revealed that personal hygiene, including fingernail care and grooming was to be provided to all residents each shift as needed. On 4/07/25 at 4:30 PM an interview with the Administrator revealed it was very important to ensure appropriate care was provided for each resident including grooming, including fingernail care.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement care plan intervention related to activities of daily living (ADL) care and hydration for one (1) of four (4) sampled residents, Resident #1. Findings Included: Review of the facility's policy, Care Plans, dated 1/15, revealed, .Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care Record review of the Admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD). Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. Further review revealed Resident #1 was dependent upon staff for ADL care. Record review of the Order Summary Report for Resident #1 revealed the resident had physician order listed as Increase water intake by mouth eight ounces three times daily in between meals three times a day with Start Date 8/01/24. Record review of the current Care Plan for Resident #1 revealed the resident had a 'Focus' listed as has the potential for constipation with 'Interventions' listed as 'Encourage adequate fluid intake'; she had a 'Focus' listed as 'has the potential for complications/fluid volume imbalance' with 'Interventions' listed as 'Encourage adequate fluid intake. Fluids with meals/meds, per hydration cart, and at request'; the resident had 'Focus' listed as 'has a self- care deficit due to impaired mobility' with 'Interventions' listed as 'assist with ADLs (activities of daily living) as indicated .nail care to be performed by nursing .one person assistance with eating .hygiene'. On 4/07/25 at 12:15 PM, an observation revealed Resident #1 had no water, water pitcher or water glass in their room. There was an unopened eight (8) ounce bottle of water and a half-filled gallon labeled water on the top of the resident's chest of drawers, out of reach of the resident. Resident #1 had ten (10) fingernails with a thick, grayish brown substance beneath each nail. On 4/07/25 at 12:22 PM, during an observation, the Medical Records Nurse entered the room and offered to assist Resident #1 with lunch and assisted her to drink the water in her glass. The resident's lunch tray was removed, including fluids from the room. There was no water or fluids, or container left for the resident. On 4/07/25 at 1:25 PM, an interview with the Administrator revealed she was aware that Resident #1 had bottled water in her room out of her reach and no water glass or pitcher. On 4/07/25 at 2:05 PM, an observation revealed Resident #1 did not have any water, glass or pitcher in reach. On 4/07/25 at 2:06 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed she said the staff took ice and water to residents. She reported that fluids for oral intake (PO fluids) were provided on meal trays, with medication administration and in Styrofoam cups for all residents unless contraindicated by the resident's condition based on physician orders and resident's care plan. She confirmed that the nurses were responsible for the supervision of care for assigned residents and the implementation of care plan interventions. She stated that Resident #1 received oral (PO) fluids with her breakfast tray, she was not sure how much of those were consumed. She confirmed that the resident received PO fluid with administration of medications and that Resident #1 did not have water provided during the morning of 4/07/25. She stated, We dropped the ball there with the water. She said she believed that ice and water were to be provided at 10:00 AM and 2:00 PM. She confirmed that she had not provided any other PO fluids for Resident #1 on 4/07/25 and she was not sure of the amount of PO fluids consumed by Resident #1 on 4/07/25, she stated, I can't say, I didn't give her any before lunch. On 4/07/25 at 2:30 PM, an observation revealed Resident did not have any water, glass or pitcher in reach and Certified Nurse's Aide (CNA) #1 brought a Styrofoam cup of ice water with straw to Resident #1. On 4/07/25 at 3:00 PM an interview with the Director of Nurses (DON) revealed she said that making sure residents were well hydrated was important and that she expected resident care plans to be followed because it was very important to implement interventions which were in place to address issues the residents had. She said that all nurses had access to resident care plans and all CNAs had access to resident care instructions in each resident's Kardex, which had interventions pulled from the residents' care plans. On 4/07/25 at 4:30 PM an interview with the Administrator revealed she stated that implementation of residents' care plans was very important to ensure appropriate care was provided for each resident.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide hydration care and services to one (1) of four (4) sampled residents, Resident #1. Findings Included: Policy review of the facility policy titled 'Water Pitchers/Water Glasses' with review date 10/09 revealed the policy stated, Each resident will be provided with ice water/tap water at the bedside .Responsibility Nursing Assistants. Record review of the Admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD). Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. Further review revealed Resident #1 was dependent upon staff for ADL care. Record review of the Order Summary Report for Resident #1 revealed the resident had physician order listed as Increase water intake by mouth eight ounces three times daily in between meals three times a day with Start Date 8/01/24. During an observation on 4/07/25 at 12:15 PM, Resident #1 had no water, water pitcher or water glass in their room. There was an unopened eight (8) ounce bottle of water and a half filled gallon labeled water on the top of the resident's chest of drawers, out of reach of the resident. During an observation on 4/07/25 at 12:22 PM, the Medical Records Nurse, entered the room and offered to feed the resident lunch, and assisted the resident to drink the water in her glass. The resident's lunch tray was removed, including fluids from the room, leaving no water or fluids or container left for the resident. The resident consumed all the water in the glass. During an interview on 4/07/25 at 1:20 PM, the Director of Nursing (DON) stated that unless clinically contraindicated, all residents should have fresh water available at all times. During an interview on 4/07/25 at 1:25 PM, the Administrator revealed that she was aware that Resident #1 had bottled water in her room that was out of her reach and had no water glass or pitcher. During an observation on 4/07/25 at 2:05 PM, Resident #1 did not have any water, glass or pitcher in reach. During an interview on 4/07/25 at 2:06 PM, Licensed Practical Nurse (LPN) #1 revealed she said the staff took ice and water to residents. She reported that fluids for oral intake (PO fluids) were provided on meal trays, with medication administration and in Styrofoam cups for all residents unless contraindicated by the resident's condition based on physician orders. She confirmed that the nurses were responsible for the supervision of care for assigned residents and the implementation of care planned interventions. She stated that Resident #1 received PO fluids with her breakfast tray, she was not sure how much of those were consumed. She confirmed that the resident received PO fluid with administration of medications and that Resident #1 had not had water provided during the morning of 4/07/25. She stated, We dropped the ball there with the water. She said she believed that ice and water was to be provided at 10:00 AM and 2:00 PM. She confirmed that she had not provided any other PO fluids for Resident #1 on 4/07/25 and she was not of the mouth of PO fluids consumed by Resident #1 on 4/07/25, she stated, I can't say, I didn't give her any before lunch. During an interview on 4/07/25 at 3:00 PM, the DON revealed she said that making sure residents were well hydrated was important and that she expected resident care plans to be followed because it was very important to implement interventions which were in place to address issues the residents had. She said that all nurses had access to resident care plans and all CNAs had access to resident care instructions in each resident's Kardex, which had interventions pulled from the residents' care plans. During an interview on 4/07/25 at 4:00 PM, CNA #3 revealed that it was her understanding that fresh water was to be provided to all residents unless contraindicated at least one time each shift. During an interview on 4/07/25 at 4:30 PM, the Administrator revealed she stated that it was very important to ensure appropriate care was provided for each resident. She confirmed that providing and offering water for all residents was very important and that the facility provided ice and Styrofoam cups and straws for the disbursement of water to all residents for which there was no contraindications.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure proper hand hygiene and enhanced barrier precautions were followed prior to providing care for a resident with an indwelling catheter, for one (1) of one (1) resident observed for urinary catheter care. Resident #18. Findings Include: A review of the facility's policy titled Enhanced Barrier Precautions (EBP), dated 4/24, revealed . Definition: 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in Nursing Homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g. residents with wounds or indwelling medical devices) A review of the facility's policy titled Catheter Care, dated 5/22 revealed, Catheter care is performed to keep the catheter insertion site clean .Procedure: 1. Complete perineal care. 2. Wash hands and apply gloves . A review of the facility's Hand Washing policy, dated 9/19, revealed Staff are expected to use proper handwashing techniques to prevent the spread of infection . On 9/9/24 at 2:38 PM, prior to entering the room on Resident #18, signage of resident's door was observed. The sign indicated that the resident was on Enhanced Barrier Precautions and stated that everyone entering the resident's room must clean their hands when entering and leaving the room. Further information intended for staff directed staff performing high-contact resident care activities to wear gloves and a gown. Upon entering the room, it was noted that Resident #18 had an indwelling urinary catheter. On 09/13/24 at 10:25 AM, during an observation of care provided by Certified Nursing Aide(CNA) #2, entered Resident #18's room without performing hand hygiene. Prior to beginning perineal care, CNA #2 applied gloves, however, CNA#2 did not put on a gown. During the procedure, CNA #2 did not remove his soiled gloves to open the drawer to the bedside table to retrieve additional supplies. At one point, CNA #3, who was assisting CNA #2, reminded CNA #2 to remove his gloves prior to opening the resident's closet door to retrieve a clean brief for the resident. CNA #2 removed his gloves, but failed to perform hand hygiene prior to applying clean gloves. On 09/13/24 at 10:53 AM, during an interview, CNA #2 admitted that he forgot to wear a gown and should have washed his hands prior to beginning care and after each glove change. He acknowledged that failing to wash his hands could increase the risk of infection to the resident. On 09/13/24 at 11:14 AM, during an interview, Licensed Practical Nurse (LPN) #5, the Infection Preventionist, confirmed CNA #2 failed to follow proper hand hygiene protocols. She emphasized that the CNA's failure to wear a gown and perform hand hygiene increased the risk of infection for Resident #18. On 09/13/24 at 1:07 PM, during an interview, the DON, also reiterated that by CNA #2 not wearing a gown and his lack of hand hygiene could increase the risk of infection for Resident #18, as well other residents receiving care provided by the CNA. A record review of Resident #18's Admission Record revealed that the facility admitted the resident on 1/10/22, The resident's diagnoses included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Retention of Urine, and Urinary Tract Infection. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/24 revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact.

48669 Based on observation, interviews, and record reviews, the facility failed to provide the resident or the Resident Representative (RR) with written notification of the bed-hold policy at the time of transfer for one (1) of one (1) sampled residents reviewed for hospitalization . Resident #18. Findings Include: Record review of a typed statement on facility letterhead, dated September 13, 2024, and signed by the Administrator revealed, (Proper name of facility) does not have a policy regarding bed holds. On 09/13/24 at 8:16 AM, during an interview with the RR for Resident #18, he stated that he did not receive a call from the Business Office Manager (BOM) or anyone from the facility regarding his father's bed hold for the hospital transfer that occurred on 09/10/24. The RR explained that no written notification or information was provided about the bed-hold process On 09/13/24 at 8:36 AM, during an interview with the BOM she revealed that she does not send out a bed-hold letter to families when residents are transferred to the hospital. She explained that residents and their families are given the bed-hold information upon admission to the facility. She stated that after each hospital transfer, she typically calls the family to notify them about the bed hold. When the State Agency (SA) requested a copy of the documented bed-hold notification in her system as proof of RR notification for Resident #18, the BOM admitted that she had not placed a note in the system. She also confirmed that she does not document bed-hold notifications in the system for any residents. On 09/13/24 at 11:02 AM, during an interview with the Administrator, she explained that the facility's procedure for notifying families of bed holds occurs upon admission. She stated that she was unaware that the facility was required to provide bed-hold notification at each hospital transfer. The Administrator acknowledged that the facility did not have a policy regarding bed-hold notifications for hospital transfers. A record review of the After Visit Summary revealed that Resident #18 was transferred to the hospital on 09/10/24 and returned to the facility on [DATE]. A record review of the Admission Record revealed that the facility admitted Resident #18 on 01/10/2022 with diagnoses that included Atrial Fibrillation and Heart Failure. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/24 revealed that Resident #18 had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact.

Based on staff interviews, record reviews, and facility policy review, the facility failed to implement the care plan interventions as reflected in the resident's comprehensive Care Plan related to a fall for one (1) of twenty-three (23) sampled residents. Resident #37. Findings Include: A review of the facility's policy titled Comprehensive Person Centered Care Plans, (D.3) dated 3/18, revealed, Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .Definitions .Comprehensive Person Centered Care Plan (CCP) - contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines .Procedure: .4. The Interdisciplinary Team along with the resident and /or Resident Representative will identify resident problems, needs, strengths, life history, preferences, and goals . A record review of Resident #37's care plan with a start date of 5/7/2024 revealed (Proper name of Resident #37) has the potential for falls .Intervention: Dycem to w/c (wheelchair) . A record review of Resident #37's care plan with a start date of 5/7/2024 revealed (Proper name of Resident #37) has a self care deficit .Intervention: Dycem to w/c . During an interview on 09/12/24 at 9:13 AM, Certified Nursing Assistant (CNA) #1 stated that she had not witnessed any falls during the day shift but recalled receiving a report of a fall approximately two weeks ago. She confirmed that there was not a Dycem non-slip mat in the Resident #37's wheelchair. On 09/12/24 at 9:15 AM, during an interview and observation with Licensed Practical Nurse (LPN) #3, she explained that the staff assisted the resident whenever she called and routinely asked if she needed to be repositioned, even when performing other tasks in the room. She emphasized reminding the resident to use the call light and avoid getting up without assistance. LPN #3 confirmed that there was not a Dycem nonslip mat in the resident's wheelchair. During an interview on 09/12/24 at 9:40 AM, with the Speech Therapist (ST), Director of the Therapy Department, she explained that they held weekly Interdisciplinary Team (IDT) fall meetings to review falls, assess previous interventions, and analyze the circumstances leading to each fall. She remarked, You can't stop a fall, but the purpose of these interventions is to minimize the risk and keep residents safe. The ST emphasized that failing to follow recommendations could compromise both resident and staff safety. On 09/13/24 at 9:14 AM, Resident #37 was observed asleep in her bed, with her wheelchair positioned at the bedside. There was not a non-slip mat (Dycem) noted in the resident's wheelchair as indicated as an intervention on the care plan. A record review of Resident #37's Order Summary Report with active orders as of 9/13/24, revealed an order dated 8/20/24 Skilled Physical Therapy four (4) times a week for six (6) weeks, including therapeutic exercise, therapeutic activities, neuromuscular reeducation, gait training, moderate complexity evaluation, electrical stimulation, ultrasound, and short-wave diathermy for diagnoses of Muscle Weakness (M62.81) and Difficulty Walking (R26.2). A record review of Resident #37's Admission Record revealed the facility admitted the resident on 5/27/24 with diagnoses that included Unspecified Dementia, with other behavioral disturbance and Other symptoms and signs involving the musculoskeletal system. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/2/24, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Review of Section J revealed that the resident had experienced two (2) or more fall since admission without injury.

Based on observation, interview, record review, and facility policy review, the facility failed to provide timely incontinence care and oral care for one (1) of four (4) residents reviewed for activities of daily living (ADL) care. Resident #73 Findings Include: A review of the facility's policy titled A.M. Care, dated 10/09, revealed: Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants . On 09/09/24 at 11:48 AM, during an interview, the Resident Representative (RR) of Resident #73 stated that the Certified Nursing Assistants (CNAs) did not regularly brush her daughter's teeth or wash her hair. She explained that her daughter was unable to perform personal care independently and could not feed herself. The RR expressed her wish was that staff would more consistently perform these tasks. On 09/09/24 at 11:52 AM, an observation revealed Resident #73's RR brushing and flossing the resident's teeth. The resident's hair appeared short and oily. On 09/12/24 at 2:39 PM, during an interview, CNA #4 stated that ADL care, which includes perineal care, tooth cleaning, and hair care, is performed daily. She explained that if residents refuse care, the refusal is documented in the CNA book, and occasionally the nurse is notified. On 09/13/24 at 9:52 AM, during an observation and interview with Licensed Practical Nurse (LPN) #6, the Unit Manager, he explained that ADL care includes cleaning the face and brushing the teeth and should be completed before breakfast. He noted that Resident #73's hair was oily and could benefit from a wash. He emphasized that he expects CNAs to provide total ADL care. On 09/13/24 at 10:07 AM, during an interview, CNA #1 stated that she washed Resident #73's face before breakfast and would perform peri-care once the resident got up. She initially stated that she had completed all ADL care for Resident #73 but later admitted that she had not brushed the resident's teeth or washed her hair that day or week. She confirmed that both tasks should have been completed. On 09/13/24 at 1:15 PM, during an interview, the Director of Nursing (DON) confirmed that ADL care includes brushing teeth and washing hair as needed. She emphasized that CNAs are responsible for ensuring that residents' nails are clean and that all aspects of ADL care are performed. A record review of Resident #73's Admission Record revealed that the facility admitted the resident on 7/28/22 with diagnoses that included Hemiplegia, Unspecified Affecting the Left Non-Dominant Side and Unspecified Intellectual Disabilities. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/29/24 revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 99, indicated the resident could not participate in the interview. Section GG of the MDS revealed that Resident #73 is dependent on staff for oral hygiene, showering, and hair care. 47873 48669

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in a manner to prevent the possibility of complications as evidenced by oxygen tubing that was not dated to indicate weekly oxygen tubing/nasal cannula changes and not cleaning the oxygen concentrator filter as required for one (1) of one (1) resident reviewed for respiratory care. Resident #26 Findings Include: A review of the facility's policy titled Oxygen Therapy, dated 8/14 revealed, Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress .Procedure: . 8. Change tubing weekly. 9. Date tube when changed (weekly). On 9/9/24 at 10:30 AM, during an observation of Resident #26, who was sitting in her wheelchair in her room with a nasal cannula in her nose, it was noted that the oxygen tubing was not dated. On 9/9/24 at 10:35 AM, during an observation and interview with the Director of Nursing (DON), she explained that staff should write the date on a clear plastic bag when the tubing is changed weekly. Upon inspection of the bedside table, the DON pulled out two clear plastic bags, neither of which were dated. She confirmed that the bags should have been dated and that staff are expected to check the tubing and when not in use, store it in a clear plastic bag, which should be changed weekly to maintain infection control. She added that she expects staff to clean the filter when they change the tubing. On 9/9/24 at 10:40 AM, during an interview with Licensed Practical Nurse (LPN) #4, she stated that oxygen tubing is changed weekly for infection control purposes and should be dated when changed. On 9/9/24 at 12:55 PM, during an interview and observation with LPN #4, the oxygen concentrator filter for Resident #26 was found to have a moderate amount of grey lint along the edges and support grid. LPN #4 confirmed that the filter should have been cleaned when the tubing was changed. She acknowledged that the filter had not been cleaned, citing the amount of lint as evidence. She emphasized that cleaning the filter is necessary to ensure the resident receives clean air. On 9/12/24 at 3:39 PM, during an interview with LPN #5, the Infection Preventionist (IP), he stated that the oxygen tubing is supposed to be changed weekly to prevent the buildup of bacteria and reduce the risk of respiratory infections for the resident. On 9/13/24 at 9:56 AM, during an interview with LPN #6, Unit One Nurse Manager, he confirmed that oxygen tubing should be changed every Saturday night and dated to verify it had been changed. He explained that the tubing is replaced to protect the resident from infection and that the oxygen concentrator filter should also be cleaned at the same time, as it filters the air. A record review of Resident #26's Admission Record revealed the facility admitted the resident on 2/9/24. The resident's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, and Dependence on Supplemental Oxygen. A record review of the Order Summary report, with active order as of 9/1/24 revealed Resident #26 had a physician order, dated 2/9/24, to change the oxygen tubing and clean the oxygen filter every Saturday night. A record review of Resident #26's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/29/24 revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Section O indicated that the resident was receiving oxygen therapy. 47873

Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to provide urinary catheter care in a manner that prevents possible complications for one (1) of one (1) residents reviewed for urinary catheter care. Resident #18. Findings Include: A review of the facility's policy titled Catheter Care, dated 5/22, revealed, Catheter care is performed to keep the catheter insertion site clean .3. Cleanse around the area where the catheter enters the urethral meatus with an incontinent wipe in a downward motion about 4 inches . Discard soiled incontinent wipes and plastic bag appropriately. On 09/09/24 at 02:38 PM, during an observation and interview, it was noted that Resident #18 had a urinary catheter. The resident was unable to recall how long he had a urinary catheter, however, he stated that it had been for some time. A record review of Order Summary Report, with active orders as of 9/13/24, revealed Resident #18 had a physician order, dated 8/15/24, for urinary catheter and another order, with the same order date, for urinary catheter care every twelve (12) hours as needed. On 09/13/24 at 10:25 AM, during an observation of perineal care, including urinary catheter care provided for Resident #18 by Certified Nursing Assistant (CNA) #2, revealed CNA #2 used the same area of the wipe with each stroke while cleaning the resident's penis. Rather than cleaning the resident's penis with a downward stroke, CNA #2 wiped from bottom to top. CNA #2 then cleaned the urinary catheter tubing, using a back to forth motion, once again using the same area of a single wipe. On 09/13/24 at 10:53 AM, during an interview, CNA #2 admitted that he should have used a clean wipe for each stroke and cleaned from the top to bottom, while providing perineal care to Resident #18. He acknowledged that his care could possibly cause complications. On 09/13/24 at 11:14 AM, during an interview, Licensed Practical Nurse (LPN) #5, the Infection Preventionist, confirmed that CNA #2 should have used downward strokes while cleaning the resident and used clean wipes with each stroke. She emphasized that improper cleaning could lead to complications. On 09/13/24 at 1:07 PM, during an interview, the Director of Nurses (DON) stated that she expected CNA #2 to perform care correctly, as taught during in-service training. She explained that going from a dirty area to a clean area could possibly result in the resident developing a urinary tract infection (UTI) or skin irritation. A record review of Resident #18's Admission Record revealed that the facility admitted the resident on 1/10/22, The resident's diagnoses included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Retention of Urine, and Urinary Tract Infection. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/24 revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. 47873

Based on observation, staff interviews, and facility policy review, the facility failed to ensure staff washed or sanitized hands during wound care for one (1) of four (4) residents reviewed with wounds. Resident #4 Findings include: A record review of the facility's policy, Pressure Ulcer/Injury and Skin Conditions Guide for Wound Evaluation Documentation, undated, revealed, It is the practice of this facility to ensure residents with pressure ulcers receive necessary evaluation and treatment to promote healing, prevent infection . During the wound care observation, on 05/31/23 at 2:30 PM, for Resident #4, Licensed Practical Nurse (LPN) #1 removed his gloves after removing the soiled dressing but did not perform hand hygiene prior to applying clean gloves and cleaning the wound. After cleaning the wound, he did not remove the soiled gloves and perform hand hygiene prior to applying the clean dressing. On 05/31/23 at 2:55 PM, in an interview with LPN #1, he acknowledged that he did not wash his hands after removing the soiled dressing and should have washed his hands and changed gloves after cleaning the wound, before applying the clean dressing to the wound. On 05/31/23 at 3:29 PM in an interview with the Director of Nursing (DON), she confirmed LPN #1 should have washed his hands after removing the soiled dressing and applying clean gloves and should have removed his gloves and performed hand hygiene prior to applying the clean dressing. The DON acknowledged that LPN #1's actions were an infection control issue. A record review of Resident #4's Face Sheet, revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Pressure ulcer left buttock,stage 2 and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the Physician Orders, dated 05/23/23, for Resident #4 revealed, Clean stage two to left buttock with normal saline apply skin prep and cover with dry dressing daily.

Based on record review, interviews, and facility policy review, the facility failed to prevent the misappropriation of property for one (1) of four (4) residents reviewed for misappropriation of property. Based on implementation of the facility's corrective actions on 12/21/22, this was determined to be Past Non Compliance. Resident #1 Findings include: Record review of the facility's policy, Abuse Prevention, with a revision date October 2022, revealed . The facility is committed to protecting the residents from abuse .Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent . Exploitation: Taking advantage of a resident for personal gain through the use of manipulations, intimidation, threats or coercion . Mistreatment means inappropriate treatment or exploitation of a resident . Review of facility's document entitled, Vulnerable Adults in Mississippi, undated, revealed . What is a Vulnerable Adult? . includes all residents or patients, regardless of age, in a care facility .It shall be unlawful for any person to abuse, neglect or exploit any vulnerable adult . Record review of the facility Supervisor Investigation Summary Form, dated 12/23/22, and signed by the Executive Director (ED) revealed, On December 21, 2022, the Resident (Resident #1) reported to a Certified Nursing Assistant (CNA) that he gave a CNA his debit card to buy him (Proper Name) Chicken and the CNA spent his money .On December 21, 2022, during interview with the ED, Director of Nursing (DON), and Social Service Director (LSW), the Resident (Resident #1) stated that on November 25, 2022, he gave (proper name) CNA #1 his debit card to purchase chicken for him from (Proper Name) Restaurant. He stated that she brought him the chicken but that she did not return his debit card and she still had the debit card. The Resident confirmed that he had willfully given the CNA (CNA #1) his debit card but stated that the CNA had spent $450 from his bank account without his permission. Further details within the facility investigation reveal the ED called CNA #1 and requested that she come to the facility to meet the ED and DON to discuss an issue. As the CNA #1 did not come to the facility, the ED called the CNA again and was told that CNA #1 revealed that she did not have a babysitter and would not be able to come to the facility. It was at that time that the ED informed CNA #1 that the DON was in the room and asked the CNA questions about using the Resident #1's debit card to purchase the Resident chicken from (Proper Name) Restaurant. CNA #1 confirmed that she had purchased the chicken, but she had returned the debit card to Resident #1. CNA #1 stated that Resident #1 said she owed him $450, and she told him that she would pay him back on Friday, even though she didn't spend his money. She further stated that she didn't spend his money but since she was the last one who had his card, she was going to make it right even though it was causing a hardship on her. At this time, the investigation revealed that the ED reviewed the purchases on Resident #1's bank statement that he provided to the ED. CNA #1 verbally confirmed making the purchases but stated that Resident #1 consented to the purchases. The ED asked CNA #1 what the facility's policy said regarding using resident funds, and the CNA replied we ain't suppose to. Following this statement, the investigation revealed that the ED informed the CNA that she was being terminated for violation of Resident Rights. The facility investigation of the alleged incident also revealed that the ED notified the (Proper Name) Police Department of the allegation on December 21, 2022, at approximately 9:00 AM. When the (Proper Name) Police Officer arrived at the facility at approximately 1:40 PM, the ED was present during his interview with the Resident #1. The ED recorded in investigation that the Police Officer informed the Resident that he could not take a police report because the Resident willingly gave the CNA his debit card to purchase food for him. The last portion of the investigation revealed that on December 23, 2022, the ED calculated the total amount of the debit card transactions and submitted a check request to the facility Accounts Payable Department in the amount of $419.65 to refund the money to Resident #1. Record review of the personnel file for CNA #1 confirmed her employment at the facility was terminated effective 12/21/22, for violation of facility policies. Record review of the Face Sheet for Resident #1 revealed he had been admitted by the facility on 4/01/22, with an admitting diagnosis of Encounter for Orthopedic Aftercare. Resident #1 also had diagnoses including Cervical Disc Disorder with Myelopathy, Diabetes, and Anemia. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date 10/11/22, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. On 1/03/23, at 12:40 PM, in an interview with Resident #1, he did not state that he had willingly given CNA #1 his debit card to purchase chicken. Resident #1 explained he knew he had his debit card on Thanksgiving Day (11/24/22) because he had gone to Thanksgiving dinner at the home of his son and used the debit card on the return drive to the facility to put gas in his son's car. He revealed during his Thanksgiving visit at his son's home, he had gotten sick and had gone to bed immediately upon return to the facility. He stated he must have left his card on his over-the-bed table. He stated that the following day, CNA #1 visited him in his room and inquired about his Thanksgiving. He stated, I guess that's when she got it. He said he initially thought he had lost his card and checked with a laundry worker to see if he had left his card in his pants pocket, but she told him she had not seen it. He stated when he called the bank, they told him his card had been used a lot. Resident #1 confirmed that the bank canceled his debit card and issued him a new one. Resident #1 also revealed that when the Police Officer came to the facility, the officer told him that he would need to go to the police station to make an official report. Resident #1 confirmed that a family member had assisted him with doing so, but said he did not have a copy of the police report. Resident #1 stated he had not seen CNA #1 since he discovered the money missing from his bank account. On 1/03/22 at 2:15 PM, an interview with the facility Social Worker Director revealed he became aware of the alleged abuse when the ED asked him if he was aware of the abuse on the morning of 12/21/22. The Licensed Social Worker/Director (LSW) stated he attended a conference on the morning of 12/21/22 with the ED and Resident #1, during which time, Resident #1 reported that CNA #1 had his debit card and had taken approximately four hundred and fifty dollars ($450.00) out of his account without his permission. The LSW stated, No staff is supposed to take any resident's debit or credit card for any reason. On 1/03/23 at 3:16 PM, a telephone interview with the Responsible Representative (RR) for Resident #1 revealed he had been notified of the incident of misappropriation but could not recall when. He confirmed that Resident #1 was very independent and took care of his own business. He said he did not have any information to add but confirmed that he had been made aware of the incident. On 1/03/23 at 3:30 PM a telephone interview with CNA #2 revealed she said that between 8:00 AM and 8:30 AM on 12/21/22 Resident #1 had disclosed to her that CNA #1 had taken his debit card and made several transactions, however, she stated she was not sure of the amount spent. CNA #2 explained she immediately reported the allegation to the facility ED and provided a written statement. On 1/03/23 at 5:20 PM an interview with Laundry Aide #1 revealed she reported Resident #1 came to her while she was in the hallway on 11/25/22, asking if she had seen his debit card. She stated that she had told Resident #1 that she had not seen his card but went with the resident to his room to assist him in searching for his card, but they had been unable to locate the card. On 1/03/23 at 5:28 PM an interview with RN #1 revealed she stated that she was familiar with Resident #1 and had never observed him in a state of confusion or disorientation. On 1/03/23 at 6:05 PM during an interview with the ED, she revealed as the facility Abuse Coordinator, she had served as the lead investigator of the incident. She confirmed as soon as she had been notified of the incident on 12/21/22, she began the investigation and notified the (Proper Name) Police Department, the Attorney General's Office (AGO) and the State Agency. The ED provided a copy of the reimbursement check in the amount of $419.65 paid to the order of Resident #1. The SA validated through record review and staff interview the in-service training regarding Abuse, Neglect, Misappropriation and Exploitation Prevention and Reporting was provided on 12/21/22. The SA valided through interview on 1/3/23 with the ED that the Quality Assurance and Assessment (QAA)Committee received the results of the investigation for the allegation on 12/22/22.

Based on record review, Resident Bill of Rights review and staff interviews the facility failed to ensure residents had readily available and reasonable access to their personal funds on weekends. This had the potential to affect 55 of 112 residents who had funds managed by the facility. Findings Include: Record review of the facility's policy, Resident Bill Of Rights, with a revision date of 11/2017, revealed, .A. Facility residents shall have the right to . 22. Manage his or her financial affairs. The resident must authorize the facility in writing to manage any personal funds and the facility must ensure the resident has reasonable and ready access to those funds . On 12/05/22 at 11:16 AM, in an interview with Resident # 29, he stated that he has a trust fund at the facility, but he is not able to get money on the weekends. He stated that if he wanted money for the weekends, it would have to be requested on Friday, as the lady that disperses the money does not work on weekends. On 12/7/22 at 3:40 PM, in an interview with the Manager of Payroll and Resident Trust Accounts, she confirmed residents cannot get money on weekends. She revealed that she checks with residents on Friday before she leaves, as she would be unavailable to assist residents with their monetary requests on weekends. On 12/7/22 at 4:38 PM, in an interview with Administrator, she confirmed staff are not available on weekends to assist residents with access to their personal funds, as she was unaware that residents wanted to get money on weekends. Record review of the Statement Register for the month of December 2022 revealed Resident #29 has an active account with the facility. Record review of the Resident #29's Face Sheet, revealed the facility admitted the resident to the facility on [DATE], with medical diagnoses including Type 2 Diabetes Mellitus and Hypothyroidism. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/27/2022, revealed a Brief Interview of Mental Status (BIMS) of 09, which indicated the resident had moderate cognitive impairment. Record review of the facility's Active Patient Trust Accounts, revealed Resident #29, along with 54 other residents currently have a trust account with the facility.

Based on observation, record review, and facility and staff interviews, the facility failed to ensure a resident received services included in the plan of care related to a condom catheter for one (1) of 23 sampled residents. Resident #68 Findings include: On 12/05/22 at 11:50 AM, the State Agency (SA) observed Resident #68 lying in bed. There was a urinary catheter privacy bag attached to the bed with no urine observed in the bag. Record review of the Face Sheet revealed the facility admitted Resident #68 on 06/05/19 with diagnoses including Anoxic Brain Damage and Persistent Vegetative State. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/22 revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 3 which indicates severe cognitive impairment. Record review of Resident #68's December 2022 Physician Orders, revealed an order dated 11/14/22, Freedom (Name brand of condom catheter) Cath (catheter), leg strap and privacy bag in place each shift. On 12/05/22 at 03:34 PM, during a phone interview with the Resident Representative (RR), she explained Resident #68 previously had an indwelling catheter, but it was removed. She stated that he had a Physician's Order to wear a condom catheter, but she was told by the facility that it was on order and had not been received. Every time she has visited, she has not seen Resident #68 wearing the condom catheter.She commented that he voids frequently, and she requested a condom catheter because she felt like it would help to prevent skin breakdown. On 12/06/22 at 3:00 PM, during an interview with Certified Nurse Aide (CNA) #2, she explained Resident #68 has not worn a condom catheter for several weeks because the nurses said there were no condom catheters for him. On 12/06/22 at 3:30 PM, during an interview with the Director of Nursing (DON), she stated that it was decided to place a condom catheter on Resident #68 to keep him dry and to prevent skin break. She explained the last she heard the resident was using the condom catheter. She confirmed that Resident #68 does have a Physician's Order to wear a condom catheter. On 12/06/22 at 3:40 PM, during an observation of Resident #68 with the DON, she confirmed the resident was not wearing a condom catheter, and she had no clue that a condom catheter was not being placed on the resident. She explained she expected staff to follow the physician orders and the care plan. On 12/07/22 at 1:40 PM, during an interview with Licensed Practical Nurse (LPN) #1/Unit Manager, she explained that the purpose of the condom catheter was to keep Resident #68 dry. She stated that Resident #68 has not worn the condom catheter. On 12/07/22 at 3:00 PM, during an interview with the Administrator, she explained she was aware that Resident #68 had a Physician's Order to wear a condom catheter and there had been an issue with receiving the catheters. She stated she was not aware that the Physician's Order was not discontinued when the condom catheters were not available. She expected staff to carry out physician orders and to follow the plan of care.

Based on interview, record review, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic drugs were discontinued or documented as necessary after 14 days for one (1) of five (5) residents reviewed for unnecessary medications. Resident # 57. Findings include: A record review of the facility's policy, Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, updated 3/18, revealed . Procedure: . 3. PRN (as needed) psychotropic drugs should be limited to 14 days unless the primary physician has documentation supporting the rational in the medical record and has indicated the duration for the PRN order. 4. PRN antipsychotic drugs are limited to 14 days and cannot be renewed unless the primary physician or prescribing practitioner evaluates the resident. Record review of the December 2022 Physician Orders, for Resident #57 revealed, .Diazepam (Valium) 5 MG (milligrams) tablet give one tablet by mouth every six hours as needed .Order date 9/16/11 and Start Date 9/16/22 . The diagnosis related to the order was written as, Anxiety Disorder, unspecified, but did not include a specific duration of time for administration of the medication. Record review of Note to Attending Physician/Prescriber, dated 09/21/22, written by the Consultant Pharmacist (CP) for Resident #57 revealed, .RE: PRN Valium . Recommend discontinue PRN use of the above medication per the following federal guideline: .Orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then he/she should document the rationale in the resident's medical record and indication the duration for the PRN order On Physician/Prescriber Response section of the form, the Disagree box was checked, and the signed notation, dated 9/27/22, revealed, Pt takes medication for anxiety PRN - When scheduled routine Pt is too drowsy. Anxiety is an approved diagnosis for this med. The additional comments made by the CP revealed, - Not PRN - dx (diagnosis) irrelevant. Record review of the Face Sheet, revealed the facility admitted Resident #57 on 07/19/21. The resident's current diagnoses included with diagnoses of Major Depressive Disorder and Anxiety. Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/22, revealed that Resident #57 had a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impairment. The Medication Section of the MDS revealed that the resident had received five (5) days of an antianxiety medication during the last seven (7) days. Record Review of the December 2022, EMAR (Electronic Medication Administration Record), revealed nurse initials indicating Resident #57 had been administered Diazepam (Valium) 5 mg by mouth five (5) times in the first eight (8) days. On 12/08/22 at 1:50 PM, during a telephone interview with the CP, she confirmed that on 9/21/22, she had sent a note to the facility for the Physician/Prescriber regarding the PRN (as needed) use of Valium for Resident #57. She revealed that although the information reviewed the CMS (Centers for Medicare & Medicaid Services) regulations regarding the use of PRN psychotropic medications, she cannot make the physicians write the orders per regulations, all she can do is keep asking for their review and document her recommendations. On 12/08/22 at 2:10 PM, during a telephone interview with the Nurse Practitioner (NP), she revealed she had been unaware of the PRN regulations for psychotropic medications. She confirmed that she had received the pharmacy review regarding Resident #57 and the PRN use of Valium. The NP acknowledged the Valium order written for Resident #57 did not have an indication for continued use or duration of time for administration. On 12/08/22 at 2:30 PM, during an interview with the Director of Nurses (DON), she confirmed the Note to Attending Physician/Prescriber, revealed the specific CMS regulations for the use of PRN psychotropic medications. However, the DON acknowledged Resident #57 had an order for Valium PRN and there was no documentation regarding the indication for continued use with a specific duration of time.

Based on observation, record review, facility policy review, review of the safety restraint manufacturer's recommendations, and staff and resident interviews, the facility failed to secure the safety restraints for Residents # 1 and #2 in a manner to prevent an injury during transport in the facility van. As a result, Resident #1 sustained serious injuries, and was admitted to the hospital. Resident #2 sustained a skin tear, and abrasions. The facility failed to prevent Resident #5 from falling out of a lift sling during transfer from the bed to a chair, which resulted in the resident's transport to the emergency room , and evaluated for a contusion to the right hip. This affected three of five (3 of 5) residents reviewed for incidents and accidents within the facility. Findings include: Review of the Q Straint Driver/Operator Instruction Guide, The QStraint & M-Series, last revised September 24, 2008, revealed: Instructions For The Use Of The Restraint System Manufactured By Q'Straint. Lap - Shoulder Belts. The instructions included a diagram and written instructions for the proper use and application of this restraint. The belt should bear upon the bony structure of the body, and should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger's hip. Adjust the belts as firmly as possible consistent with user comfort. Ensure that the belt is not twisted. Use height adjuster if applicable. Warning: The upper torso/lap belt must always lie against the bony structure of the occupant's body, and it must never infringe on any component of the wheelchair such as; armrest, panel, wheel, or frame. Review of the facility's policy titled, Resident Transportation Guidelines, dated 11/10, revealed equipment (i.e. vehicle, lift, restraint systems) is maintained in accordance with manufacturer recommended preventative maintenance schedule. The Vehicle Maintenance Log documents such maintenance as well as repairs. A log of routine safety inspections and repairs will be maintained. The driver will conduct a monthly vehicle safety check utilizing the Vehicle Self-Inspection Worksheet to identify any obvious and outwardly appearing defects in the vehicle, safety restraint system(s), and appliances. Resident passengers will be assessed by nursing staff to determine medical and other required needs to safely complete the trip (i.e. oxygen, dependence, IV (Intravenous) pole, lift/transfer requirements). Such requirements will be made available prior to loading. Appropriately trained staffing is provided to meet passenger medical and other required needs during the trip as necessary. Prior to departure the driver will check to ensure all passengers are properly seated with safety restraints appropriately applied and any other vehicle contents (i.e. fire extinguisher, medical kit, oxygen) are securely stowed. Negative findings will be resolved prior to vehicle movement. Review of the Invacare Full Body Sling manufacturer's recommendations, dated 10/05, revealed: Warning-Maximum weight capacity 450 lbs. (pounds). Before using sling, read and understand Invacare Owner's Manual. Bleached, torn, cut, frayed, or broken slings are unsafe, and could result in injury. Discard immediately. Do not alter slings. Use only Invacare Lift Products. Washing Instructions: Water temperature of 180 degrees Fahrenheit (F) {82 degrees Celsius (C)}. Do not bleach. Air dry or dry at low temperature. inspect with each use. Review of the facility's investigation, dated July 7, 2017, and signed by the Director of Nurses (DON), revealed: On Friday 7/7/17, at approximately 8:20 AM, Residents #1 and #2 were transported in the facility's van by Certified Nursing Assistant (CNA) #1, the van driver, to doctor appointments. CNA #1 stated as she was approaching a stop light, the light was green, and then changed to yellow, and she applied the brakes in an abrupt manner to prevent running the red light. When the van came to a stop, Resident #2 had slid from his wheelchair to the floor of the van, and was on his hands and knees. Resident #1 was still seated upright in her wheelchair. CNA #1 pulled the van into the nearest parking lot for safety. CNA #1 stated Resident #2 remained on his hands and knees when she pulled into the parking lot with the seat belt around his ankle area, and Resident #1 remained seated in her wheelchair in an upright position. CNA #1 exited the van, went around to the passenger side door, where the wheelchair mechanical lift was located. CNA #1 reported when she opened the door, and began lowering the lift she observed Resident #1was sitting on the edge of her wheelchair with her seat belt located around her chest area. CNA #1 removed the seat belt, and eased Resident #1 down to the floor of the van. CNA #1 asked Resident #1 what happened, and she replied, I slid out of my chair. CNA #1 notified the facility's Executive Director (ED) of the incident. The ED, the DON, and two (2) Licensed Practical Nurses (LPNs) immediately went to the scene. Both residents were asked by the ED, DON, and the LPNs if they were okay, and both replied, yes, and neither wanted to go the emergency room /Hopital for evaluation when asked by the facility staff. Both residents were transported back to the facility via the facility van. Resident #1 was seated in the front area of the van directly behind the driver's seat, and was assessed first. She was on the floor of the van, sitting up between the leg rests of her wheelchair. Resident #1 denied any pain, other than her legs. Her legs were checked for injury, with none noted. Resident #1 did not complain of any pain during the transport back to the facility. At the facility Resident #1 was assessed by the Nurse Practitioner (NP). The NP noted a discoloration approximately the size 2 x 2 (two by two) to the left upper arm, and approximately quarter size to the right lower abdomen. During the NP's assessment, Resident #1 complained of neck pain, left shoulder pain, chest wall pain, lower extremity pain, and hip pain. The NP ordered Resident #1 to be transferred to the hospital emergency room for evaluation. A CT (Computed Tomography) scan revealed a Pulmonary Embolism, and recent appearing superior endplate compression fractures of the spine at T (Thoracic) 12, L (Lumbar) 1, L2, L3, and L4, many degenerative changes, including anterior subluxation (a partial or complete dislocation) of L4 and L5, with moderate to severe spinal stenosis of L4 and L5. Resident #1 was admitted to the hospital for treatment of [REDACTED].#2 was observed in an upright position in front of his wheelchair. There was a skin tear, approximately 2 x 0.1 (two by one tenth), on his outer right hand with scant amount of blood. Both knees had abrasions with no active bleeding. Resident #2 stated, I am okay, just help me up from here. Resident #2 was asked again if he had any pain, and he again replied, no. Resident #2 did not voice any complaint of pain during the ride back to the facility. Upon arrival to the facility, Resident #2 was assessed by the NP. Orders were received and implemented for the treatment of [REDACTED]. Resident #2 was assessed for pain, and had orders for Tylenol as needed for pain, but the resident stated he did not need anything for pain. During the interview with the van driver (CNA #1) by the ED, the van driver reported she had the residents secured with safety belts to the wheel chairs, and safety belts across the resident. Resident #1 confirmed her safety belt was in place, and it just didn't catch me when I started sliding. Review of CNA #1's (van driver) signed statement, dated 7/7/17, revealed she was driving the van with two residents on (Name of Avenue). The stop light was green, and turned to yellow, and she pushed on the brakes hard, and came to stop to keep from running the red light. CNA #1 stated she saw Resident #2 on the floor of the van, on his hands and knees. She asked him if he was okay, and he said yes. Resident #1 was still sitting up in her wheelchair. CNA #1 pulled the van into the nearest parking lot, and at that time, Resident #1 was still sitting up in her wheelchair, and she went around the van to lower the mechanical lift, and at that time she saw Resident #1 had scooted half way out of her wheelchair, and her seat belt was around her upper chest. CNA #1 removed the seat belt from around her chest, and eased her to the floor. CNA #1 asked Resident #1 if she was hurt, and she said no. CNA #1 went to check on Resident #2, who was still on his hands and knees, with the seat belt at his ankles. CNA #1 asked Resident #2 if he was okay, and he said yes. CNA #1 notified the ED, and told her what happened. An interview, and observation, on 7/21/17 at 2:20 PM, revealed CNA #1 was asked by the surveyor to demonstrate the applications of the seat belts, and go the route taken on the day of the incident. CNA #1 revealed, on 7/7/17, she was transporting Resident #1 and #2 in the facility van to doctor appointments. CNA #1 stated she was getting closer to a green stop light, and it changed to red, she stepped on the brakes really hard. Resident #2 fell , and when she got to check on him, she observed Resident #1 had slid out of the chair. CNA #1 said she asked them if they were okay. CNA #1 stated she had placed the chest restraint across Resident #1, but she had not tightened it. CNA #1 stated she put the shoulder strap across the resident, and that both the shoulder and waist strap are together, and were across the resident. CNA #1 stated Resident #2 was in the back of the van, and the van only had a waist belt in the back, no shoulder strap. CNA #1 stated she had been driving the van for a year, and there had not been any other accidents. CNA #1 stated there were no distractions, and you never talk on a phone while driving. CNA #1 stated she did hit the brake pedal hard to keep from going under the red light. CNA #1 stated the safety belt was across Resident #2's legs so the wheelchair would not roll to the back of the van, and the waist belt was all she used on Resident #2. CNA #1 stated Resident #1 was seated behind her in the front of the van. CNA #1 stated she had to slam/step on the brakes hard to stop at a light. She was asked how she secured Resident #1. CNA #1 stated she put the shoulder strap on the resident, but didn't tighten the belt. CNA #1 stated for Resident #2 she only put on a waist belt, and that no shoulder belt was available in the back of the van. During CNA #1's demonstration of the seat belt use, she failed both times to adjust/tighten the straps. The straps were not pulled across the bony part of the shoulder, nor was the waist belt tightened. Review of CNA #1's Annual Driver Assessment, dated 1/18/17, revealed she was checked yes regarding understands and practices proper use of safety restraint systems. The form was signed by the Maintenance Director. Resident #1 An interview, on 7/22/17 at 8:35 AM, revealed Resident #1 recalled the incident on 7/7/17. Resident #1 reported they were running a little late, and the van driver took a side street to get around the traffic. Resident #1 reported they were coming up to a stop sign, no red light, and there was a big hole the van driver did not see until she got to it, and she swerved to miss it, and then slammed on the brakes for the stop sign. Resident #1 stated she fell out of her wheelchair when the van driver slammed on the brakes. Resident #1 stated she did feel pain in her legs, arms, shoulders, chest, and back. Resident #1 said she told them right away she had pain. Resident #1 also said they asked her if she was hurt, and she told them she was okay. The Nurse Practictioner (NP) came to see her, and asked if she was okay, and she told her was, but she wasn't okay. Resident #1 said she thought she was in shock. Resident #1 stated she had breathing problems, and blood clots before this, but no back or neck problems. The pain in her legs was not the same as the pain she had prior to the incident. Resident #1 stated her legs were folded up under her, and they remained that way until the other staff arrived, and she was assisted back into her wheelchair. Resident #1 stated she was not strapped in the van like you would be in a car. She demonstrated the strap came across her under the arm of the wheelchair, and the strap was loose, the seat belt wasn't right. Resident #1 stated she fell out of the wheelchair when asked by the surveyor if she was eased to the floor by the van driver, or did she fall out of the wheelchair. Review of the emergency room (ER) Physician's H&P (History and Physical) dated 7/7/17 at 1100 (11:00 AM), revealed Resident #1's chief complaint (cc) was diffuse pain. Patient reports pain in neck, upper abdomen, left hip. Pain is worse with movement, and better with rest. Patient was being transported on a nursing home van this AM, it stopped suddenly, and she slipped down in between the seats. Also reports some mild mid back pain. The Physical Exam: Back: Mild mid-lower T (Thoracic) tenderness. Extremities: Left sided weakness from previous stroke at baseline. Mild left hip tenderness, good passive ROM (Range of Motion). Differential Diagnosis (Dx): Multiple trauma Dx: back strain, cervical sprain or fracture, chest wall contusion, contusion, head injury, liver injury, myocardial contusion, pneumothorax, splenic injury, sprained or fractured extremity. Review of the CT of the Chest, Abdomen, and Pelvis, with and without contrast, dated 7/7/17, revealed, Impression: 1. Recent appearing superior endplate compression fractures of T12, L1, L2, L3, and L4. 2. Incidently identified acute pulmonary emboli in the right upper lobe, right lower lobe, left upper lobe. 3. There is ill-defined, somewhat spiculated nodular density in the right upper lobe adjacent to the minor fissure. This is new from the recent comparison examination. This is probably represents infiltrate or atelectasis. Review of (Name of Hospital) Consultation Note, dated 7/11/17 at 6:49 PM, revealed the Consult was requested by the Emergency Department for mulitple compression fractures. The Consult Note revealed: Resident #1 was a nursing home resident, who on the day of admission was being transported in the nursing home van when the van had to suddenly stop. She fell down between the seats, and began complaining of back pain. Review of systems: Patient complains of back pain. Denies any numbness or weakness in her lower extremities. CT Scan done of her thorax and abdomen. This shows what appears to be acute T12, L1, L2, L3, and L4 superior endplate compression fractures, minimal depression. She also has an L4 and 5 Spondylolisthesis that appears chronic. She has multiple vacuum disks, and spinal stenosis at the L4, L5. Due to the spondyloisthesis, particularly at the foramen, bilaterally. Review of Resident #1's Skin and Wound Form, dated 7/7/17, revealed the human body diagram was marked for a bruise to the right lower abdomenal quardrant, and two bruises to the left upper arm. Review of the facility's Readmission Evaluation, dated 7/13/17, revealed Resident #1's pain locations were her back and neck. Resident #1 reported it was a level seven (7), which is a severe level per the facility's Pain Scale, aching type pain, that was continuous, worsened with movement, and pain medication made it better. Review of Resident #1's Electronic Medication Administration Record (EMAR) for July 2017 revealed Norco 5 (five) - 325 tablet, one to two (1 to 2) tablets every 4 (four) hours as needed for pain dated 7/13/17. Further review of the EMAR revealed Resident #1 was admininstered 17 doses of the Norco from 7/13/17 to 7/22/17 for pain. Review of the EMAR revealed, prior to 7/7/17, Acetaminophen 500 mg. (milligram) tablet was ordered every 6 (six) hours as needed for pain, and three (3) doses were administered for pain from 7/1/17 to 7/7/17. Resident #1 was also administered Eliquis five milligram (5mg.) (anticoagulant) tablet twice daily for personal history of other venous thrombosis and embolism. Review of Resident #1's Care Plan revealed a Problem/Need, dated 6/12/17, for falls related to impaired mobility, and bowel and bladder (b&b) incontinence. The Care Plan was updated, on 7/7/17, for an actual fall. Review of the Approaches revealed prior to the update on 7/7/17, there were no Approaches to address the resident's transportation needs/requirements. The update on 7/7/17 stated, All staff who provide transportation inserviced on correct use of van and checked off with return demonstration. Further review of the Care Plan revealed an Instant Care Plan, dated 7/12/17, for Pain related to Back Fracures. Approaches included: Pain meds as ordered, monitor for effectiveness, assess pain intensity, non-pharmacy interventions, and a brace when out of bed. DVT (Deep Vein Thrombsis), which included interventions for meds and labs as ordered, observe for signs and symptoms (s/s) of bleeding. Review of the facility's Vehicle Maintenance Log revealed the following checks: 9/1/16 Checked front and rear brakes. 3/29/17 Oil change. Tire rotation. 4/12/17 Replace battery. 4/17/17 Check for van dying. 7/13/17 Had lift inspection mobility system. Record review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's 5 (five)- day scheduled assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/19/17, revealed the resident had clear speech-distinct intelligible words, able to make herself understood, and understood others with clear comprehension. Vision was adequate, sees fine detail, including regular print in newspapers/books. Resident #1's Basic Interivew for Mental Status (BIMS) score was 12, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #1 required extensive assistance with two person physical assist with bed mobility, transfers, and toilet use. Extensive assistance with one person physical assist with dressing, personal hygiene, and bathing. Supervision with set up assist with eating. Resident #1 was always incontinent of bowel and bladder. Resident #2 An interview, on 7/21/17 at 3:30 PM, with Resident #2 revealed he was able to recall the details of his fall on the facility van on 7/7/17. Resident #2 stated they had gone about two or three blocks, and the van was behind a tractor hauling hay. Resident #2 stated the van driver said she was not going to go that slow, so they went a couple of blocks, and were back on (Name of Avenue) to go to the interstate. Resident #2 stated there was no red light when they flew out of their chairs. Resident #2 stated the van driver stepped on the brakes when there was no more lane, and the lady in the front fell down with her head between the front seat and the wall, and her legs bent between the seat. Resident #2 stated he fell out of his wheelchair onto his hands and knees. Resident #2 stated he did not have a seat belt on at all, and if he had been properly strapped in, he would not have come out of his wheelchair at all when the van driver slammed on the brakes. Resident #2 stated the van driver told them to stay down, and don't move because someone would be there in a minute to help. Resident #2 reported four ladies came up, and three of them assisted him to get back in his wheelchair. Resident #2 stated that there was usually two people on the van, and had never seen this before. Review of Resident #2's 60-Day Scheduled Assessment MDS, with an ARD of 7/19/17, revealed he was admitted by the facility on 5/24/17. Resident #2's speech was clear-distinct intelligible words. He made himself understood, and he understood others with clear comprehension. Resident #2's vision was adequate-sees fine detail, including regular print in newspapers/books. Resident #2's BIMS score was 12, which indicated moderate cognitive impairment. Resident #2 required extensive assistance with one person physical assist with bed mobility, transfers, walking in the room/corridor, toilet use, personal hygiene, and bathing, and limited assist with one person physical assist with dressing. Resident #2 required supervision with set up help for locomotion on and off the unit, and supervision with set up help for eating. His [DIAGNOSES REDACTED]. Review of Resident #2's Skin & Wound Evaluation Form, dated 7/7/17, revealed the human body diagram documented an abraision to the right and left knee, and a skin tear to the left hand. Review of Resident #2's Care Plan revealed the Problem/Need, dated 6/6/17, for potential injury from falls related to impaired mobility, history (hx) of falls, and multiple medication use. The Care Plan was updated, on 7/7/17, for an actual fall, and an Approach stated all staff who provide transportation inserviced on correct use of van and checked off with return demonstration. Further reveiw of the Care Plan revealed no Approaches addressed Resident #2's transportation needs/requirements prior to the update on 7/7/17. An Instant Care Plan was developed, on 7/9/17, for Skin Issues: Skin Tears to Right and Left Hand, Abrasions to Left and Right Knee. An interview, and record review, on 7/21/17 at 1:05 PM, revealed the Administrator stated the van driver/CNA #1 called her, and reported a resident was on the floor of the van due to they had slid out of their wheelchair, and that everyone was okay. When they got to the scene, both residents were on the floor, and neither complained of pain. The nurses checked the residents for bruises/pain. Both residents said they were fine, and did not want to go to the emergency room . Two nurses rode back to the facility with the residents as they completed the body assessments. Both residents were on their way to a doctor's apppointment. The Nurse Practictioner was here when they returned, and assessed them. She assessed Resident #1 first, and ordered for her to go to the emergency room . Review of the facility's Van Drivers list at this time revealed CNA #1's name was not on the list. The Administrator stated CNA #1 was on the list up until the incident, and then it was removed because it is the facility's protocol they can't drive the van any more. An interview, 7/21/17 at 1:20 PM, with the Director of Nurses (DON), revealed when they arrived at the van, the lift was down, and Resident #1 was between the wheelchair and the driver's seat, facing the driver's seat, with her knees and feet between the wheelchair foot rests. The wheelchair was strapped down, would not move. There were no visible signs of injuries at the scene, but she complained of her legs due to the way she was sitting. The DON reported she did not see a waist belt on Resident #1, or a shoulder strap, but the driver did say she had removed them. The DON reported Resident #2 was sitting on his buttocks, with his legs in front of him, and nothing hurt except his hemorroids. He had a skin tear on his hand with a slight amount of bleeding, and skin abrasions to both knees. An interview, on 7/21/17 at 1:25 PM, revealed Licensed Practical Nurse (LPN) #2 stated when they arrived at the van, the lift was down, and Resident #1 was sitting in the front of the wheelchair, and she was awake and alert. Resident #2 was in the back of the van, sitting in front of his wheelchair. LPN #1 and LPN #2 did body assessments on both of the residents, and brought them both back to the facility. LPN #2 stated Resident #1 reported to them, they were going down the road, came to a stop, and she slid out of her wheelchair, and Resident #2 reported they came up to some construction, when she hit the brakes, and he fell out of his wheelchair. LPN #2 stated she did not see any seat belts in place due to the driver had already removed them, but she did see the wheelchairs were still strapped down. LPN #2 stated they rode back to the facility with the residents, and on arrival to the facility the residents were returned to their rooms for the Nurse Practictioner to see them. An interview, on 7/21/17 at 2:00 PM, with LPN #1, revealed when they pulled up, and entered the van, Resident #1 was in the front on her buttocks with her legs in front of her. She was not hurting, and was ready to get up. Resident #2 was sitting on his buttocks with his legs out in front of him, and was also ready to get up off the floor. LPN #1 reported she was on the right side of the van, and could only assess the resident's right arms/leg, but the residents did not complain of anything. There were no bruises, skin tears, or bleeding. LPN #1 stated the van driver reported the residents slid out of the wheelchairs. Resident #1 had a lift pad under her, and we used it to transfer her back into her wheelchair. The wheelchair was strapped down to the van floor. LPN #1 stated she could not recall if a shoulder or waist belt was present. LPN #1 stated Resident #2 reported the driver didn't know there was construction ahead, when she slammed on her brakes, and we slid to the floor. LPN #1 stated there was not a shoulder strap in the back for Resident #2 that she could recall while she was doing the assessments, but did recall a waist belt. An interview, on 7/22/17 at 8:15 AM, with the Administrator, revealed she agreed if the van seat belts were not applied appropriately, it could result in a fall or injury to the resident. She revealed during the interview, the demonstration of the application of the seat belt with the van driver, on 07/21/17, revealed the seat belts were not applied appropriately. They should have been applied like a seat belt in a car, across the shoulder and waist, and if not applied correctly it could have resulted in Residents #1 and # 2's fall in the van. Review of the facility's Educational In-Service Record, dated 7/7/17 - 7/11/17, revealed the Title: Transporting Residents in the Facility Van. The Subject: When transporting residents in the facility van it is the responsibility of the person driving the van to ensure all safety precautions are followed. The driver of the van is responsbile for ensuring the resident and the resident's wheelchair are secured in a manner to prevent injury. It is the responsibility of the person driving the van to ensure that all equipment is functioning properly prior to transporting a resident. In the event you identify equipment that is not functioning properly you can not transport the resident, and you must immediately notify the Maintenance Supervisor and the Executive Director. The van will be taken out of service until the necessary repairs have been done. A copy of the facility's Resident Transportation Guidelines was attached to the in-service form. Resident #5 Review of Resident #5's Aftercare Instructions, dated 6/10/17, from (Name of Hospital), revealed she arrived to the hospital at 11:08 AM. The discharge [DIAGNOSES REDACTED]. tablet, one (1) by mouth every four to six (4 to 6) as needed for pain. Review of the facility's investigation, no date, signed by the DON, revealed on 6/10/17 at approximately 10:30 AM, Registered Nurse (RN) #3, and CNA #2 transferred Resident #5 from her wheelchair to the bed with the total lift to provide incontinent care. The staff transferred Resident #5 from the bed back to her wheelchair after completion of the care, using the total lift again. As the resident was being transferred, the lift sling began to tear, and Resident #5 slid to the floor. Resident #5 complained of back pain, and was provided comfort care until the ambulance arrived to transfer her to the emergency room for evaluation. Resident #5 returned to the facility from the emergency room with no fractures or any other serious injury. Upon investigation, it was noted the sling had shown no signs of wear prior to either transfer. Staff was in-serviced on lift procedures, observing for any signs of wear, and if wear is noted, to immediately turn in to administration for replacement, laundry was in-serviced on the proper procedures for washing and drying slings (not to be put in the dryer), observing for any type of wear and reporting any wear to receive a replacement sling. Staff were checked off on the proper use of the lifts. All lift pads were assessed for wear. Inventory sheets were implemented to keep track of all slings with monitoring for any signs of wear. Review of CNA #2's written statement, dated 6/10/17, revealed when she and RN #3 transferred Resident #5 back to the chair, the sling broke, and the resident fell on her buttocks, and from what she and RN #3 could tell, there were no tears in the sling. Review of RN #3's written statement, dated 6/10/17, revealed when she and CNA #2 entered Resident #5's room, the resident was sitting up in her electric wheelchair with the lift pad under her. RN #3 stated they transferred Resident #5 from the chair to the bed with that lift pad, and there was a small amount of wear and tear to the sling. RN #3 reported during the transfer back to the chair, the lift strap ripped off of the sling, dropping the resident straight to the floor. She landed on her buttocks with her legs outstretched and propped on the base of the lift. Once the lift pad was removed, staff was able to visualize weakened areas to the sling. An interview, on 7/22/17 at 8:10 AM, revealed Resident #5 stated the strap tore on the sling, and she fell to the floor. Resident #5 stated she did not think they used the right size sling to transfer her. Resident #5 reported it hurt her hip, and she had been taking medication for pain in her legs. She also reported she had concerns with her legs before this happened. Review of Resident #5's EZ Move Screen Invacare Products, dated 5/1/17, revealed her weight was 316.2 pounds, and her lifting/mobility needs required the Total Lift Invare, with the full body sling for 400 lbs. extra large size. Review of Resident #5's Care Plan revealed a Problem/Need, dated 5/9/16, for self care deficit related to impaired mobility/weakness with a diagnosis (dx) of morbid obesity/COPD (Chronic Obstructive Pulmonary Disease). The Approaches included: Total lift with two person assist with transfers. Large Sling. An interview, on 7/22/17 at 2:00 PM, revealed CNA #2 could not remember the staff person on the night shift who got Resident #5 up in the wheelchair that morning. CNA #2 stated Resident #2 was suppose to have the extra large size sling, the blue one, but was not able to recall what the color of the sling that was under her that morning. CNA #2 reported she did see some wear on the mesh on the bottom of the sling, but no other wear. CNA #2 said if a sling was not in good repair, it could tear. CNA #2 stated the sling under Resident #5 tore at the rectangle where the strap was located. An interview, on 7/22/17 at 1:50 PM, with RN #3, revealed she assisted CNA #2 transfer Resident #5 from the wheelchair to the bed. RN #3 reported Resident #5 had the sling under her, and thinks maybe it was a green color. RN #3 stated they transferred Resident #5 from the bed back to the wheelchair with the total lift, and the sling ripped, and she fell to the floor. The ambulance was called, and we did not move her until they arrived. No injuries were observed, but she did complain of pain. Has a history of a bad back. RN #3 stated they determine the size of the sling by the resident's weight, will go up to 400 pounds, and how much assistance the resident requires to transfer. RN #3 stated they had used the sling when they transferred her from the wheelchair to the bed because it was already under her. RN #3 also stated, that if she had seen the worn area on the sling before the fall, they would not have used that sling. RN #3 stated, per the Care Guide, this was the correct sling. An interview, on 7/22/17 at 1:55 PM, revealed CNA #3 stated she took care of Resident #5 at times, and she required the extra large sling with the total lift for transfers. CNA #3 stated it was the blue colored sling. An interview, on 7/22/17 at 1:00 (TRUNCATED)

Based on record review, staff interview, and facility policy review, the facility failed to ensure care plans were developed for transportation, and transportation safety, for Residents #1 and #2. The facility failed to secure the safety restraints for Residents # 1 and #2 in a manner to prevent an injury during transport in the facility van, and prevent Resident #5's fall from a lift sling during transfer from the bed to a wheelchair. Findings include: Review of the facility's policy titled, Comprehensive Person Centered Care Plans, revealed: Policy: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care .Comprehensive Person Centered Care Plan (CCP) -contains services provided, preference, ability and care level guidelines. Review of Resident #1's Care Plan revealed no Problems/Needs, or Approaches to address the residents safety requirements for transportation outside the facility in a wheelchair, prior to 7/7/17. Further review of Resident #1's Care Plan revealed a Problem/Need, dated 6/12/17, for falls related to impaired mobility, and bowel and bladder (b&b) incontinence. The Care Plan was updated, on 7/7/17, for an actual fall. Review of the Approaches updated on 7/7/17 revealed, All staff who provide transportation inserviced on correct use of van, and checked off with return demonstration. Review of Resident #1's 5 (five)- day scheduled assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/19/17, revealed the resident had clear speech-distinct intelligible words, able to make herself understood, and understood others with clear comprehension. Vision was adequate, sees fine detail, including regular print in newspapers/books. Resident #1's Basic Interivew for Mental Status (BIMS) score was 12, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #1 required extensive assistance with two person physical assist with bed mobility, transfers, and toilet use. Extensive assistance with one person physical assist with dressing, personal hygiene, and bathing. Supervision with set up assist with eating. Resident #1 was always incontinent of bowel and bladder. Review of Resident #2's Care Plan revealed the Problem/Need, dated 6/6/17, for potential injury from falls related to impaired mobility, history (hx) of falls, and multiple medication use. The Care Plan was updated, on 7/7/17, for an actual fall, and an Approach stated all staff who provide transportation inserviced on correct use of van, and checked off with return demonstration. Further reveiw of the Care Plan revealed no Approaches addressed Resident #2's transportation needs/requirements prior to the update on 7/7/17. Review of Resident #2's 60-Day Scheduled Assessment MDS, with an ARD of 7/19/17, revealed he was admitted by the facility on 5/24/17. Resident #2's speech was clear-distinct intelligible words. He made himself understood, and he understood others with clear comprehension. Resident #2's vision was adequate-sees fine detail, including regular print in newspapers/books. Resident #2's BIMS score was 12, which indicated moderate cognitive impairment. Resident #2 required extensive assistance with one person physical assist with bed mobility, transfers, walking in the room/corridor, toilet use, personal hygiene, and bathing, and limited assist with one person physical assist with dressing. Resident #2 required supervision with set up help for locomotion on and off the unit, and supervision with set up help for eating. His [DIAGNOSES REDACTED]. Review of Resident #5's Care Plan revealed a Problem/Need, dated 5/9/16, for self care deficit related to impaired mobility/weakness with a diagnosis (dx) of [MEDICAL CONDITION]/[MEDICAL CONDITIONS]. The Approaches included: Total lift with two person assist with transfers. Large Sling. Further review of the Care Plan revealed there were not Approaches to address checking the lift sling condition prior to use. Review of Resident #5's Quarterly MDS, with an ARD of 7/4/17, revealed her speech was clear-distinct intelligible word. Resident #5 was able to make herself understood, and she understood others with clear comprehension. Her vision was adequate to see fine detail, including regular print in newspapers/books. Resident #5's BIMS score was 15, which indicated no cognitive impairment. Resident #5 required extensive assistance with two person physical assist with bed mobility, transfers, eating, toilet use, personal hygiene, and bathing. Required supervision with one person physical assist with dressing. Resident #5 had Range of Motion (ROM) impairment to the both lower extremities. Resident #5 was occasionlly incontinent of bowel and bladder. An interview, on 8/12/17 at 8:20 AM, revealed the Minimum Data Set (MDS) Nurse revealed the floor nurses were responsible for developing the Instant Care Plans, and the MDS Nurse was responsible for the Comprehensive Care Plans. The MDS Nurse stated the nurses should add to the care plan as the residents care or status changes, and the the typed Care Plan is done at the next assessment. The MDS Nurse stated they just added the approaches to Resident #1 and #2's current Falls care plans. The MDS Nurse confirmed there were no Care Plans for transportation/transportation safety for Resident's #1 and #2 prior to 7/7/17, and staff was to provide proper transportation was the Approach added. The MDS Nurse stated she had not included transportation/transportation safety care plans in all the years she had been developing care plans. The MDS Nurse stated Care Plans are developed for pain, falls, constipation, Activities of Daily Living (ADLs), and Skin Concerns.

Based on observation, record review, staff interview and policy review, the facility failed to prevent, identify, investigate, protect, and report an incident of Resident on Resident sexual abuse for two (2) of twenty-seven (27) residents reviewed (Resident #9 and Resident #20). An annual survey was conducted from 12/5/12 to 12/8/12; an extended survey was conducted from 12/7/12 to 12/8/12. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 12/7/12 at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on 12/7/12. The IJ was determined to begin on 9/17/12. The facility submitted the first (1st) Allegation of Compliance (AoC) on 12/7/12 at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on 12/8/12 at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on 12/8/12 at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on 12/8/12, and is considered ongoing. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable.

Based on observation, record review, staff interview and facility policy review, the facility failed to report to the State Agency Resident to Resident sexual abuse for three (3) of twenty-seven (27) residents reviewed (Residents #1, #9, and #20). An annual survey was conducted from 12/5/12 to 12/8/12; an extended survey was conducted from 12/7/12 to 12/8/12. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 12/7/12 at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on 12/7/12. The IJ was determined to begin on 9/17/12. The facility submitted the first (1st) Allegation of Compliance (AoC) on 12/7/12 at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on 12/8/12 at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on 12/8/12 at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on 12/8/12, and is considered ongoing. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable.

Based on observation, record review, staff interview and policy review, the facility failed to update Resident #1's Care Plan to address interventions and concerns for his sexual inappropriate behaviors or his expressed desires for sex for one (1) of fourteen (14) residents reviewed (Resident #1). An annual survey was conducted from 12/5/12 to 12/8/12; an extended survey was conducted from 12/7/12 to 12/8/12. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 12/7/12 at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on 12/7/12. The IJ was determined to begin on 9/17/12. The facility submitted the first (1st) Allegation of Compliance (AoC) on 12/7/12 at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on 12/8/12 at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on 12/8/12 at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on 12/8/12, and is considered ongoing. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. A review of the facility's "Care Plans" policy, documented "Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care."

Based on the survey results dated 12/8/12, the facility failed to update Resident #1's Care Plan to address interventions and concerns for his sexual inappropriate behaviors or his expressed desires for sex for one (1) of fourteen (14) residents reviewed (Resident #1). This was deemed an Immediate Jeopardy (IJ) on 12/7/12 at 1:30 p.m. A revisit survey was conducted on 12/27-28/12 to validate the Allegation of Compliance (AoC). The IJ which began on 12/7/12 was determined to be removed on 12/21/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 12/21/12. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9 shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of 13 female Residents reviewed (Residents #9 and #20). The facility provided an Allegation of Compliance (AoC) that was accepted on 12/27/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy (IJ). Information contained in the Credible AoC, submitted by the facility, revealed: "On 9/17/12 at approximately 12:39 p.m. CNA #2 reported to (licensed practical nurse) LPN #2 an observation of Resident #1 with his hand down Resident #9's shirt, rubbing her breast (inappropriate behavior/physical contact). At that time, LPN #2 walked down the hallway and approached Resident #1, who rolled his wheelchair to his room. LPN #2 moved Resident #9 closer to Resident #9's room and performed an interview and determined no negative outcomes related to occurrence. LPN #2 failed to document this interview and observations in the Medical Record. LPN #2 was in-serviced on failure to document in medical record on 12/11/12. Resident #9 had a skin audit conducted on 9/18/12 which revealed no visible bruising, redness or signs of trauma. Resident #1 and Resident #9 have the same primary Physician and Nurse Practitioner (NP). The NP was notified of the incident between Resident #1 and Resident #9 on 9/17/12. Physicians telephone order to transfer Resident #1 to Behavioral Health Unit (BHU) was received and written at 12:51 p.m. The NP notified Resident #1 and Resident #9's primary Physician after the 9/17/12 incident (date uncertain). On 9/17/12 at approximately 12:39 p.m. the facility failed to place Resident #1 on one (1) on one (1) observation until he was transferred to the BHU on 9/18/12 at 11:50 am. Resident #1 was sent to a BHU on 9/18/12 for behaviors (related to his inappropriate sexual contact with Resident #9). On 9/17/12 LPN #4 ( Unit Manager) failed to initiate an investigation and complete a documented assessment on Resident #9, protect Resident #9 by placing Resident #1 on one on one (1:1) observation, notify Resident #9's responsible party (RP), notify primary Physician for Resident #1 and Resident #9, care planning occurrence for Resident #1 and Resident #9, notify the Director of Nursing (DNS) and the Executive Director (ED). Due to LPN #4's ( Unit Manager) noted failures, LPN#4 (Unit Manager) was placed on suspension on 12/7/12 regarding Resident #1 and Residents #9's incident. Subsequently, written disciplinary action and re-education on abuse and reporting , abuse coordinator, behavior management program, incident investigation, documentation, one on one (1:1) utilization, resident assessments and care planning were completed on 12/13/12. On 9/17/12 at approximately 2:30 p.m. Social Service (SS#1) interviewed Resident #9. At that time Resident #9 stated that she was OK. Resident #9 was pleasant with no recollection of the 9/17/12 incident. On 9/18/12 SS#1 again interviewed Resident #9. At that time Resident #9 was pleasant with no recollection of the 9/17/12 incident. SS #1 failed to document the 9/17/12 and the 9/18/12 interviews with Resident #9 in the medical record. The DNS and ED were notified of inappropriate behavior/sexual contact between Resident #1 and Resident #9 on 12/6/12. On 12/6/12 the facility initiated an investigation concerning inappropriate sexual contact between Resident #1 and Resident #9. This investigation was initiated by the DNS and ED. The facility substantiated that inappropriate sexual contact was made by Resident #1 to Resident #9. On 12/6/12 at approximately 2:30 p.m. the Abuse Coordinator in the facility was changed from SS#1 to Executive Director. Executive Director and Director of Nursing were in serviced on reporting procedures and regulations by Facility Vice President on 12/11/12. On 12/6/12, SS#1 interviewed Resident #9 and at that time Resident #9 was noted to be pleasant with no recollection of the 9/17/12 incident. On 12/6/12, SS#1 was suspended pending investigation. SS#1 was issued corrective counseling on 12/13/12 for the failure to document Resident #9's interviews and failure to report incident. Subsequently, SS#1 received re-education on 12/13/12 including abuse and reporting, documentation of incidents/investigations, Medical Director (MD) and Responsible Party (RP) Notification, resident assessment and care planning, behavior management program and one on one (1:1) utilization. On 12/6/12 Resident #9's care plan was updated to include "potential to be abused". Resident #9's Responsible Party (RP) was notified on 12/8/12 that Resident #1 had placed his hand inside of Resident #9's shirt on 9/17/12. On 10/2/12 Resident #1 returned to the facility from the BHU with recommendations to follow up with his Physician for medical conditions and psychiatric services. The facility failed to document notification to Physician of BHU recommendation. Resident #1's 10/2/12 readmission orders [REDACTED]. On 10/2/12 Resident #1 returned to the facility from the BHU and at that time was placed on a "Behavior Monthly Flow Record" for "Danger to others". The facility failed to update Resident #1's care plan on 9/17/12 related to inappropriate sexual contact with Resident #9. On 10/10/12 Resident #1's care plan was updated to include "Inappropriate sexual behaviors". Resident #1 was observed for potential "Danger to others" behaviors with documentation on the "Behavior Intervention Monthly Flow" record from 10/2/12-12/7/12. Resident #1 was evaluated by NP on 10/18/12 with no new recommendation. Resident #1 was monitored for "Danger to others" behaviors until discharged from the facility on 12/7/12. Review of the "Behavior Intervention Monthly Flow" records dated, 10/2/12-12/7/12, revealed no documented behaviors noted or negative outcomes. On 12/7/12 at 1:35 p.m. Resident #1 was placed on 1:1 with CNA #2 until 3:00 p.m. At 3:00 p.m. CNA #3 began 1:1 observation of Resident #1 until 6:40 p.m. which was when Resident #1 was transferred and discharged to the BHU. The 1:1 was documented with no negative behaviors. On 12/21/12 the BHU notified the facility that Resident #1 will return on 12/21/12. Upon return, Resident #1 will be placed on 1:1 observation with a staff member until the interdisciplinary teams deems the need to make changes. Upon return, the facility will enter into a behavior contract with Resident #1. This contract will include but is not limited to; No sexual gestures, comments or sexually inappropriate behavior will be allowed. The care plan, assessments, behavior monitoring flow record and other risk evaluations will be initiated upon return to the facility. All recommendations and orders on return from BHU will be reviewed with the NP/MD for further orders. On 12/10/12 all current cognitive residents were interviewed and resident questionnaire completed to determine if they had been abused. A body audit was initiated on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. There were no negative outcomes. During the 12/10/12 interview of cognitive residents, Resident #20 stated that she believed she had been previously abused within the facility but currently feels safe and is not afraid of anyone within the facility. An investigation was initiated by the abuse coordinator (ED). A follow up interview was conducted by the ED as part of this investigation. Resident #20 stated that she had been grabbed on her wrist by Resident #1 in the past with no known date of occurrence. On 12/13/12 Resident #20 denied any current concerns since Resident #1 has been discharged . On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. Facility staff also re-in serviced 26 staffs members on abuse reporting. On 12/13/12 the facility notified the state agencies (State Survey Agency and Attorney Generals Office), resident #20's RP and the Physician of the alleged occurrence. The facility was not able to substantiate inappropriate physical contact or abuse. The SSD will visit Resident #20 daily for two (2) days starting 12/13/12 and weekly for two (2) weeks. Resident #20's care plan was updated. Abuse Coordinator will visit with resident #20 once weekly for four weeks starting 12/13/12 to further ensure residents remains comfortable with addressing any issues identified. The NP made rounds and ordered a psychiatric consult due to her observation of Resident #20 attention seeking behaviors. On 12/13/12 there were 41 male residents in the facility. 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. There were no males with physical behavior symptoms directed toward others. On 12/6/12 the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". This policy includes abuse/neglect, staff treatment of [REDACTED]. The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. This change was posted at all three (3) nurse's stations, the time clock and at a central location on wing 1. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The Abuse Coordinator is to be notified for all suspected or reported abuse and neglect. This in-service also included, protecting the victim and one on one monitoring of perpetrator. No employee will be allowed to return to work until they have been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12 the SDC initiated in-servicing licensed nursing staff on assessments, body audits and care planning, notification to MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing twenty four hour report. In Serviced: Assessments Policy - purpose is to identify and document the residents condition/status in efforts to develop a plan of care. Care Plan Policy - purpose is to identify problems and needs that will assist the Interdisciplinary team in providing care. Accident and Incident Policy - purpose is the guide of documenting and investigating occurrences that involve residents. Behavior Management Committee Policy - Purpose is the guide that is used to identify and track behavior(s) that are displayed routinely that may affect the resident(s). Abuse Prevention Policy - Purpose is to define the facilities commitment to protect the residents from abuse from anyone. Notification to MD/RP Policy - Purpose is to inform MD/RP of change in resident's condition. On 12/11/12 the SDC initiated in-servicing for licensed nursing staff concerning resident assessment, documentation, physician/RP notification and following MD orders. On 12/13/12 the interdisciplinary team were in-serviced on the facility behavior management program. On 12/13/12 the DNS in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. Starting 12/11/12 the social service department will visit Resident #9 twice a day for four (4) days, then three (3) times a week for two (2) weeks. The Abuse Coordinator initiated twice a week rounds starting 12/10/12 for four (4) weeks to ensure accessibility to residents and staff on abuse reporting. On 12/13/12 the DNS initiated monitoring of any allegation of abuse and neglect through review of any incident logs for five (5) days per week for four (4) weeks. The results of the findings were reported to the ED. All components of deficiencies cited and corrective action taken thus far were reviewed by the Quality Assurance Committee on 12/12/12 by committee members and facility Medical director. A follow up Quality Assurance meeting was held on 12/14/12 to discuss additional action taken and the conclusion of Resident #20's allegation of abuse and the reporting process. A Quality Assurance Committee meeting was held on 12/20/12 with committee members and the Facility Medical Director to further review polices (no policy changes were noted) and the facilities allegation of compliance as well as monitoring/audit reports with no findings of recurrence of deficient practice. We are alleging that the allegation is removed as of 12/21/12 of all Immediate Jeopardy deficiencies cited." The aforementioned information is quoted in the AoC. Review of the AoC conducted from 12/27/12 at 11:30 a.m. through 12/28/12 at 5:30 p.m., revealed the following information was validated: On 12/6/12, the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The in-service also included protecting the victim and one on one monitoring of perpetrator. No employee was allowed to return to work until they had been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12, the SDC in-serviced licensed nursing staff on assessments, body audits and care planning, notification of MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing 24 hour report. On 12/10/12, the facility interviewed all current cognitive residents and a resident questionnaire was completed to determine if they had been abused. Body audits were initiated by the facility staff on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. On 12/11/12, the Social Service Department (SSD) began visiting Resident #9 twice a day for 4 days, the 3 times a week for 2 weeks. The Abuse Coordinator initiated twice a week rounds on 12/10/12. On 12/11/12, the Staff Develop Coordinator (SDC) in-serviced licensed nursing staff on resident assessment, documentation, physician/RP Notification and following MD orders. On 12/13/12, the facility notified the state agencies (State Survey Agency and Attorney General's Office), Resident #20's Responsible Party and the Physician of the alleged occurrence. The SSD visited Resident #20 daily for 2 days starting 12/13/12 and weekly for 2 weeks. Resident #20's care plan was updated. The Abuse Coordinator visited Resident #20 once weekly beginning 12/13/12. Also on 12/13/12 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. On 12/13/12, the interdisciplinary team was in-serviced on the facility behavior management program. On 12/13/12, the DON in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. On 12/14/12, the DON and Regional Clinical Operations Nurse initiated in-servicing on care planning and investigation procedures. Facility staff re-in-serviced 26 staff members on abuse reporting. Interviews of 13 residents individually on 12/27/12 and 12/28/12 and review of Resident Questionnaires provided by the facility verified that the facility had spoken with each resident regarding abuse/reporting on 12/10/12. The facility performed body audits on 80 non-cognitive residents to determine if any signs of abuse were present as verified by record review of body audits. Interviews of 28 staff members from all 3 shifts on 12/27/12 and 12/28/12 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, care planning, documentation, protection of residents, incident investigation, notification of MD/RP, Abuse Coordinator, behavior management program, 1:1 utilization, resident assessments, and following up on reports of suspected/alleged abuse/neglect. These policies were reviewed as well. Staff members included in these interviews were CNAs, nurses, Administrator, Maintenance Director, Dietary Manager, PT/OT staff, Activities Director, housekeeping, and DON. These in-services were conducted by the facility on the following dates: 12/10/12, 12/11/12, 12/12/12, 12/13/12, 12/14/12, 12/15/12, 12/17/12, 12/20/12, 12/21/12, 12/24/12, and 12/26/12. Review of 15 Resident records on 12/27/12 and 12/28/12 revealed no concerns regarding abuse/neglect or care plans. The facility entered into a Behavior Contract with Resident #1 on 12/21/12. Review of this document verified the contract was signed by Resident #1, the Administrator, and the DON on 12/21/12. Resident #1 was discharged from BHU and returned to the facility on [DATE]. Upon his return, Resident #1 was placed on 1:1 observation with a staff member. The facility entered into a behavior contract with Resident #1 on 12/21/12. The care plan, assessments, behavior monitoring flow record and other risk evaluations were initiated on his return. Resident #1 was also moved from Wing II to Wing III. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/21/12 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee.

Based on the survey results dated 12/8/12, the facility failed to develop interventions and monitor a resident with known inappropriate sexual behaviors for one (1) of one (1) residents reviewed (Resident #1). This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 12/7/12 at 1:30 p.m. A revisit survey was conducted on 12/27-28/12 to validate the Allegation of Compliance (AoC). The IJ which began on 12/7/12 was determined to be removed on 12/21/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 12/21/12. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9 shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of 13 female Residents reviewed (Residents #9 and #20). The facility provided an Allegation of Compliance (AoC) that was accepted on 12/27/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy (IJ). Information contained in the Credible AoC, submitted by the facility, revealed: "On 9/17/12 at approximately 12:39 p.m. CNA #2 reported to (licensed practical nurse) LPN #2 an observation of Resident #1 with his hand down Resident #9's shirt, rubbing her breast (inappropriate behavior/physical contact). At that time, LPN #2 walked down the hallway and approached Resident #1, who rolled his wheelchair to his room. LPN #2 moved Resident #9 closer to Resident #9's room and performed an interview and determined no negative outcomes related to occurrence. LPN #2 failed to document this interview and observations in the Medical Record. LPN #2 was in-serviced on failure to document in medical record on 12/11/12. Resident #9 had a skin audit conducted on 9/18/12 which revealed no visible bruising, redness or signs of trauma. Resident #1 and Resident #9 have the same primary Physician and Nurse Practitioner (NP). The NP was notified of the incident between Resident #1 and Resident #9 on 9/17/12. Physicians telephone order to transfer Resident #1 to Behavioral Health Unit (BHU) was received and written at 12:51 p.m. The NP notified Resident #1 and Resident #9's primary Physician after the 9/17/12 incident (date uncertain). On 9/17/12 at approximately 12:39 p.m. the facility failed to place Resident #1 on one (1) on one (1) observation until he was transferred to the BHU on 9/18/12 at 11:50 am. Resident #1 was sent to a BHU on 9/18/12 for behaviors (related to his inappropriate sexual contact with Resident #9). On 9/17/12 LPN #4 ( Unit Manager) failed to initiate an investigation and complete a documented assessment on Resident #9, protect Resident #9 by placing Resident #1 on one on one (1:1) observation, notify Resident #9's responsible party (RP), notify primary Physician for Resident #1 and Resident #9, care planning occurrence for Resident #1 and Resident #9, notify the Director of Nursing (DNS) and the Executive Director (ED). Due to LPN #4's ( Unit Manager) noted failures, LPN#4 (Unit Manager) was placed on suspension on 12/7/12 regarding Resident #1 and Residents #9's incident. Subsequently, written disciplinary action and re-education on abuse and reporting , abuse coordinator, behavior management program, incident investigation, documentation, one on one (1:1) utilization, resident assessments and care planning were completed on 12/13/12. On 9/17/12 at approximately 2:30 p.m. Social Service (SS#1) interviewed Resident #9. At that time Resident #9 stated that she was OK. Resident #9 was pleasant with no recollection of the 9/17/12 incident. On 9/18/12 SS#1 again interviewed Resident #9. At that time Resident #9 was pleasant with no recollection of the 9/17/12 incident. SS #1 failed to document the 9/17/12 and the 9/18/12 interviews with Resident #9 in the medical record. The DNS and ED were notified of inappropriate behavior/sexual contact between Resident #1 and Resident #9 on 12/6/12. On 12/6/12 the facility initiated an investigation concerning inappropriate sexual contact between Resident #1 and Resident #9. This investigation was initiated by the DNS and ED. The facility substantiated that inappropriate sexual contact was made by Resident #1 to Resident #9. On 12/6/12 at approximately 2:30 p.m. the Abuse Coordinator in the facility was changed from SS#1 to Executive Director. Executive Director and Director of Nursing were in serviced on reporting procedures and regulations by Facility Vice President on 12/11/12. On 12/6/12, SS#1 interviewed Resident #9 and at that time Resident #9 was noted to be pleasant with no recollection of the 9/17/12 incident. On 12/6/12, SS#1 was suspended pending investigation. SS#1 was issued corrective counseling on 12/13/12 for the failure to document Resident #9's interviews and failure to report incident. Subsequently, SS#1 received re-education on 12/13/12 including abuse and reporting, documentation of incidents/investigations, Medical Director (MD) and Responsible Party (RP) Notification, resident assessment and care planning, behavior management program and one on one (1:1) utilization. On 12/6/12 Resident #9's care plan was updated to include "potential to be abused". Resident #9's Responsible Party (RP) was notified on 12/8/12 that Resident #1 had placed his hand inside of Resident #9's shirt on 9/17/12. On 10/2/12 Resident #1 returned to the facility from the BHU with recommendations to follow up with his Physician for medical conditions and psychiatric services. The facility failed to document notification to Physician of BHU recommendation. Resident #1's 10/2/12 readmission orders [REDACTED]. On 10/2/12 Resident #1 returned to the facility from the BHU and at that time was placed on a "Behavior Monthly Flow Record" for "Danger to others". The facility failed to update Resident #1's care plan on 9/17/12 related to inappropriate sexual contact with Resident #9. On 10/10/12 Resident #1's care plan was updated to include "Inappropriate sexual behaviors". Resident #1 was observed for potential "Danger to others" behaviors with documentation on the "Behavior Intervention Monthly Flow" record from 10/2/12-12/7/12. Resident #1 was evaluated by NP on 10/18/12 with no new recommendation. Resident #1 was monitored for "Danger to others" behaviors until discharged from the facility on 12/7/12. Review of the "Behavior Intervention Monthly Flow" records dated, 10/2/12-12/7/12, revealed no documented behaviors noted or negative outcomes. On 12/7/12 at 1:35 p.m. Resident #1 was placed on 1:1 with CNA #2 until 3:00 p.m. At 3:00 p.m. CNA #3 began 1:1 observation of Resident #1 until 6:40 p.m. which was when Resident #1 was transferred and discharged to the BHU. The 1:1 was documented with no negative behaviors. On 12/21/12 the BHU notified the facility that Resident #1 will return on 12/21/12. Upon return, Resident #1 will be placed on 1:1 observation with a staff member until the interdisciplinary teams deems the need to make changes. Upon return, the facility will enter into a behavior contract with Resident #1. This contract will include but is not limited to; No sexual gestures, comments or sexually inappropriate behavior will be allowed. The care plan, assessments, behavior monitoring flow record and other risk evaluations will be initiated upon return to the facility. All recommendations and orders on return from BHU will be reviewed with the NP/MD for further orders. On 12/10/12 all current cognitive residents were interviewed and resident questionnaire completed to determine if they had been abused. A body audit was initiated on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. There were no negative outcomes. During the 12/10/12 interview of cognitive residents, Resident #20 stated that she believed she had been previously abused within the facility but currently feels safe and is not afraid of anyone within the facility. An investigation was initiated by the abuse coordinator (ED). A follow up interview was conducted by the ED as part of this investigation. Resident #20 stated that she had been grabbed on her wrist by Resident #1 in the past with no known date of occurrence. On 12/13/12 Resident #20 denied any current concerns since Resident #1 has been discharged . On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. Facility staff also re-in serviced 26 staffs members on abuse reporting. On 12/13/12 the facility notified the state agencies (State Survey Agency and Attorney Generals Office), resident #20's RP and the Physician of the alleged occurrence. The facility was not able to substantiate inappropriate physical contact or abuse. The SSD will visit Resident #20 daily for two (2) days starting 12/13/12 and weekly for two (2) weeks. Resident #20's care plan was updated. Abuse Coordinator will visit with resident #20 once weekly for four weeks starting 12/13/12 to further ensure residents remains comfortable with addressing any issues identified. The NP made rounds and ordered a psychiatric consult due to her observation of Resident #20 attention seeking behaviors. On 12/13/12 there were 41 male residents in the facility. 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. There were no males with physical behavior symptoms directed toward others. On 12/6/12 the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". This policy includes abuse/neglect, staff treatment of [REDACTED]. The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. This change was posted at all three (3) nurse's stations, the time clock and at a central location on wing 1. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The Abuse Coordinator is to be notified for all suspected or reported abuse and neglect. This in-service also included, protecting the victim and one on one monitoring of perpetrator. No employee will be allowed to return to work until they have been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12 the SDC initiated in-servicing licensed nursing staff on assessments, body audits and care planning, notification to MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing twenty four hour report. In Serviced: Assessments Policy - purpose is to identify and document the residents condition/status in efforts to develop a plan of care. Care Plan Policy - purpose is to identify problems and needs that will assist the Interdisciplinary team in providing care. Accident and Incident Policy - purpose is the guide of documenting and investigating occurrences that involve residents. Behavior Management Committee Policy - Purpose is the guide that is used to identify and track behavior(s) that are displayed routinely that may affect the resident(s). Abuse Prevention Policy - Purpose is to define the facilities commitment to protect the residents from abuse from anyone. Notification to MD/RP Policy - Purpose is to inform MD/RP of change in resident's condition. On 12/11/12 the SDC initiated in-servicing for licensed nursing staff concerning resident assessment, documentation, physician/RP notification and following MD orders. On 12/13/12 the interdisciplinary team were in-serviced on the facility behavior management program. On 12/13/12 the DNS in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. Starting 12/11/12 the social service department will visit Resident #9 twice a day for four (4) days, then three (3) times a week for two (2) weeks. The Abuse Coordinator initiated twice a week rounds starting 12/10/12 for four (4) weeks to ensure accessibility to residents and staff on abuse reporting. On 12/13/12 the DNS initiated monitoring of any allegation of abuse and neglect through review of any incident logs for five (5) days per week for four (4) weeks. The results of the findings were reported to the ED. All components of deficiencies cited and corrective action taken thus far were reviewed by the Quality Assurance Committee on 12/12/12 by committee members and facility Medical director. A follow up Quality Assurance meeting was held on 12/14/12 to discuss additional action taken and the conclusion of Resident #20's allegation of abuse and the reporting process. A Quality Assurance Committee meeting was held on 12/20/12 with committee members and the Facility Medical Director to further review polices (no policy changes were noted) and the facilities allegation of compliance as well as monitoring/audit reports with no findings of recurrence of deficient practice. We are alleging that the allegation is removed as of 12/21/12 of all Immediate Jeopardy deficiencies cited." The aforementioned information is quoted in the AoC. Review of the AoC conducted from 12/27/12 at 11:30 a.m. through 12/28/12 at 5:30 p.m., revealed the following information was validated: On 12/6/12, the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The in-service also included protecting the victim and one on one monitoring of perpetrator. No employee was allowed to return to work until they had been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12, the SDC in-serviced licensed nursing staff on assessments, body audits and care planning, notification of MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing 24 hour report. On 12/10/12, the facility interviewed all current cognitive residents and a resident questionnaire was completed to determine if they had been abused. Body audits were initiated by the facility staff on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. On 12/11/12, the Social Service Department (SSD) began visiting Resident #9 twice a day for 4 days, the 3 times a week for 2 weeks. The Abuse Coordinator initiated twice a week rounds on 12/10/12. On 12/11/12, the Staff Develop Coordinator (SDC) in-serviced licensed nursing staff on resident assessment, documentation, physician/RP Notification and following MD orders. On 12/13/12, the facility notified the state agencies (State Survey Agency and Attorney General's Office), Resident #20's Responsible Party and the Physician of the alleged occurrence. The SSD visited Resident #20 daily for 2 days starting 12/13/12 and weekly for 2 weeks. Resident #20's care plan was updated. The Abuse Coordinator visited Resident #20 once weekly beginning 12/13/12. Also on 12/13/12 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. On 12/13/12, the interdisciplinary team was in-serviced on the facility behavior management program. On 12/13/12, the DON in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. On 12/14/12, the DON and Regional Clinical Operations Nurse initiated in-servicing on care planning and investigation procedures. Facility staff re-in-serviced 26 staff members on abuse reporting. Interviews of 13 residents individually on 12/27/12 and 12/28/12 and review of Resident Questionnaires provided by the facility verified that the facility had spoken with each resident regarding abuse/reporting on 12/10/12. The facility performed body audits on 80 non-cognitive residents to determine if any signs of abuse were present as verified by record review of body audits. Interviews of 28 staff members from all 3 shifts on 12/27/12 and 12/28/12 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, care planning, documentation, protection of residents, incident investigation, notification of MD/RP, Abuse Coordinator, behavior management program, 1:1 utilization, resident assessments, and following up on reports of suspected/alleged abuse/neglect. These policies were reviewed as well. Staff members included in these interviews were CNAs, nurses, Administrator, Maintenance Director, Dietary Manager, PT/OT staff, Activities Director, housekeeping, and DON. These in-services were conducted by the facility on the following dates: 12/10/12, 12/11/12, 12/12/12, 12/13/12, 12/14/12, 12/15/12, 12/17/12, 12/20/12, 12/21/12, 12/24/12, and 12/26/12. Review of 15 Resident records on 12/27/12 and 12/28/12 revealed no concerns regarding abuse/neglect or care plans. The facility entered into a Behavior Contract with Resident #1 on 12/21/12. Review of this document verified the contract was signed by Resident #1, the Administrator, and the DON on 12/21/12. Resident #1 was discharged from BHU and returned to the facility on [DATE]. Upon his return, Resident #1 was placed on 1:1 observation with a staff member. The facility entered into a behavior contract with Resident #1 on 12/21/12. The care plan, assessments, behavior monitoring flow record and other risk evaluations were initiated on his return. Resident #1 was also moved from Wing II to Wing III. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/21/12 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee.

Based on observation, record review, staff interview and policy review, the facility failed to develop interventions and monitor a resident with known inappropriate sexual behaviors for one (1) of one (1) residents reviewed (Resident #1). An annual survey was conducted from 12/5/12 to 12/8/12; an extended survey was conducted from 12/7/12 to 12/8/12. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 12/7/12 at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on 12/7/12. The IJ was determined to begin on 9/17/12. The facility submitted the first (1st) Allegation of Compliance (AoC) on 12/7/12 at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on 12/8/12 at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on 12/8/12 at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on 12/8/12, and is considered ongoing. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable.

PART 1 Based on observation, record review, staff interview and policy review, the facility failed to provide adequate supervision of Resident #1 to ensure an environment free from potential reoccurrence of sexual inappropriate behavior (of touching another Resident breast) for one (1) of one (1) identified resident with inappropriate sexual behavior reviewed (Resident #1). An annual survey was conducted from 12/5/12 to 12/8/12; an extended survey was conducted from 12/7/12 to 12/8/12. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 12/7/12 at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on 12/7/12. The IJ was determined to begin on 9/17/12. The facility submitted the first (1st) Allegation of Compliance (AoC) on 12/7/12 at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on 12/8/12 at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on 12/8/12 at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on 12/8/12, and is considered ongoing. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. PART 2 Based on observation, record review, staff interview and policy review, the facility failed to ensure that residents with cognitive deficits were provided supervision during smoking, and not allowed to handle fire devices for two (2) of five (5) residents reviewed for smoking (Resident #15 and Resident #18). Findings Include: Group Interview Group interview on 12/5/12 at 3:00 p.m. with six (6) of the facility Residents revealed three (3) of three (3) males expressed concerns with having to watch out for their peers while smoking. Resident #13, Unsampled Residents E and F acknowledged they watch out for their peers when smoking. Record review of the Minimum Data Set (MDS) for Resident #13 showed a cognitive status of not assessed but he was named on the 11/16/12 interviewable list, Unsampled Resident E's cognitive status was listed as severely impaired, but was listed on the 11/16/12 interviewable list. Unsampled Resident F was not listed on the interviewable list, but has a cognitive status of independent. Observation on 12/6/12 at 6:00 p.m., of the gazebo smoking area, revealed three (3) male and two (2) female Residents smoking without any staff present. Resident #15 was noted to be one of the smokers present during the observation. Resident #15 Record review of the December 2012 Physician order [REDACTED]. On 12/6/12 at 5:45 p.m., Resident #15 was observed on the 100-hall self propelling in a wheelchair with a pack of cigarettes and a blue lighter in her right jacket pocket. Record review of Resident #15's cognitive status revealed her quarterly Minimum Data Set (MDS), dated [DATE], with the cognitive status as not assessed. A Nurses Note, dated 9/17/12, revealed the cognitive status as severely impaired. A Social Services progress note for Resident #15, dated 9/19/12, reflected her mood and feeling of being better off dead. Record review of the Smoking Assessment revealed an update of 12/6/12 as an independent smoker. Interview with the Administrator on 12/8/12 at 2:30 p.m., when told of the concerns with the lack of supervision for the smoking Residents and the observation of a lighter on Resident #15, the Administrator acknowledged none of the smokers are supervised during smoking and the smoking schedule is from 6:00 a.m. until 8:00 p.m. in designated smoking areas. Resident #18 Record review of Resident #18 revealed he was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with the Administrator on 12/8/12 at 2:30 p.m., revealed Resident #18 as a smoking resident that was required to wear a smoking apron, but none of the Residents require supervision while smoking. Observation on 12/8/12 at 3:00 p.m. of Resident #18 revealed him in bed with full padded side rails and saying he's tired and wants some peace. Record review of the Departmental Notes for Nursing and Social Services revealed notes, dated 10/9/12, 10/19/12 and 11/27/12, reflected Resident #18 with confusion but also stating he's a smoker with an apron. Record review of Resident #18's Smoking Safety Evaluation, dated 9/24/12, reflected issues with cognitive status and psychiatric concerns but stated he understands the smoking policy. Another Smoking Safety Evaluation dated 12/6/12 after his hospital stay with confusion as a returning [DIAGNOSES REDACTED]. The facility's policy "Smoking", dated 10/09, stated "Smoking is to occur only in designated areas and in accordance with each smoking residents' individualized plan of care based on the Smoking Safety Assessment. All residents who smoke will be assessed for his/her ability to smoke safely, the ability to handle smoking material and the need for supervision while smoking. Residents that are assessed as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials (i.e. cigarettes), and may smoke in designated areas without limitations. The resident may be permitted to keep fire materials on his/her person during waking hours if deemed appropriate per smoking assessment. Residents found to have modified independence with smoking: may be subject to smoking limitations. Limitations may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products, assistance to hold cigarette, supervised smoking by staff and/or other protective/safety measures as determined appropriate by the individualized plan of care based on the smoking assessment."

Based on the survey results dated 12/8/12, the facility failed to protect a cognitively impaired Resident #9 from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of ten (10) female residents reviewed (Residents #9 and #20). This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 12/7/12 at 1:30 p.m. A revisit survey was conducted on 12/27-28/12 to validate the Allegation of Compliance (AoC). The IJ which began on 12/7/12 was determined to be removed on 12/21/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 12/21/12. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9 shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of 13 female Residents reviewed (Residents #9 and #20). The facility provided an Allegation of Compliance (AoC) that was accepted on 12/27/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy (IJ). Information contained in the Credible AoC, submitted by the facility, revealed: "On 9/17/12 at approximately 12:39 p.m. CNA #2 reported to (licensed practical nurse) LPN #2 an observation of Resident #1 with his hand down Resident #9's shirt, rubbing her breast (inappropriate behavior/physical contact). At that time, LPN #2 walked down the hallway and approached Resident #1, who rolled his wheelchair to his room. LPN #2 moved Resident #9 closer to Resident #9's room and performed an interview and determined no negative outcomes related to occurrence. LPN #2 failed to document this interview and observations in the Medical Record. LPN #2 was in-serviced on failure to document in medical record on 12/11/12. Resident #9 had a skin audit conducted on 9/18/12 which revealed no visible bruising, redness or signs of trauma. Resident #1 and Resident #9 have the same primary Physician and Nurse Practitioner (NP). The NP was notified of the incident between Resident #1 and Resident #9 on 9/17/12. Physicians telephone order to transfer Resident #1 to Behavioral Health Unit (BHU) was received and written at 12:51 p.m. The NP notified Resident #1 and Resident #9's primary Physician after the 9/17/12 incident (date uncertain). On 9/17/12 at approximately 12:39 p.m. the facility failed to place Resident #1 on one (1) on one (1) observation until he was transferred to the BHU on 9/18/12 at 11:50 am. Resident #1 was sent to a BHU on 9/18/12 for behaviors (related to his inappropriate sexual contact with Resident #9). On 9/17/12 LPN #4 ( Unit Manager) failed to initiate an investigation and complete a documented assessment on Resident #9, protect Resident #9 by placing Resident #1 on one on one (1:1) observation, notify Resident #9's responsible party (RP), notify primary Physician for Resident #1 and Resident #9, care planning occurrence for Resident #1 and Resident #9, notify the Director of Nursing (DNS) and the Executive Director (ED). Due to LPN #4's ( Unit Manager) noted failures, LPN#4 (Unit Manager) was placed on suspension on 12/7/12 regarding Resident #1 and Residents #9's incident. Subsequently, written disciplinary action and re-education on abuse and reporting , abuse coordinator, behavior management program, incident investigation, documentation, one on one (1:1) utilization, resident assessments and care planning were completed on 12/13/12. On 9/17/12 at approximately 2:30 p.m. Social Service (SS#1) interviewed Resident #9. At that time Resident #9 stated that she was OK. Resident #9 was pleasant with no recollection of the 9/17/12 incident. On 9/18/12 SS#1 again interviewed Resident #9. At that time Resident #9 was pleasant with no recollection of the 9/17/12 incident. SS #1 failed to document the 9/17/12 and the 9/18/12 interviews with Resident #9 in the medical record. The DNS and ED were notified of inappropriate behavior/sexual contact between Resident #1 and Resident #9 on 12/6/12. On 12/6/12 the facility initiated an investigation concerning inappropriate sexual contact between Resident #1 and Resident #9. This investigation was initiated by the DNS and ED. The facility substantiated that inappropriate sexual contact was made by Resident #1 to Resident #9. On 12/6/12 at approximately 2:30 p.m. the Abuse Coordinator in the facility was changed from SS#1 to Executive Director. Executive Director and Director of Nursing were in serviced on reporting procedures and regulations by Facility Vice President on 12/11/12. On 12/6/12, SS#1 interviewed Resident #9 and at that time Resident #9 was noted to be pleasant with no recollection of the 9/17/12 incident. On 12/6/12, SS#1 was suspended pending investigation. SS#1 was issued corrective counseling on 12/13/12 for the failure to document Resident #9's interviews and failure to report incident. Subsequently, SS#1 received re-education on 12/13/12 including abuse and reporting, documentation of incidents/investigations, Medical Director (MD) and Responsible Party (RP) Notification, resident assessment and care planning, behavior management program and one on one (1:1) utilization. On 12/6/12 Resident #9's care plan was updated to include "potential to be abused". Resident #9's Responsible Party (RP) was notified on 12/8/12 that Resident #1 had placed his hand inside of Resident #9's shirt on 9/17/12. On 10/2/12 Resident #1 returned to the facility from the BHU with recommendations to follow up with his Physician for medical conditions and psychiatric services. The facility failed to document notification to Physician of BHU recommendation. Resident #1's 10/2/12 readmission orders [REDACTED]. On 10/2/12 Resident #1 returned to the facility from the BHU and at that time was placed on a "Behavior Monthly Flow Record" for "Danger to others". The facility failed to update Resident #1's care plan on 9/17/12 related to inappropriate sexual contact with Resident #9. On 10/10/12 Resident #1's care plan was updated to include "Inappropriate sexual behaviors". Resident #1 was observed for potential "Danger to others" behaviors with documentation on the "Behavior Intervention Monthly Flow" record from 10/2/12-12/7/12. Resident #1 was evaluated by NP on 10/18/12 with no new recommendation. Resident #1 was monitored for "Danger to others" behaviors until discharged from the facility on 12/7/12. Review of the "Behavior Intervention Monthly Flow" records dated, 10/2/12-12/7/12, revealed no documented behaviors noted or negative outcomes. On 12/7/12 at 1:35 p.m. Resident #1 was placed on 1:1 with CNA #2 until 3:00 p.m. At 3:00 p.m. CNA #3 began 1:1 observation of Resident #1 until 6:40 p.m. which was when Resident #1 was transferred and discharged to the BHU. The 1:1 was documented with no negative behaviors. On 12/21/12 the BHU notified the facility that Resident #1 will return on 12/21/12. Upon return, Resident #1 will be placed on 1:1 observation with a staff member until the interdisciplinary teams deems the need to make changes. Upon return, the facility will enter into a behavior contract with Resident #1. This contract will include but is not limited to; No sexual gestures, comments or sexually inappropriate behavior will be allowed. The care plan, assessments, behavior monitoring flow record and other risk evaluations will be initiated upon return to the facility. All recommendations and orders on return from BHU will be reviewed with the NP/MD for further orders. On 12/10/12 all current cognitive residents were interviewed and resident questionnaire completed to determine if they had been abused. A body audit was initiated on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. There were no negative outcomes. During the 12/10/12 interview of cognitive residents, Resident #20 stated that she believed she had been previously abused within the facility but currently feels safe and is not afraid of anyone within the facility. An investigation was initiated by the abuse coordinator (ED). A follow up interview was conducted by the ED as part of this investigation. Resident #20 stated that she had been grabbed on her wrist by Resident #1 in the past with no known date of occurrence. On 12/13/12 Resident #20 denied any current concerns since Resident #1 has been discharged . On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. Facility staff also re-in serviced 26 staffs members on abuse reporting. On 12/13/12 the facility notified the state agencies (State Survey Agency and Attorney Generals Office), resident #20's RP and the Physician of the alleged occurrence. The facility was not able to substantiate inappropriate physical contact or abuse. The SSD will visit Resident #20 daily for two (2) days starting 12/13/12 and weekly for two (2) weeks. Resident #20's care plan was updated. Abuse Coordinator will visit with resident #20 once weekly for four weeks starting 12/13/12 to further ensure residents remains comfortable with addressing any issues identified. The NP made rounds and ordered a psychiatric consult due to her observation of Resident #20 attention seeking behaviors. On 12/13/12 there were 41 male residents in the facility. 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. There were no males with physical behavior symptoms directed toward others. On 12/6/12 the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". This policy includes abuse/neglect, staff treatment of [REDACTED]. The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. This change was posted at all three (3) nurse's stations, the time clock and at a central location on wing 1. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The Abuse Coordinator is to be notified for all suspected or reported abuse and neglect. This in-service also included, protecting the victim and one on one monitoring of perpetrator. No employee will be allowed to return to work until they have been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12 the SDC initiated in-servicing licensed nursing staff on assessments, body audits and care planning, notification to MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing twenty four hour report. In Serviced: Assessments Policy - purpose is to identify and document the residents condition/status in efforts to develop a plan of care. Care Plan Policy - purpose is to identify problems and needs that will assist the Interdisciplinary team in providing care. Accident and Incident Policy - purpose is the guide of documenting and investigating occurrences that involve residents. Behavior Management Committee Policy - Purpose is the guide that is used to identify and track behavior(s) that are displayed routinely that may affect the resident(s). Abuse Prevention Policy - Purpose is to define the facilities commitment to protect the residents from abuse from anyone. Notification to MD/RP Policy - Purpose is to inform MD/RP of change in resident's condition. On 12/11/12 the SDC initiated in-servicing for licensed nursing staff concerning resident assessment, documentation, physician/RP notification and following MD orders. On 12/13/12 the interdisciplinary team were in-serviced on the facility behavior management program. On 12/13/12 the DNS in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. Starting 12/11/12 the social service department will visit Resident #9 twice a day for four (4) days, then three (3) times a week for two (2) weeks. The Abuse Coordinator initiated twice a week rounds starting 12/10/12 for four (4) weeks to ensure accessibility to residents and staff on abuse reporting. On 12/13/12 the DNS initiated monitoring of any allegation of abuse and neglect through review of any incident logs for five (5) days per week for four (4) weeks. The results of the findings were reported to the ED. All components of deficiencies cited and corrective action taken thus far were reviewed by the Quality Assurance Committee on 12/12/12 by committee members and facility Medical director. A follow up Quality Assurance meeting was held on 12/14/12 to discuss additional action taken and the conclusion of Resident #20's allegation of abuse and the reporting process. A Quality Assurance Committee meeting was held on 12/20/12 with committee members and the Facility Medical Director to further review polices (no policy changes were noted) and the facilities allegation of compliance as well as monitoring/audit reports with no findings of recurrence of deficient practice. We are alleging that the allegation is removed as of 12/21/12 of all Immediate Jeopardy deficiencies cited." The aforementioned information is quoted in the AoC. Review of the AoC conducted from 12/27/12 at 11:30 a.m. through 12/28/12 at 5:30 p.m., revealed the following information was validated: On 12/6/12, the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The in-service also included protecting the victim and one on one monitoring of perpetrator. No employee was allowed to return to work until they had been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12, the SDC in-serviced licensed nursing staff on assessments, body audits and care planning, notification of MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing 24 hour report. On 12/10/12, the facility interviewed all current cognitive residents and a resident questionnaire was completed to determine if they had been abused. Body audits were initiated by the facility staff on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. On 12/11/12, the Social Service Department (SSD) began visiting Resident #9 twice a day for 4 days, the 3 times a week for 2 weeks. The Abuse Coordinator initiated twice a week rounds on 12/10/12. On 12/11/12, the Staff Develop Coordinator (SDC) in-serviced licensed nursing staff on resident assessment, documentation, physician/RP Notification and following MD orders. On 12/13/12, the facility notified the state agencies (State Survey Agency and Attorney General's Office), Resident #20's Responsible Party and the Physician of the alleged occurrence. The SSD visited Resident #20 daily for 2 days starting 12/13/12 and weekly for 2 weeks. Resident #20's care plan was updated. The Abuse Coordinator visited Resident #20 once weekly beginning 12/13/12. Also on 12/13/12 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. On 12/13/12, the interdisciplinary team was in-serviced on the facility behavior management program. On 12/13/12, the DON in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. On 12/14/12, the DON and Regional Clinical Operations Nurse initiated in-servicing on care planning and investigation procedures. Facility staff re-in-serviced 26 staff members on abuse reporting. Interviews of 13 residents individually on 12/27/12 and 12/28/12 and review of Resident Questionnaires provided by the facility verified that the facility had spoken with each resident regarding abuse/reporting on 12/10/12. The facility performed body audits on 80 non-cognitive residents to determine if any signs of abuse were present as verified by record review of body audits. Interviews of 28 staff members from all 3 shifts on 12/27/12 and 12/28/12 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, care planning, documentation, protection of residents, incident investigation, notification of MD/RP, Abuse Coordinator, behavior management program, 1:1 utilization, resident assessments, and following up on reports of suspected/alleged abuse/neglect. These policies were reviewed as well. Staff members included in these interviews were CNAs, nurses, Administrator, Maintenance Director, Dietary Manager, PT/OT staff, Activities Director, housekeeping, and DON. These in-services were conducted by the facility on the following dates: 12/10/12, 12/11/12, 12/12/12, 12/13/12, 12/14/12, 12/15/12, 12/17/12, 12/20/12, 12/21/12, 12/24/12, and 12/26/12. Review of 15 Resident records on 12/27/12 and 12/28/12 revealed no concerns regarding abuse/neglect or care plans. The facility entered into a Behavior Contract with Resident #1 on 12/21/12. Review of this document verified the contract was signed by Resident #1, the Administrator, and the DON on 12/21/12. Resident #1 was discharged from BHU and returned to the facility on [DATE]. Upon his return, Resident #1 was placed on 1:1 observation with a staff member. The facility entered into a behavior contract with Resident #1 on 12/21/12. The care plan, assessments, behavior monitoring flow record and other risk evaluations were initiated on his return. Resident #1 was also moved from Wing II to Wing III. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/21/12 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee.

Based on observation, staff interview, record review and facility policy review, the facility failed to protect a cognitively impaired Resident #9 from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of ten (10) female residents reviewed (Residents #9 and #20). An annual survey was conducted from [DATE] to [DATE]; an extended survey was conducted from [DATE] to [DATE]. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on [DATE] at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on [DATE]. The IJ was determined to begin on [DATE]. The facility submitted the first (1st) Allegation of Compliance (AoC) on [DATE] at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on [DATE] at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on [DATE] at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on [DATE], and is considered ongoing. Findings Include: Review of the facility's policy "Resident Bill of Rights", documented "It is the objective of the facility to herein forth the rights of Residents so as to assure the protection and preservation of dignity, individuality and, to the extent medically feasible, independence. #7 be free from mental and physical abuse." Review of the facility's policy "Abuse Prevention", dated reviewed ,[DATE], documented "Policy: The facility is committed to protecting the residents from abuse by anyone including, but necessarily limited to: facility staff, other residents etc.: c) Sexual Abuse: This includes, but not limited to sexual harassment, sexual coercion or sexual assault. Investigation: #1. The facility will initiate at the time of any finding or potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The Executive Director or designee shall report any instances of suspected abuse, neglect, or misappropriation of resident property to the Department of Health as required. Protection: #2 Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state." Resident # 9 A record review for Resident # 9 revealed, she moved into the home on [DATE] with [DIAGNOSES REDACTED]. A review of Resident # 9 Minimum Data Set (MDS), with an Assessment Review Date (ARD) of [DATE] and [DATE] revealed, Resident # 9 Brief Interview of Mental Status (BIMS) summary score was 99, which reflects Resident # 9 was unable to complete the interview. A score of 2 for cognitive skills for daily decision making which reflect; moderately impaired-decisions poor; cues/supervision required. The Functional Status revealed a one-person assist in all areas of Activity of Daily Living (ADL). Record review of Resident #1 on [DATE] at 3:10 p.m., documentation dated [DATE] (no time noted) in the Social Services (SS) Progress Notes written by SS #1, revealed "Resident #1 visited the Social Services Department (SSD) wanting to know what was the procedure for having sex. SSD explained to Resident that sex was not prohibited. However, he needs to be sure that his mate is able to make decisions for herself and that she does not have a dx (diagnosis) that would cognitively impair her from making that decision as well. Resident states "I'm glad I asked. When I was in Vietnam an had sex w/them (with) girls I used x2 (times two) rubbers in case one would break. That's kind of the same thing huh". SSD responded "No, it is the way I explained it to you". He states "Well I don't have anyone in mind right now & (and) no one is after me but I wanted to know so when I get ready I'll know the procedure." SSD asked the Resident to let SS know so that privacy can be given." Addendum on [DATE], stated "Addendum SSA (Social Services Assistant) present." Review of Resident #1's records on [DATE] through [DATE] revealed no care plan was initiated to address Resident #1's sexual needs. A review of Departmental Notes (Social Service) dated [DATE] at 4:12 p.m., revealed the following: Resident asked "If I was to have sex with a female in this place, what would be the rules? Would I get in trouble or thrown out of this place? I don't want any trouble." According to Departmental Note (Social Service) dated [DATE] at 10:24 a.m. "Resident has referral/order for BHU (behavioral health unit)." Interview with Social Services (SS) #1 on [DATE] at 2:45 p.m., revealed the following: SS #1 stated "Yes, I talked with him about what should be done. I've got a folder in my office. Let me get it. Then I can tell you what happened." Further interview with SS #1 on [DATE] at 3:00 p.m. when she returned with folder, SS #1 stated "Here is the folder." It was noted that the folder contained the SSD Progress Note dated [DATE]. No other documents were in the folder. SS #1 stated, "We didn't do a Care Plan for when he asked about how does he have sex." Surveyor asked why Resident #1 was sent to a local behavioral health unit (BHU). SS #1 stated "The first time he was pulling a female Resident backward in her w/c (wheelchair) and he was sent out, and then right after that he did that incident where he stuck his hand down a resident's shirt. We didn't have time for the care plan because it happened right after he came back. He was sent out again for that." SS #1 stated Resident was supposed to be seen by (A Mental Health Provider). Surveyor requested all follow-up notes, where he went for follow up, the name of the female resident, her cognitive status, the name of the person who witnessed the incident, and all investigations that was done. SS #1 stated "I'll get the information for you." SS #1 never came back with this or any information. On [DATE] at 9:10 a.m., the Director of Nursing (DON) brought in a copy of "Category One Violation, Employee Corrective Counseling Memorandum" which stated "(SS #1) had been suspended on [DATE] at 8:17 p.m. via text, with violation "Received report of male resident touching a female resident. Did not report this to the DON or Administrator." It was signed by the Facility Administrator on [DATE]. A review of the facility's written statement provided by the DON during the survey on [DATE] at 9:10 a.m., from (SS) # 1 dated [DATE], revealed "On [DATE] a nurse came to social service reported a (Resident #1) had put his hand down another resident shirt, (Resident #9)." Interview with the Director of Nursing (DON) on [DATE] at 3:20 p.m., regarding Resident #1's sexual behavior, the surveyor requested incident reports with the investigation. The DON stated "I should have one, I'll go get it for you, and I'll be right back." Further interview with the DON on [DATE] at 5:30 p.m., stated "When I went back to look at my records no incident report or investigation was done. I didn't know he (Resident # 1) had touched anybody, I thought it was verbal, I can tell you it was not reported to me or the State but we did start a behavior sheet on him." Surveyor told the DON that she had requested the name of the female resident, her cognitive status, who witnessed the incident, the follow up treatment, care plan and documentation of all notes from the social worker, and nothing had been received. The DON said "Ok, I'll get those for you." Further interview with the DON on [DATE] at 9:10 a.m., stated "I was unaware of the situation previously. An investigation was started immediately." Copies of the facility's employees statements were given to surveyor at this time. A review of the facility's undated typed statement (obtained during survey), provided to surveyor on [DATE] at 9:10 a.m. by the DON, revealed the following: "On [DATE], it was reported to me by surveyors that (Resident #1) had put his hand down a female residents blouse. I was unaware of the situation previously. An investigation was started immediately ..." "....FNP (Family Nurse Practitioner), for both residents was notified of incident. She stated that she was aware of the incident when it occurred, that she had been notified by Unit Manager." This typed statement also reflected the following: "Disciplinary action was taken with social services and unit manager for failure to report occurrence to Administrator or DON. Staff is being re-inserviced on reporting any inappropriate behavior to Administrator and/or DON. In summary, even though facility failed to report incident, there was no negative outcome to (Resident #9) as evidenced by interviews and body audit. Appropriate interventions were put into place such as geripsych admit and observation for any inappropriate behaviors." Signed by DON. A review of Resident #9 records on [DATE] through [DATE], revealed there was no documentation of notification of the incident to the Primary Physician or the Responsible Party. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 3:50 p.m., regarding incident of Resident #9 putting his hand inside a resident's shirt, stated "Yes I remember. I didn't see it, it was reported to me by the Certified Nurse's Aides (CNAs) or I think maybe a nurse reported it, I'm not sure. I'm going to have to look at his notes. I do know that he was sent out." A review of Departmental Notes (Nursing) dated [DATE] at 12:39 p.m., revealed the note was signed by LPN #4, revealed "Resident setting at the end of wing two near exit door. Female resident sitting near exit door in butten (button) down blouse. Resident observed to reach hand in females shirt without given consent. Resident was redirected not to do that per staff, and female resident escorted to her room per staff." A review of the facility's written statement from LPN #4 provided by the DON during the survey on [DATE] at 9:10 a.m., revealed "On [DATE] it was reported to me that (Resident #1) put his hand down a female residents shirt in the hallway near his room on Wing II. (Resident #1) was redirected and observed per staff. There was no further incidents thru his time of transfer to geri-psych." Statement were signed by LPN #4 and dated [DATE]. On [DATE] at 9:10 a.m., the Director of Nursing (DON) brought in a copy of "Category One Violation, Employee Corrective Counseling Memorandum" documented "(LPN #4), 2. Category One Warning: If a further incident of this nature occurs, your employment will be terminated. Violation No. 1.3. Description: Did report to SSD but not to DON or Administrator. Need more documentation after the fact. How did you protect Resident? How did we monitor male resident...etc. ED, DNS must be notified of abuse or neglect or resident on resident. Must report & complete investigation." The employee's response was "I did call the Doctor to report the incident and received the order to send resident out. As stated I did report to SS. I did report to the nurse that was working with the resident to monitor and observe both residents." This memorandum was signed by facility Administrator and dated [DATE]. A review of the facility's typed statement from LPN #2 provided by the DON during the survey on [DATE] at 9:10 a.m., revealed "I, (LPN #2) was working on the day of the incident. I recall a staff member reported that (Resident #1) touched (Resident #9) on her breast. I observed the two sitting in the hallway of Wing 2 near the back of the building. I quickly proceeded toward the back. (Resident #9) was looking out the window. (Resident #1) was looking at me approaching. He abruptly moved away from (Resident #9) and started going into his room. I asked (Resident #9) how was she doing. She said "fine". She was moved closer to her room and didn't appear to be in any distress or discomfort. I spoke to (Resident #1). I asked him if he was fondling (Resident #9). He didn't respond. I asked him again. He held his head down. He did not deny touching (Resident #9). I told (Resident #1) that was wrong, and that he should not touch her in that way, and not to do it again. He never responded. (LPN #4), Unit Supervisor, also assessed (Resident #9) and spoke to (Resident #1). LPN #4 called a staff member from SS and they proceeded to have (Resident #1) sent out for evaluation. For the duration of my shift, (Resident #1) remained in his room. (Resident #9) proceeded about the day in her usual way; either sitting in her room or ambulating the halls by wheelchair. She displayed no signs of distress." This statement was signed by LPN #2 and dated [DATE]. A review of the facility's written statement from LPN #3 provided by the DON during the survey on [DATE] at 9:10 a.m., revealed "On [DATE] I spoke with (LPN #2) about [DATE] incident involving (Resident #1) and (Resident #9). (LPN #2) stated she was standing at her med cart when she heard someone say that (Resident #1) put his hand down (Resident #9's) blouse. She stated that (LPN #4) picked up the phone and reported statement to social services and then she was told that he had to go to geri-psych. She stated that she did not remember who made the statement about the incident. When I asked her about any changes (mental or physical) with (Resident #9) she told me I didn't notice any. She told me that (Resident #9) was up in her wheelchair moving about unit as usual. I asked her (LPN #2) about (Resident #1). She told me that he went to his room and just sat there. She stated that (Resident #1) did not attempt to go into anyone else's room nor did he come out of room to talk with any other residents." A review of Departmental Notes (Nursing) dated from [DATE] at 12:39 p.m. to [DATE] at 2:49 p.m., revealed there was no documentation of Resident #1 remaining in his room after the incident. Telephone interview with LPN #2 on [DATE] at 3:55 p.m., regarding the incident of Resident #1 putting his hand down Resident #9's shirt, revealed "I don't remember who told me that (Resident #1) had touched (Resident #9) on her breast. I seen them in back of hallway on Wing 2, and when he seen me coming, he immediately started moving toward his room. He had this "look" on his face. I asked (Resident #9) how she was doing and she said fine. I did assess her, you know she has dementia. I went to Resident #1 about why he was fondling her. He never said anything. I think he felt bad about it. He stayed in his room the rest of the day. On my shift, LPN #4, the Unit Manager and SS were at the desk getting ready to send him out. I have worked here a while. I never seen this type of behavior." One (1) "Behavior/Medication Monitoring Summary" was noted in Resident #1's medical record, dated [DATE] with no time noted and signed by SS #1, revealed "Section 3: Review of Mood & Behavior A) Cursing, and B) Inappropriate sexual behavior" with a check mark beside D (day shift). Section 6: Summary: "Resident has noted sticking his hand down female resident shirt. Referral to BHU made this day. C/P (care plan) added to reflect Res. behavior." Review of Resident #1's records on [DATE] through [DATE] revealed there was no care plan initiated on [DATE] regarding inappropriate sexual contact with a cognitively impaired female resident. Review of Resident #9's records on [DATE] through [DATE] revealed no care plan initiated on [DATE] to protect Resident #9 from inappropriate sexual contact by another Resident. A review of the facility's written statement from CNA #2 provided by the DON during the survey on [DATE] at 9:10 a.m. , undated, revealed "On [DATE] I was coming from charting in the dayroom when I look down the hall and saw (Resident # 1) with his hand reaching over Resident # 9 wheelchair (W/C) so I walked down that way to see what was going on. He had his hand down in her shirt rubbing on her breast so I told him to stop then I reported it to the nurse (LPN #1) and she went down there push him into his room and (Resident #9) too." Interview with CNA #2 on [DATE] at 3:00 p.m., revealed "I was coming down the hall by the dining room, I was going to answer a call light and noticed (Resident #1) reaching over her (Resident #9) w/c, they were down close to his room near the exit door. When I walked down there, that's when I seen his hand down her (Resident #9) shirt, rubbing around. She had a button up shirt on. I told him to stop it. He drew his hand back and he looked toward the exit door. That's when I went and told the nurse. I told (LPN #1) and then she went down and talked to him and pushed him down to his room. I don't know of anybody else he has touched or said anything to. I did write a statement about what happened." A review of the facility's written statement from CNA #1 provided by the DON during the survey on [DATE] at 9:10 a.m., revealed "On [DATE] (CNA #2) told me to look down hall at Resident #1 and Resident #9. I saw Resident # 1 with his hand down Resident #9 shirt. We told the nurse and (CNA #2) went down hall and told (Resident #1) to stop. I went back to my work." Interview with CNA #1 on [DATE] at 3:10 p.m., revealed "I was coming from the dining room, Wing 2 and CNA #2 told me to look and I saw that (Resident #1) had his hand inside (Resident #9) shirt. (CNA #2) went down and separated them and we told (LPN #1). I went on and finished my work. I don't know what happened after that. There has been hearsay that he has been after (Resident #20). She's on Wing 1. But you know he's just a man. You know men will be men. He said something to staff like, I can't do nothing (sex) if I wanted to. I just don't let it bother me because he's just a man. I did write a statement today. I didn't know I was supposed to write it up. No, I haven't heard of any other incidents. I only been here since February. He's just being a man." A review of the facility's written statement from LPN #3 provided by the DON during the survey on [DATE] at 9:10 a.m., revealed "[DATE] I called (FNP) to inform her about the resident on resident incident on [DATE]." (FNP) stated "Yes, I was called and I remember that. I take care of them both. (Resident # 9) was seen by (FNP) on [DATE] and by (Primary Physician) on [DATE], without mention of incident by resident." Resident #1 Record review of Resident #1 revealed, he moved into the home on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 Minimum Data Set (MDS), with an Assessment Review Date (ARD) of [DATE], revealed Resident #1 Brief Interview of Mental Status (BIMS) summary score was 15, which reflects Resident #1 was cognitively intact. The Functional Status revealed a one-person assist in all areas of Activity of Daily Living (ADL) except transfers which was a 2-person assist. A review of the Departmental Notes (Nursing) dated [DATE] at 9:11 a.m., revealed "At 0902 (9:02 a.m.) noticed resident in hall with resident from room [ROOM NUMBER]B pulling on her wheelchair. She was attempting to pull side rail and pull herself down the hall and he continued to pull her wheelchair back from a position that she could not see him. Resident stopped as soon as he noticed me headed toward him. I told resident that was very inappropriate. He didn't say a word he just continued to wheel himself down the hall. Notified social services (SS #2) and nurse." Signed by NAME RN. A review of Resident #1's Departmental Notes (Nursing) dated [DATE] at 12:15 p.m. written by (RN), revealed "(Resident #1) gave inappropriate answers when asked BIMS questions such as "I've been hurting for all you women". Resident #1 has neither short or long term memory deficits. He has independent daily decision making abilities." Review of Resident #1's records on [DATE] through [DATE] revealed that there was no care plan regarding the incident on [DATE] initiated regarding Resident #1's inappropriate behavior and/or his sexual needs. A review of Departmental Note (Nursing) dated [DATE] at 12:16 p.m. written by NAME LPN, revealed "Resident #1 picked up by behavioral health facility van at 12:10 p.m." A review of Resident #1's Discharge Summary dated [DATE] from local Behavioral Hospital, with an admitted [DATE], revealed History of present illness/reason for admission: "The patient is referred here for irritability, cursing, not sleeping; he is having outbursts, mood swings. He is grabbing the wheelchair of other Residents. He is restless, being sexual inappropriate and sarcastic." Condition at the time of discharge: "He needs continue work on boundary setting." Resident returned to the facility on [DATE]. A review of Resident #1's Departmental Notes (Nursing) dated [DATE] at 12:39 p.m., revealed "Female Resident sitting near exit door in button down blouse. (Resident #1) observed to reach hand in female shirt without given consent." Signed by (LPN #4). A review of Departmental Notes (Nursing) dated [DATE] "at 2:39 p.m., Resident left facility per (facility) van." A review of local Behavior Hospital Discharge Summary, dated [DATE], revealed "Date of admission [DATE] and date of discharge [DATE]." Reason for admission: "He has a history of agitation. He has taken [MEDICATION NAME] in the past for agitation. He has mood swings. He is asking the staff inappropriate sexual comments. He has poor impulse control and increased anxiety. He was irritable, hard to redirect, sarcastic and telling staff members to come sit on his lap." Resident was returned to the facility on [DATE]. "Aftercare Recommendations: local Psych Services to follow him in the nursing home in one to two weeks." Record review of Resident #1 on [DATE] through [DATE], revealed there was no documentation as to follow up with local Psych Services as recommended by behavioral health unit for aftercare. Record review of Resident #1's medical record, revealed "Behavior/Medication Monitoring Summary dated [DATE]. Section 5 - Care Plan Review Changes yes is checked. Section 6 - Summary of review period: C/P update if recent behaviors noted. Resident recent return from BHU for inappropriately touching another resident. Behavior of that activity noted since his return." Members present: SS #1 & SS #2, (LPN) (unreadable), Activity Director #1. No check marks in Section 3 - Review of mood & behavior. Record review of Resident #1's Care Plan, revealed inappropriate sexual behavior was initiated on [DATE]. "Goal & Target Date: *Resident will not touch another resident in inappropriate sexual manner [DATE]. *Resident will not make verbal sexual gestures to others [DATE]. Approaches: *Educate resident on violating the privacy of others. *Redirect any sexually/verbally inappropriate behaviors. *Recommend psych counseling/geri-psych prn." A review of Social Service Progress Notes, dated [DATE], revealed "Resident #1 visited SSD wanting to know how he can have sex with her, resident or staff as he is lonely for female attention. (Resident #1) asked writer if she would be available later for attention." A review of Departmental Notes (Social Service) dated [DATE] at 9:56 a.m., revealed "14 day assessment ARD [DATE]. Resident is alert and is oriented and able to make needs known. According to resident interview, indications of feeling down, trouble sleeping, low energy x2 of past 14 days. Resident indicated during interview that he gets lonesome for some female company. He has had new roommate by which he states they get along just fine. He indicated that he wants to return to community and does want to be asked about his return. Resident has no noted behavior problems this look back period..." Resident #20 Interview with the Administrator on [DATE] at 4:10 p.m. revealed she was aware of another female Resident who was concerned about Resident #1's inappropriateness and identified her as Resident #20. The Administrator did not acknowledge how she was aware of Resident #20's concern with Resident #1's inappropriateness. Record review revealed Resident #20 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. A record review of Resident #20's annual Minimum Data Set (MDS), dated [DATE], revealed her cognitive status was independent with decisions consistent and reasonable. Interview with Resident #20 on [DATE] at 5:00 p.m., revealed Resident #1 often approached her and that it made her feel very uncomfortable with his advances and comments. Resident #20 stated, "He would engage me in conversation and would say something not really bad but I didn't like his advances. He did approach me and grabbed me by the arm around the first part of October and he said, "Let's go do some exercise." It made me uncomfortable. Because he grabbed my arm firmly and forcibly and the way his eyes were looking at me, it was creepy. You know what he was talking about. I told him I didn't know any exercises. He said, "I'll show you some (with this weird look in his eyes), come go with me to my room. "The Nurse on the hall got him and told him someone was waiting on him and took him away. I don't know if that was a planned thing or what. So I went to the Nurses desk to talk to the Nurse that got him and she said not to worry he was on his way out. I found out they sent him to Geri-Psy an hour after that. Then another time around [DATE] he saw me on the hallway and left two (2) staff members he was talking to and rolled towards me, I had my cell phone so I pretended to be talking on the phone. He stopped his wheelchair next to a lift on the hallway and blocked my path. I asked him to move and let me by. He told me, you can get by, but didn't move. A Staff person came and moved him from the area. I told the Nurse that I wanted a report done to the Director of Nursing (DON), I wanted him written up. She told me she would, but that Monday I went to the DON and asked her about the report and she said she didn't have a report on any incident. I told her (DON) I wanted to have a meeting with her and the Administrator. They met with me and I told them about the incidents, both of them, so the Administrator asked me what I wanted them to do about it. I told her I wanted him put out and she told me, that wasn't going to happen. The DON suggested that I not go to the 200 hall and told me she would talk to him and tell him not to talk to me. But he still would make comments and conversation, even after they told him not to. There was another guy who was known to approach women and he would touch, but he died . I feel like it was looked over as he was just being a man. So nothing was really done about it. I wondered if I had any options. I had even talked to a friend outside the facility (not a resident). She told me to just leave it alone because I didn't have any proof." (Resident #20 then asked that her interview not be shared with the facility. Resident #20 stated, "I like it here and I don't want them to put me out.")

Based on the survey results dated 12/8/12, the facility failed to notify the Primary Physician and the Responsible Party of a witnessed incident of resident on resident sexual abuse for one (1) of 27 residents reviewed (Resident #9). This was deemed an Immediate Jeopardy (IJ) on 12/7/12 at 1:30 p.m. A revisit survey was conducted on 12/27-28/12 to validate the Allegation of Compliance (AoC). The IJ which began on 12/7/12 was determined to be removed on 12/21/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 12/21/12. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9 shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of 13 female Residents reviewed (Residents #9 and #20). The facility provided an Allegation of Compliance (AoC) that was accepted on 12/27/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy (IJ). Information contained in the Credible AoC, submitted by the facility, revealed: "On 9/17/12 at approximately 12:39 p.m. CNA #2 reported to (licensed practical nurse) LPN #2 an observation of Resident #1 with his hand down Resident #9's shirt, rubbing her breast (inappropriate behavior/physical contact). At that time, LPN #2 walked down the hallway and approached Resident #1, who rolled his wheelchair to his room. LPN #2 moved Resident #9 closer to Resident #9's room and performed an interview and determined no negative outcomes related to occurrence. LPN #2 failed to document this interview and observations in the Medical Record. LPN #2 was in-serviced on failure to document in medical record on 12/11/12. Resident #9 had a skin audit conducted on 9/18/12 which revealed no visible bruising, redness or signs of trauma. Resident #1 and Resident #9 have the same primary Physician and Nurse Practitioner (NP). The NP was notified of the incident between Resident #1 and Resident #9 on 9/17/12. Physicians telephone order to transfer Resident #1 to Behavioral Health Unit (BHU) was received and written at 12:51 p.m. The NP notified Resident #1 and Resident #9's primary Physician after the 9/17/12 incident (date uncertain). On 9/17/12 at approximately 12:39 p.m. the facility failed to place Resident #1 on one (1) on one (1) observation until he was transferred to the BHU on 9/18/12 at 11:50 am. Resident #1 was sent to a BHU on 9/18/12 for behaviors (related to his inappropriate sexual contact with Resident #9). On 9/17/12 LPN #4 ( Unit Manager) failed to initiate an investigation and complete a documented assessment on Resident #9, protect Resident #9 by placing Resident #1 on one on one (1:1) observation, notify Resident #9's responsible party (RP), notify primary Physician for Resident #1 and Resident #9, care planning occurrence for Resident #1 and Resident #9, notify the Director of Nursing (DNS) and the Executive Director (ED). Due to LPN #4's ( Unit Manager) noted failures, LPN#4 (Unit Manager) was placed on suspension on 12/7/12 regarding Resident #1 and Residents #9's incident. Subsequently, written disciplinary action and re-education on abuse and reporting , abuse coordinator, behavior management program, incident investigation, documentation, one on one (1:1) utilization, resident assessments and care planning were completed on 12/13/12. On 9/17/12 at approximately 2:30 p.m. Social Service (SS#1) interviewed Resident #9. At that time Resident #9 stated that she was OK. Resident #9 was pleasant with no recollection of the 9/17/12 incident. On 9/18/12 SS#1 again interviewed Resident #9. At that time Resident #9 was pleasant with no recollection of the 9/17/12 incident. SS #1 failed to document the 9/17/12 and the 9/18/12 interviews with Resident #9 in the medical record. The DNS and ED were notified of inappropriate behavior/sexual contact between Resident #1 and Resident #9 on 12/6/12. On 12/6/12 the facility initiated an investigation concerning inappropriate sexual contact between Resident #1 and Resident #9. This investigation was initiated by the DNS and ED. The facility substantiated that inappropriate sexual contact was made by Resident #1 to Resident #9. On 12/6/12 at approximately 2:30 p.m. the Abuse Coordinator in the facility was changed from SS#1 to Executive Director. Executive Director and Director of Nursing were in serviced on reporting procedures and regulations by Facility Vice President on 12/11/12. On 12/6/12, SS#1 interviewed Resident #9 and at that time Resident #9 was noted to be pleasant with no recollection of the 9/17/12 incident. On 12/6/12, SS#1 was suspended pending investigation. SS#1 was issued corrective counseling on 12/13/12 for the failure to document Resident #9's interviews and failure to report incident. Subsequently, SS#1 received re-education on 12/13/12 including abuse and reporting, documentation of incidents/investigations, Medical Director (MD) and Responsible Party (RP) Notification, resident assessment and care planning, behavior management program and one on one (1:1) utilization. On 12/6/12 Resident #9's care plan was updated to include "potential to be abused". Resident #9's Responsible Party (RP) was notified on 12/8/12 that Resident #1 had placed his hand inside of Resident #9's shirt on 9/17/12. On 10/2/12 Resident #1 returned to the facility from the BHU with recommendations to follow up with his Physician for medical conditions and psychiatric services. The facility failed to document notification to Physician of BHU recommendation. Resident #1's 10/2/12 readmission orders [REDACTED]. On 10/2/12 Resident #1 returned to the facility from the BHU and at that time was placed on a "Behavior Monthly Flow Record" for "Danger to others". The facility failed to update Resident #1's care plan on 9/17/12 related to inappropriate sexual contact with Resident #9. On 10/10/12 Resident #1's care plan was updated to include "Inappropriate sexual behaviors". Resident #1 was observed for potential "Danger to others" behaviors with documentation on the "Behavior Intervention Monthly Flow" record from 10/2/12-12/7/12. Resident #1 was evaluated by NP on 10/18/12 with no new recommendation. Resident #1 was monitored for "Danger to others" behaviors until discharged from the facility on 12/7/12. Review of the "Behavior Intervention Monthly Flow" records dated, 10/2/12-12/7/12, revealed no documented behaviors noted or negative outcomes. On 12/7/12 at 1:35 p.m. Resident #1 was placed on 1:1 with CNA #2 until 3:00 p.m. At 3:00 p.m. CNA #3 began 1:1 observation of Resident #1 until 6:40 p.m. which was when Resident #1 was transferred and discharged to the BHU. The 1:1 was documented with no negative behaviors. On 12/21/12 the BHU notified the facility that Resident #1 will return on 12/21/12. Upon return, Resident #1 will be placed on 1:1 observation with a staff member until the interdisciplinary teams deems the need to make changes. Upon return, the facility will enter into a behavior contract with Resident #1. This contract will include but is not limited to; No sexual gestures, comments or sexually inappropriate behavior will be allowed. The care plan, assessments, behavior monitoring flow record and other risk evaluations will be initiated upon return to the facility. All recommendations and orders on return from BHU will be reviewed with the NP/MD for further orders. On 12/10/12 all current cognitive residents were interviewed and resident questionnaire completed to determine if they had been abused. A body audit was initiated on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. There were no negative outcomes. During the 12/10/12 interview of cognitive residents, Resident #20 stated that she believed she had been previously abused within the facility but currently feels safe and is not afraid of anyone within the facility. An investigation was initiated by the abuse coordinator (ED). A follow up interview was conducted by the ED as part of this investigation. Resident #20 stated that she had been grabbed on her wrist by Resident #1 in the past with no known date of occurrence. On 12/13/12 Resident #20 denied any current concerns since Resident #1 has been discharged . On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. Facility staff also re-in serviced 26 staffs members on abuse reporting. On 12/13/12 the facility notified the state agencies (State Survey Agency and Attorney Generals Office), resident #20's RP and the Physician of the alleged occurrence. The facility was not able to substantiate inappropriate physical contact or abuse. The SSD will visit Resident #20 daily for two (2) days starting 12/13/12 and weekly for two (2) weeks. Resident #20's care plan was updated. Abuse Coordinator will visit with resident #20 once weekly for four weeks starting 12/13/12 to further ensure residents remains comfortable with addressing any issues identified. The NP made rounds and ordered a psychiatric consult due to her observation of Resident #20 attention seeking behaviors. On 12/13/12 there were 41 male residents in the facility. 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. There were no males with physical behavior symptoms directed toward others. On 12/6/12 the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". This policy includes abuse/neglect, staff treatment of [REDACTED]. The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. This change was posted at all three (3) nurse's stations, the time clock and at a central location on wing 1. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The Abuse Coordinator is to be notified for all suspected or reported abuse and neglect. This in-service also included, protecting the victim and one on one monitoring of perpetrator. No employee will be allowed to return to work until they have been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12 the SDC initiated in-servicing licensed nursing staff on assessments, body audits and care planning, notification to MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing twenty four hour report. In Serviced: Assessments Policy - purpose is to identify and document the residents condition/status in efforts to develop a plan of care. Care Plan Policy - purpose is to identify problems and needs that will assist the Interdisciplinary team in providing care. Accident and Incident Policy - purpose is the guide of documenting and investigating occurrences that involve residents. Behavior Management Committee Policy - Purpose is the guide that is used to identify and track behavior(s) that are displayed routinely that may affect the resident(s). Abuse Prevention Policy - Purpose is to define the facilities commitment to protect the residents from abuse from anyone. Notification to MD/RP Policy - Purpose is to inform MD/RP of change in resident's condition. On 12/11/12 the SDC initiated in-servicing for licensed nursing staff concerning resident assessment, documentation, physician/RP notification and following MD orders. On 12/13/12 the interdisciplinary team were in-serviced on the facility behavior management program. On 12/13/12 the DNS in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. Starting 12/11/12 the social service department will visit Resident #9 twice a day for four (4) days, then three (3) times a week for two (2) weeks. The Abuse Coordinator initiated twice a week rounds starting 12/10/12 for four (4) weeks to ensure accessibility to residents and staff on abuse reporting. On 12/13/12 the DNS initiated monitoring of any allegation of abuse and neglect through review of any incident logs for five (5) days per week for four (4) weeks. The results of the findings were reported to the ED. All components of deficiencies cited and corrective action taken thus far were reviewed by the Quality Assurance Committee on 12/12/12 by committee members and facility Medical director. A follow up Quality Assurance meeting was held on 12/14/12 to discuss additional action taken and the conclusion of Resident #20's allegation of abuse and the reporting process. A Quality Assurance Committee meeting was held on 12/20/12 with committee members and the Facility Medical Director to further review polices (no policy changes were noted) and the facilities allegation of compliance as well as monitoring/audit reports with no findings of recurrence of deficient practice. We are alleging that the allegation is removed as of 12/21/12 of all Immediate Jeopardy deficiencies cited." The aforementioned information is quoted in the AoC. Review of the AoC conducted from 12/27/12 at 11:30 a.m. through 12/28/12 at 5:30 p.m., revealed the following information was validated: On 12/6/12, the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The in-service also included protecting the victim and one on one monitoring of perpetrator. No employee was allowed to return to work until they had been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12, the SDC in-serviced licensed nursing staff on assessments, body audits and care planning, notification of MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing 24 hour report. On 12/10/12, the facility interviewed all current cognitive residents and a resident questionnaire was completed to determine if they had been abused. Body audits were initiated by the facility staff on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. On 12/11/12, the Social Service Department (SSD) began visiting Resident #9 twice a day for 4 days, the 3 times a week for 2 weeks. The Abuse Coordinator initiated twice a week rounds on 12/10/12. On 12/11/12, the Staff Develop Coordinator (SDC) in-serviced licensed nursing staff on resident assessment, documentation, physician/RP Notification and following MD orders. On 12/13/12, the facility notified the state agencies (State Survey Agency and Attorney General's Office), Resident #20's Responsible Party and the Physician of the alleged occurrence. The SSD visited Resident #20 daily for 2 days starting 12/13/12 and weekly for 2 weeks. Resident #20's care plan was updated. The Abuse Coordinator visited Resident #20 once weekly beginning 12/13/12. Also on 12/13/12 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. On 12/13/12, the interdisciplinary team was in-serviced on the facility behavior management program. On 12/13/12, the DON in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. On 12/14/12, the DON and Regional Clinical Operations Nurse initiated in-servicing on care planning and investigation procedures. Facility staff re-in-serviced 26 staff members on abuse reporting. Interviews of 13 residents individually on 12/27/12 and 12/28/12 and review of Resident Questionnaires provided by the facility verified that the facility had spoken with each resident regarding abuse/reporting on 12/10/12. The facility performed body audits on 80 non-cognitive residents to determine if any signs of abuse were present as verified by record review of body audits. Interviews of 28 staff members from all 3 shifts on 12/27/12 and 12/28/12 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, care planning, documentation, protection of residents, incident investigation, notification of MD/RP, Abuse Coordinator, behavior management program, 1:1 utilization, resident assessments, and following up on reports of suspected/alleged abuse/neglect. These policies were reviewed as well. Staff members included in these interviews were CNAs, nurses, Administrator, Maintenance Director, Dietary Manager, PT/OT staff, Activities Director, housekeeping, and DON. These in-services were conducted by the facility on the following dates: 12/10/12, 12/11/12, 12/12/12, 12/13/12, 12/14/12, 12/15/12, 12/17/12, 12/20/12, 12/21/12, 12/24/12, and 12/26/12. Review of 15 Resident records on 12/27/12 and 12/28/12 revealed no concerns regarding abuse/neglect or care plans. The facility entered into a Behavior Contract with Resident #1 on 12/21/12. Review of this document verified the contract was signed by Resident #1, the Administrator, and the DON on 12/21/12. Resident #1 was discharged from BHU and returned to the facility on [DATE]. Upon his return, Resident #1 was placed on 1:1 observation with a staff member. The facility entered into a behavior contract with Resident #1 on 12/21/12. The care plan, assessments, behavior monitoring flow record and other risk evaluations were initiated on his return. Resident #1 was also moved from Wing II to Wing III. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/21/12 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee.

PART 1 Based on the survey results dated 12/8/12, the facility failed to provide adequate supervision of Resident #1 to ensure an environment free from potential reoccurrence of sexual inappropriate behavior (of touching another Resident breast) for one (1) of one (1) identified resident with inappropriate sexual behavior reviewed (Resident #1). This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 12/7/12 at 1:30 p.m. A revisit survey was conducted on 12/27-28/12 to validate the Allegation of Compliance (AoC). The IJ which began on 12/7/12 was determined to be removed on 12/21/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 12/21/12. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9 shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of 13 female Residents reviewed (Residents #9 and #20). The facility provided an Allegation of Compliance (AoC) that was accepted on 12/27/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy (IJ). Information contained in the Credible AoC, submitted by the facility, revealed: "On 9/17/12 at approximately 12:39 p.m. CNA #2 reported to (licensed practical nurse) LPN #2 an observation of Resident #1 with his hand down Resident #9's shirt, rubbing her breast (inappropriate behavior/physical contact). At that time, LPN #2 walked down the hallway and approached Resident #1, who rolled his wheelchair to his room. LPN #2 moved Resident #9 closer to Resident #9's room and performed an interview and determined no negative outcomes related to occurrence. LPN #2 failed to document this interview and observations in the Medical Record. LPN #2 was in-serviced on failure to document in medical record on 12/11/12. Resident #9 had a skin audit conducted on 9/18/12 which revealed no visible bruising, redness or signs of trauma. Resident #1 and Resident #9 have the same primary Physician and Nurse Practitioner (NP). The NP was notified of the incident between Resident #1 and Resident #9 on 9/17/12. Physicians telephone order to transfer Resident #1 to Behavioral Health Unit (BHU) was received and written at 12:51 p.m. The NP notified Resident #1 and Resident #9's primary Physician after the 9/17/12 incident (date uncertain). On 9/17/12 at approximately 12:39 p.m. the facility failed to place Resident #1 on one (1) on one (1) observation until he was transferred to the BHU on 9/18/12 at 11:50 am. Resident #1 was sent to a BHU on 9/18/12 for behaviors (related to his inappropriate sexual contact with Resident #9). On 9/17/12 LPN #4 ( Unit Manager) failed to initiate an investigation and complete a documented assessment on Resident #9, protect Resident #9 by placing Resident #1 on one on one (1:1) observation, notify Resident #9's responsible party (RP), notify primary Physician for Resident #1 and Resident #9, care planning occurrence for Resident #1 and Resident #9, notify the Director of Nursing (DNS) and the Executive Director (ED). Due to LPN #4's ( Unit Manager) noted failures, LPN#4 (Unit Manager) was placed on suspension on 12/7/12 regarding Resident #1 and Residents #9's incident. Subsequently, written disciplinary action and re-education on abuse and reporting , abuse coordinator, behavior management program, incident investigation, documentation, one on one (1:1) utilization, resident assessments and care planning were completed on 12/13/12. On 9/17/12 at approximately 2:30 p.m. Social Service (SS#1) interviewed Resident #9. At that time Resident #9 stated that she was OK. Resident #9 was pleasant with no recollection of the 9/17/12 incident. On 9/18/12 SS#1 again interviewed Resident #9. At that time Resident #9 was pleasant with no recollection of the 9/17/12 incident. SS #1 failed to document the 9/17/12 and the 9/18/12 interviews with Resident #9 in the medical record. The DNS and ED were notified of inappropriate behavior/sexual contact between Resident #1 and Resident #9 on 12/6/12. On 12/6/12 the facility initiated an investigation concerning inappropriate sexual contact between Resident #1 and Resident #9. This investigation was initiated by the DNS and ED. The facility substantiated that inappropriate sexual contact was made by Resident #1 to Resident #9. On 12/6/12 at approximately 2:30 p.m. the Abuse Coordinator in the facility was changed from SS#1 to Executive Director. Executive Director and Director of Nursing were in serviced on reporting procedures and regulations by Facility Vice President on 12/11/12. On 12/6/12, SS#1 interviewed Resident #9 and at that time Resident #9 was noted to be pleasant with no recollection of the 9/17/12 incident. On 12/6/12, SS#1 was suspended pending investigation. SS#1 was issued corrective counseling on 12/13/12 for the failure to document Resident #9's interviews and failure to report incident. Subsequently, SS#1 received re-education on 12/13/12 including abuse and reporting, documentation of incidents/investigations, Medical Director (MD) and Responsible Party (RP) Notification, resident assessment and care planning, behavior management program and one on one (1:1) utilization. On 12/6/12 Resident #9's care plan was updated to include "potential to be abused". Resident #9's Responsible Party (RP) was notified on 12/8/12 that Resident #1 had placed his hand inside of Resident #9's shirt on 9/17/12. On 10/2/12 Resident #1 returned to the facility from the BHU with recommendations to follow up with his Physician for medical conditions and psychiatric services. The facility failed to document notification to Physician of BHU recommendation. Resident #1's 10/2/12 readmission orders [REDACTED]. On 10/2/12 Resident #1 returned to the facility from the BHU and at that time was placed on a "Behavior Monthly Flow Record" for "Danger to others". The facility failed to update Resident #1's care plan on 9/17/12 related to inappropriate sexual contact with Resident #9. On 10/10/12 Resident #1's care plan was updated to include "Inappropriate sexual behaviors". Resident #1 was observed for potential "Danger to others" behaviors with documentation on the "Behavior Intervention Monthly Flow" record from 10/2/12-12/7/12. Resident #1 was evaluated by NP on 10/18/12 with no new recommendation. Resident #1 was monitored for "Danger to others" behaviors until discharged from the facility on 12/7/12. Review of the "Behavior Intervention Monthly Flow" records dated, 10/2/12-12/7/12, revealed no documented behaviors noted or negative outcomes. On 12/7/12 at 1:35 p.m. Resident #1 was placed on 1:1 with CNA #2 until 3:00 p.m. At 3:00 p.m. CNA #3 began 1:1 observation of Resident #1 until 6:40 p.m. which was when Resident #1 was transferred and discharged to the BHU. The 1:1 was documented with no negative behaviors. On 12/21/12 the BHU notified the facility that Resident #1 will return on 12/21/12. Upon return, Resident #1 will be placed on 1:1 observation with a staff member until the interdisciplinary teams deems the need to make changes. Upon return, the facility will enter into a behavior contract with Resident #1. This contract will include but is not limited to; No sexual gestures, comments or sexually inappropriate behavior will be allowed. The care plan, assessments, behavior monitoring flow record and other risk evaluations will be initiated upon return to the facility. All recommendations and orders on return from BHU will be reviewed with the NP/MD for further orders. On 12/10/12 all current cognitive residents were interviewed and resident questionnaire completed to determine if they had been abused. A body audit was initiated on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. There were no negative outcomes. During the 12/10/12 interview of cognitive residents, Resident #20 stated that she believed she had been previously abused within the facility but currently feels safe and is not afraid of anyone within the facility. An investigation was initiated by the abuse coordinator (ED). A follow up interview was conducted by the ED as part of this investigation. Resident #20 stated that she had been grabbed on her wrist by Resident #1 in the past with no known date of occurrence. On 12/13/12 Resident #20 denied any current concerns since Resident #1 has been discharged . On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. Facility staff also re-in serviced 26 staffs members on abuse reporting. On 12/13/12 the facility notified the state agencies (State Survey Agency and Attorney Generals Office), resident #20's RP and the Physician of the alleged occurrence. The facility was not able to substantiate inappropriate physical contact or abuse. The SSD will visit Resident #20 daily for two (2) days starting 12/13/12 and weekly for two (2) weeks. Resident #20's care plan was updated. Abuse Coordinator will visit with resident #20 once weekly for four weeks starting 12/13/12 to further ensure residents remains comfortable with addressing any issues identified. The NP made rounds and ordered a psychiatric consult due to her observation of Resident #20 attention seeking behaviors. On 12/13/12 there were 41 male residents in the facility. 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. There were no males with physical behavior symptoms directed toward others. On 12/6/12 the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". This policy includes abuse/neglect, staff treatment of [REDACTED]. The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. This change was posted at all three (3) nurse's stations, the time clock and at a central location on wing 1. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The Abuse Coordinator is to be notified for all suspected or reported abuse and neglect. This in-service also included, protecting the victim and one on one monitoring of perpetrator. No employee will be allowed to return to work until they have been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12 the SDC initiated in-servicing licensed nursing staff on assessments, body audits and care planning, notification to MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing twenty four hour report. In Serviced: Assessments Policy - purpose is to identify and document the residents condition/status in efforts to develop a plan of care. Care Plan Policy - purpose is to identify problems and needs that will assist the Interdisciplinary team in providing care. Accident and Incident Policy - purpose is the guide of documenting and investigating occurrences that involve residents. Behavior Management Committee Policy - Purpose is the guide that is used to identify and track behavior(s) that are displayed routinely that may affect the resident(s). Abuse Prevention Policy - Purpose is to define the facilities commitment to protect the residents from abuse from anyone. Notification to MD/RP Policy - Purpose is to inform MD/RP of change in resident's condition. On 12/11/12 the SDC initiated in-servicing for licensed nursing staff concerning resident assessment, documentation, physician/RP notification and following MD orders. On 12/13/12 the interdisciplinary team were in-serviced on the facility behavior management program. On 12/13/12 the DNS in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. Starting 12/11/12 the social service department will visit Resident #9 twice a day for four (4) days, then three (3) times a week for two (2) weeks. The Abuse Coordinator initiated twice a week rounds starting 12/10/12 for four (4) weeks to ensure accessibility to residents and staff on abuse reporting. On 12/13/12 the DNS initiated monitoring of any allegation of abuse and neglect through review of any incident logs for five (5) days per week for four (4) weeks. The results of the findings were reported to the ED. All components of deficiencies cited and corrective action taken thus far were reviewed by the Quality Assurance Committee on 12/12/12 by committee members and facility Medical director. A follow up Quality Assurance meeting was held on 12/14/12 to discuss additional action taken and the conclusion of Resident #20's allegation of abuse and the reporting process. A Quality Assurance Committee meeting was held on 12/20/12 with committee members and the Facility Medical Director to further review polices (no policy changes were noted) and the facilities allegation of compliance as well as monitoring/audit reports with no findings of recurrence of deficient practice. We are alleging that the allegation is removed as of 12/21/12 of all Immediate Jeopardy deficiencies cited." The aforementioned information is quoted in the AoC. Review of the AoC conducted from 12/27/12 at 11:30 a.m. through 12/28/12 at 5:30 p.m., revealed the following information was validated: On 12/6/12, the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The in-service also included protecting the victim and one on one monitoring of perpetrator. No employee was allowed to return to work until they had been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12, the SDC in-serviced licensed nursing staff on assessments, body audits and care planning, notification of MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing 24 hour report. On 12/10/12, the facility interviewed all current cognitive residents and a resident questionnaire was completed to determine if they had been abused. Body audits were initiated by the facility staff on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. On 12/11/12, the Social Service Department (SSD) began visiting Resident #9 twice a day for 4 days, the 3 times a week for 2 weeks. The Abuse Coordinator initiated twice a week rounds on 12/10/12. On 12/11/12, the Staff Develop Coordinator (SDC) in-serviced licensed nursing staff on resident assessment, documentation, physician/RP Notification and following MD orders. On 12/13/12, the facility notified the state agencies (State Survey Agency and Attorney General's Office), Resident #20's Responsible Party and the Physician of the alleged occurrence. The SSD visited Resident #20 daily for 2 days starting 12/13/12 and weekly for 2 weeks. Resident #20's care plan was updated. The Abuse Coordinator visited Resident #20 once weekly beginning 12/13/12. Also on 12/13/12 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. On 12/13/12, the interdisciplinary team was in-serviced on the facility behavior management program. On 12/13/12, the DON in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. On 12/14/12, the DON and Regional Clinical Operations Nurse initiated in-servicing on care planning and investigation procedures. Facility staff re-in-serviced 26 staff members on abuse reporting. Interviews of 13 residents individually on 12/27/12 and 12/28/12 and review of Resident Questionnaires provided by the facility verified that the facility had spoken with each resident regarding abuse/reporting on 12/10/12. The facility performed body audits on 80 non-cognitive residents to determine if any signs of abuse were present as verified by record review of body audits. Interviews of 28 staff members from all 3 shifts on 12/27/12 and 12/28/12 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, care planning, documentation, protection of residents, incident investigation, notification of MD/RP, Abuse Coordinator, behavior management program, 1:1 utilization, resident assessments, and following up on reports of suspected/alleged abuse/neglect. These policies were reviewed as well. Staff members included in these interviews were CNAs, nurses, Administrator, Maintenance Director, Dietary Manager, PT/OT staff, Activities Director, housekeeping, and DON. These in-services were conducted by the facility on the following dates: 12/10/12, 12/11/12, 12/12/12, 12/13/12, 12/14/12, 12/15/12, 12/17/12, 12/20/12, 12/21/12, 12/24/12, and 12/26/12. Review of 15 Resident records on 12/27/12 and 12/28/12 revealed no concerns regarding abuse/neglect or care plans. The facility entered into a Behavior Contract with Resident #1 on 12/21/12. Review of this document verified the contract was signed by Resident #1, the Administrator, and the DON on 12/21/12. Resident #1 was discharged from BHU and returned to the facility on [DATE]. Upon his return, Resident #1 was placed on 1:1 observation with a staff member. The facility entered into a behavior contract with Resident #1 on 12/21/12. The care plan, assessments, behavior monitoring flow record and other risk evaluations were initiated on his return. Resident #1 was also moved from Wing II to Wing III. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/21/12 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. PART 2 Based on observation, record review, staff interview and policy review, the facility failed to ensure that residents with cognitive deficits were provided supervision during smoking, and not allowed to handle fire devices for two (2) of five (5) residents reviewed for smoking (Resident #15 and Resident #18). Findings Include: Group Interview Group interview on 12/5/12 at 3:00 p.m. with six (6) of the facility Residents revealed three (3) of three (3) males expressed concerns with having to watch out for their peers while smoking. Resident #13, Unsampled Residents E and F acknowledged they watch out for their peers when smoking. Record review of the Minimum Data Set (MDS) for Resident #13 showed a cognitive status of not assessed but he was named on the 11/16/12 interviewable list, Unsampled Resident E's cognitive status was listed as severely impaired, but was listed on the 11/16/12 interviewable list. Unsampled Resident F was not listed on the interviewable list, but has a cognitive status of independent. Observation on 12/6/12 at 6:00 p.m., of the gazebo smoking area, revealed three (3) male and two (2) female Residents smoking without any staff present. Resident #15 was noted to be one of the smokers present during the observation. Resident #15 Record review of the December 2012 Physician order [REDACTED]. On 12/6/12 at 5:45 p.m., Resident #15 was observed on the 100-hall self propelling in a wheelchair with a pack of cigarettes and a blue lighter in her right jacket pocket. Record review of Resident #15's cognitive status revealed her quarterly Minimum Data Set (MDS), dated [DATE], with the cognitive status as not assessed. A Nurses Note, dated 9/17/12, revealed the cognitive status as severely impaired. A Social Services progress note for Resident #15, dated 9/19/12, reflected her mood and feeling of being better off dead. Record review of the Smoking Assessment revealed an update of 12/6/12 as an independent smoker. Interview with the Administrator on 12/8/12 at 2:30 p.m., when told of the concerns with the lack of supervision for the smoking Residents and the observation of a lighter on Resident #15, the Administrator acknowledged none of the smokers are supervised during smoking and the smoking schedule is from 6:00 a.m. until 8:00 p.m. in designated smoking areas. Resident #18 Record review of Resident #18 revealed he was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with the Administrator on 12/8/12 at 2:30 p.m., revealed Resident #18 as a smoking resident that was required to wear a smoking apron, but none of the Residents require supervision while smoking. Observation on 12/8/12 at 3:00 p.m. of Resident #18 revealed him in bed with full padded side rails and saying he's tired and wants some peace. Record review of the Departmental Notes for Nursing and Social Services revealed notes, dated 10/9/12, 10/19/12 and 11/27/12, reflected Resident #18 with confusion but also stating he's a smoker with an apron. Record review of Resident #18's Smoking Safety Evaluation, dated 9/24/12, reflected issues with cognitive status and psychiatric concerns but stated he understands the smoking policy. Another Smoking Safety Evaluation dated 12/6/12 after his hospital stay with confusion as a returning [DIAGNOSES REDACTED]. The facility's policy "Smoking", dated 10/09, stated "Smoking is to occur only in designated areas and in accordance with each smoking residents' individualized plan of care based on the Smoking Safety Assessment. All residents who smoke will be assessed for his/her ability to smoke safely, the ability to handle smoking material and the need for supervision while smoking. Residents that are assessed as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials (i.e. cigarettes), and may smoke in designated areas without limitations. The resident may be permitted to keep fire materials on his/her person during waking hours if deemed appropriate per smoking assessment. Residents found to have modified independence with smoking: may be subject to smoking limitations. Limitations may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products, assistance to hold cigarette, supervised smoking by staff and/or other protective/safety measures as determined appropriate by the individualized plan of care based on the smoking assessment."

Based on record review, staff interview and policy review, the systematic failure to implement the abuse protocol, protect, investigate, report, notify, care plan and adequately supervise residents with identified sexual inappropriate behaviors, and to ensure residents were free from abuse, deemed that the facility was not administered in a manner to maintain the highest practicable mental and psychosocial well being for three (3) of twenty-seven (27) residents reviewed (Residents #1, #9 and #20). An annual survey was conducted from 12/5/12 to 12/8/12; an extended survey was conducted from 12/7/12 to 12/8/12. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 12/7/12 at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on 12/7/12. The IJ was determined to begin on 9/17/12. The facility submitted the first (1st) Allegation of Compliance (AoC) on 12/7/12 at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on 12/8/12 at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on 12/8/12 at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on 12/8/12, and is considered ongoing. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. Cross refer to tag F-224 for the facility's failure to develop interventions and monitor Resident #1 for a known inappropriate sexual behavior. Cross refer to tag F-225 for the facility's failure to report to the State Agency Resident to Resident sexual abuse for Residents #1, #9, and #20. Cross refer to F-226 for the facility's failure to prevent, identify, investigate, protect, and report an incident of Resident on Resident sexual abuse for Resident #9 and Resident #20. Cross refer to F-279 for the facility's failure to update Resident #1's Care Plan to address interventions and concerns for his sexual inappropriate behaviors or his expressed desires for sex. Cross refer to F-323 for the facility's failure to provide adequate supervision of Resident #1 to ensure an environment free from potential reoccurrence of sexual inappropriate behavior (of touching another Resident breast).

Based on the survey results dated 12/8/12, the systematic failure to implement the abuse protocol, protect, investigate, report, notify, care plan and adequately supervise residents with identified sexual inappropriate behaviors, and to ensure residents were free from abuse, deemed that the facility was not administered in a manner to maintain the highest practicable mental and psychosocial well being for three (3) of twenty-seven (27) residents reviewed (Residents #1, #9 and #20). This was deemed an Immediate Jeopardy (IJ) on 12/7/12 at 1:30 p.m. A revisit survey was conducted on 12/27-28/12 to validate the Allegation of Compliance (AoC). The IJ which began on 12/7/12 was determined to be removed on 12/21/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 12/21/12. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings Include: Cross refer to tag F-157 for the facility's failure to notify the Primary Physician and the Responsible Party of a witnessed incident of resident on resident sexual abuse for Resident #9. Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9 shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of 13 female Residents reviewed (Residents #9 and #20). Cross refer to tag F-224 for the facility's failure to develop interventions and monitor Resident #1 for a known inappropriate sexual behavior. Cross refer to tag F-225 for the facility's failure to report to the State Agency Resident to Resident sexual abuse for residents #1, #9 and #20. Cross refer to tag F-226 for the facility's failure to prevent, identify, investigate, protect and report an incident of Resident on Resident sexual abuse for Resident #9 and Resident #20. Cross refer to tag F-279 for the facility's failure to update Resident #1 Care Plan to address interventions and concerns for his sexual inappropriate behaviors or his expressed desires for sex. Cross refer to tag F-323 for the facility's failure to provide adequate supervision of Resident #1 to ensure an environment free from potential reoccurrence of sexual inappropriate behavior (of touching another Resident breast). The facility provided an Allegation of Compliance (AoC) that was accepted on 12/27/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy (IJ). Information contained in the Credible AoC, submitted by the facility, revealed: "On 9/17/12 at approximately 12:39 p.m. CNA #2 reported to (licensed practical nurse) LPN #2 an observation of Resident #1 with his hand down Resident #9's shirt, rubbing her breast (inappropriate behavior/physical contact). At that time, LPN #2 walked down the hallway and approached Resident #1, who rolled his wheelchair to his room. LPN #2 moved Resident #9 closer to Resident #9's room and performed an interview and determined no negative outcomes related to occurrence. LPN #2 failed to document this interview and observations in the Medical Record. LPN #2 was in-serviced on failure to document in medical record on 12/11/12. Resident #9 had a skin audit conducted on 9/18/12 which revealed no visible bruising, redness or signs of trauma. Resident #1 and Resident #9 have the same primary Physician and Nurse Practitioner (NP). The NP was notified of the incident between Resident #1 and Resident #9 on 9/17/12. Physicians telephone order to transfer Resident #1 to Behavioral Health Unit (BHU) was received and written at 12:51 p.m. The NP notified Resident #1 and Resident #9's primary Physician after the 9/17/12 incident (date uncertain). On 9/17/12 at approximately 12:39 p.m. the facility failed to place Resident #1 on one (1) on one (1) observation until he was transferred to the BHU on 9/18/12 at 11:50 am. Resident #1 was sent to a BHU on 9/18/12 for behaviors (related to his inappropriate sexual contact with Resident #9). On 9/17/12 LPN #4 ( Unit Manager) failed to initiate an investigation and complete a documented assessment on Resident #9, protect Resident #9 by placing Resident #1 on one on one (1:1) observation, notify Resident #9's responsible party (RP), notify primary Physician for Resident #1 and Resident #9, care planning occurrence for Resident #1 and Resident #9, notify the Director of Nursing (DNS) and the Executive Director (ED). Due to LPN #4's ( Unit Manager) noted failures, LPN#4 (Unit Manager) was placed on suspension on 12/7/12 regarding Resident #1 and Residents #9's incident. Subsequently, written disciplinary action and re-education on abuse and reporting , abuse coordinator, behavior management program, incident investigation, documentation, one on one (1:1) utilization, resident assessments and care planning were completed on 12/13/12. On 9/17/12 at approximately 2:30 p.m. Social Service (SS#1) interviewed Resident #9. At that time Resident #9 stated that she was OK. Resident #9 was pleasant with no recollection of the 9/17/12 incident. On 9/18/12 SS#1 again interviewed Resident #9. At that time Resident #9 was pleasant with no recollection of the 9/17/12 incident. SS #1 failed to document the 9/17/12 and the 9/18/12 interviews with Resident #9 in the medical record. The DNS and ED were notified of inappropriate behavior/sexual contact between Resident #1 and Resident #9 on 12/6/12. On 12/6/12 the facility initiated an investigation concerning inappropriate sexual contact between Resident #1 and Resident #9. This investigation was initiated by the DNS and ED. The facility substantiated that inappropriate sexual contact was made by Resident #1 to Resident #9. On 12/6/12 at approximately 2:30 p.m. the Abuse Coordinator in the facility was changed from SS#1 to Executive Director. Executive Director and Director of Nursing were in serviced on reporting procedures and regulations by Facility Vice President on 12/11/12. On 12/6/12, SS#1 interviewed Resident #9 and at that time Resident #9 was noted to be pleasant with no recollection of the 9/17/12 incident. On 12/6/12, SS#1 was suspended pending investigation. SS#1 was issued corrective counseling on 12/13/12 for the failure to document Resident #9's interviews and failure to report incident. Subsequently, SS#1 received re-education on 12/13/12 including abuse and reporting, documentation of incidents/investigations, Medical Director (MD) and Responsible Party (RP) Notification, resident assessment and care planning, behavior management program and one on one (1:1) utilization. On 12/6/12 Resident #9's care plan was updated to include "potential to be abused". Resident #9's Responsible Party (RP) was notified on 12/8/12 that Resident #1 had placed his hand inside of Resident #9's shirt on 9/17/12. On 10/2/12 Resident #1 returned to the facility from the BHU with recommendations to follow up with his Physician for medical conditions and psychiatric services. The facility failed to document notification to Physician of BHU recommendation. Resident #1's 10/2/12 readmission orders [REDACTED]. On 10/2/12 Resident #1 returned to the facility from the BHU and at that time was placed on a "Behavior Monthly Flow Record" for "Danger to others". The facility failed to update Resident #1's care plan on 9/17/12 related to inappropriate sexual contact with Resident #9. On 10/10/12 Resident #1's care plan was updated to include "Inappropriate sexual behaviors". Resident #1 was observed for potential "Danger to others" behaviors with documentation on the "Behavior Intervention Monthly Flow" record from 10/2/12-12/7/12. Resident #1 was evaluated by NP on 10/18/12 with no new recommendation. Resident #1 was monitored for "Danger to others" behaviors until discharged from the facility on 12/7/12. Review of the "Behavior Intervention Monthly Flow" records dated, 10/2/12-12/7/12, revealed no documented behaviors noted or negative outcomes. On 12/7/12 at 1:35 p.m. Resident #1 was placed on 1:1 with CNA #2 until 3:00 p.m. At 3:00 p.m. CNA #3 began 1:1 observation of Resident #1 until 6:40 p.m. which was when Resident #1 was transferred and discharged to the BHU. The 1:1 was documented with no negative behaviors. On 12/21/12 the BHU notified the facility that Resident #1 will return on 12/21/12. Upon return, Resident #1 will be placed on 1:1 observation with a staff member until the interdisciplinary teams deems the need to make changes. Upon return, the facility will enter into a behavior contract with Resident #1. This contract will include but is not limited to; No sexual gestures, comments or sexually inappropriate behavior will be allowed. The care plan, assessments, behavior monitoring flow record and other risk evaluations will be initiated upon return to the facility. All recommendations and orders on return from BHU will be reviewed with the NP/MD for further orders. On 12/10/12 all current cognitive residents were interviewed and resident questionnaire completed to determine if they had been abused. A body audit was initiated on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. There were no negative outcomes. During the 12/10/12 interview of cognitive residents, Resident #20 stated that she believed she had been previously abused within the facility but currently feels safe and is not afraid of anyone within the facility. An investigation was initiated by the abuse coordinator (ED). A follow up interview was conducted by the ED as part of this investigation. Resident #20 stated that she had been grabbed on her wrist by Resident #1 in the past with no known date of occurrence. On 12/13/12 Resident #20 denied any current concerns since Resident #1 has been discharged . On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. Facility staff also re-in serviced 26 staffs members on abuse reporting. On 12/13/12 the facility notified the state agencies (State Survey Agency and Attorney Generals Office), resident #20's RP and the Physician of the alleged occurrence. The facility was not able to substantiate inappropriate physical contact or abuse. The SSD will visit Resident #20 daily for two (2) days starting 12/13/12 and weekly for two (2) weeks. Resident #20's care plan was updated. Abuse Coordinator will visit with resident #20 once weekly for four weeks starting 12/13/12 to further ensure residents remains comfortable with addressing any issues identified. The NP made rounds and ordered a psychiatric consult due to her observation of Resident #20 attention seeking behaviors. On 12/13/12 there were 41 male residents in the facility. 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. There were no males with physical behavior symptoms directed toward others. On 12/6/12 the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". This policy includes abuse/neglect, staff treatment of [REDACTED]. The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. This change was posted at all three (3) nurse's stations, the time clock and at a central location on wing 1. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The Abuse Coordinator is to be notified for all suspected or reported abuse and neglect. This in-service also included, protecting the victim and one on one monitoring of perpetrator. No employee will be allowed to return to work until they have been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12 the SDC initiated in-servicing licensed nursing staff on assessments, body audits and care planning, notification to MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing twenty four hour report. In Serviced: Assessments Policy - purpose is to identify and document the residents condition/status in efforts to develop a plan of care. Care Plan Policy - purpose is to identify problems and needs that will assist the Interdisciplinary team in providing care. Accident and Incident Policy - purpose is the guide of documenting and investigating occurrences that involve residents. Behavior Management Committee Policy - Purpose is the guide that is used to identify and track behavior(s) that are displayed routinely that may affect the resident(s). Abuse Prevention Policy - Purpose is to define the facilities commitment to protect the residents from abuse from anyone. Notification to MD/RP Policy - Purpose is to inform MD/RP of change in resident's condition. On 12/11/12 the SDC initiated in-servicing for licensed nursing staff concerning resident assessment, documentation, physician/RP notification and following MD orders. On 12/13/12 the interdisciplinary team were in-serviced on the facility behavior management program. On 12/13/12 the DNS in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. Starting 12/11/12 the social service department will visit Resident #9 twice a day for four (4) days, then three (3) times a week for two (2) weeks. The Abuse Coordinator initiated twice a week rounds starting 12/10/12 for four (4) weeks to ensure accessibility to residents and staff on abuse reporting. On 12/13/12 the DNS initiated monitoring of any allegation of abuse and neglect through review of any incident logs for five (5) days per week for four (4) weeks. The results of the findings were reported to the ED. All components of deficiencies cited and corrective action taken thus far were reviewed by the Quality Assurance Committee on 12/12/12 by committee members and facility Medical director. A follow up Quality Assurance meeting was held on 12/14/12 to discuss additional action taken and the conclusion of Resident #20's allegation of abuse and the reporting process. A Quality Assurance Committee meeting was held on 12/20/12 with committee members and the Facility Medical Director to further review polices (no policy changes were noted) and the facilities allegation of compliance as well as monitoring/audit reports with no findings of recurrence of deficient practice. We are alleging that the allegation is removed as of 12/21/12 of all Immediate Jeopardy deficiencies cited." The aforementioned information is quoted in the AoC. Review of the AoC conducted from 12/27/12 at 11:30 a.m. through 12/28/12 at 5:30 p.m., revealed the following information was validated: On 12/6/12, the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The in-service also included protecting the victim and one on one monitoring of perpetrator. No employee was allowed to return to work until they had been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12, the SDC in-serviced licensed nursing staff on assessments, body audits and care planning, notification of MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing 24 hour report. On 12/10/12, the facility interviewed all current cognitive residents and a resident questionnaire was completed to determine if they had been abused. Body audits were initiated by the facility staff on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. On 12/11/12, the Social Service Department (SSD) began visiting Resident #9 twice a day for 4 days, the 3 times a week for 2 weeks. The Abuse Coordinator initiated twice a week rounds on 12/10/12. On 12/11/12, the Staff Develop Coordinator (SDC) in-serviced licensed nursing staff on resident assessment, documentation, physician/RP Notification and following MD orders. On 12/13/12, the facility notified the state agencies (State Survey Agency and Attorney General's Office), Resident #20's Responsible Party and the Physician of the alleged occurrence. The SSD visited Resident #20 daily for 2 days starting 12/13/12 and weekly for 2 weeks. Resident #20's care plan was updated. The Abuse Coordinator visited Resident #20 once weekly beginning 12/13/12. Also on 12/13/12 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. On 12/13/12, the interdisciplinary team was in-serviced on the facility behavior management program. On 12/13/12, the DON in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. On 12/14/12, the DON and Regional Clinical Operations Nurse initiated in-servicing on care planning and investigation procedures. Facility staff re-in-serviced 26 staff members on abuse reporting. Interviews of 13 residents individually on 12/27/12 and 12/28/12 and review of Resident Questionnaires provided by the facility verified that the facility had spoken with each resident regarding abuse/reporting on 12/10/12. The facility performed body audits on 80 non-cognitive residents to determine if any signs of abuse were present as verified by record review of body audits. Interviews of 28 staff members from all 3 shifts on 12/27/12 and 12/28/12 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, care planning, documentation, protection of residents, incident investigation, notification of MD/RP, Abuse Coordinator, behavior management program, 1:1 utilization, resident assessments, and following up on reports of suspected/alleged abuse/neglect. These policies were reviewed as well. Staff members included in these interviews were CNAs, nurses, Administrator, Maintenance Director, Dietary Manager, PT/OT staff, Activities Director, housekeeping, and DON. These in-services were conducted by the facility on the following dates: 12/10/12, 12/11/12, 12/12/12, 12/13/12, 12/14/12, 12/15/12, 12/17/12, 12/20/12, 12/21/12, 12/24/12, and 12/26/12. Review of 15 Resident records on 12/27/12 and 12/28/12 revealed no concerns regarding abuse/neglect or care plans. The facility entered into a Behavior Contract with Resident #1 on 12/21/12. Review of this document verified the contract was signed by Resident #1, the Administrator, and the DON on 12/21/12. Resident #1 was discharged from BHU and returned to the facility on [DATE]. Upon his return, Resident #1 was placed on 1:1 observation with a staff member. The facility entered into a behavior contract with Resident #1 on 12/21/12. The care plan, assessments, behavior monitoring flow record and other risk evaluations were initiated on his return. Resident #1 was also moved from Wing II to Wing III. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/21/12 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee.

Based on observation, staff interview, record review and facility policy review, the facility failed to notify the Primary Physician and the Responsible Party of a witnessed incident of resident on resident sexual abuse for one (1) of 27 residents reviewed (Resident #9). An annual survey was conducted from 12/5/12 to 12/8/12; an extended survey was conducted from 12/7/12 to 12/8/12. During the extended survey, the facility was found not to be in compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 12/7/12 at 1:30 p.m. The Facility Administrator and the Director of Nursing (DON) were subsequently notified of the IJ at 1:30 p.m. on 12/7/12. The IJ was determined to begin on 9/17/12. The facility submitted the first (1st) Allegation of Compliance (AoC) on 12/7/12 at 4:36 p.m. It was determined not to be acceptable. A second (2nd) AoC was submitted on 12/8/12 at 9:05 a.m. It was determined not to be acceptable. A third (3rd) AoC was submitted on 12/8/12 at 2:45 p.m. It was determined not to be acceptable. The IJ was not removed upon exit from the facility on 12/8/12, and is considered ongoing. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9's shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. Review of the facility's "Notification of a change in Resident's condition-Physician", documented "The attending physician will be notified of a change in a Resident's condition by license nurse, per standards of practice and Federal and/or State Regulations. 1. Guideline for notification of physician: e. Any accident or incident ( per Federal and State regulations)." Review of the facility's "Notification of change in Resident's Condition-Responsible Party", documented "A family member or responsible party is made aware of a change in a resident's condition by licensed personnel as warranted."

Based on the survey results dated 12/8/12, the facility failed to prevent, identify, investigate, protect, and report an incident of Resident on Resident sexual abuse for two (2) of twenty-seven (27) residents reviewed (Resident #9 and Resident #20). This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 12/7/12 at 1:30 p.m. A revisit survey was conducted on 12/27-28/12 to validate the Allegation of Compliance (AoC). The IJ which began on 12/7/12 was determined to be removed on 12/21/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 12/21/12. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings Include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #9) from sexual abuse by Resident #1. Resident #1 was observed by staff with his hand down in Resident #9 shirt, rubbing on her breasts. The facility also failed to ensure that Resident #20 was free from sexual advances and comments made by Resident #1, which made her feel very uncomfortable. This was for two (2) of 13 female Residents reviewed (Residents #9 and #20). The facility provided an Allegation of Compliance (AoC) that was accepted on 12/27/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy (IJ). Information contained in the Credible AoC, submitted by the facility, revealed: "On 9/17/12 at approximately 12:39 p.m. CNA #2 reported to (licensed practical nurse) LPN #2 an observation of Resident #1 with his hand down Resident #9's shirt, rubbing her breast (inappropriate behavior/physical contact). At that time, LPN #2 walked down the hallway and approached Resident #1, who rolled his wheelchair to his room. LPN #2 moved Resident #9 closer to Resident #9's room and performed an interview and determined no negative outcomes related to occurrence. LPN #2 failed to document this interview and observations in the Medical Record. LPN #2 was in-serviced on failure to document in medical record on 12/11/12. Resident #9 had a skin audit conducted on 9/18/12 which revealed no visible bruising, redness or signs of trauma. Resident #1 and Resident #9 have the same primary Physician and Nurse Practitioner (NP). The NP was notified of the incident between Resident #1 and Resident #9 on 9/17/12. Physicians telephone order to transfer Resident #1 to Behavioral Health Unit (BHU) was received and written at 12:51 p.m. The NP notified Resident #1 and Resident #9's primary Physician after the 9/17/12 incident (date uncertain). On 9/17/12 at approximately 12:39 p.m. the facility failed to place Resident #1 on one (1) on one (1) observation until he was transferred to the BHU on 9/18/12 at 11:50 am. Resident #1 was sent to a BHU on 9/18/12 for behaviors (related to his inappropriate sexual contact with Resident #9). On 9/17/12 LPN #4 ( Unit Manager) failed to initiate an investigation and complete a documented assessment on Resident #9, protect Resident #9 by placing Resident #1 on one on one (1:1) observation, notify Resident #9's responsible party (RP), notify primary Physician for Resident #1 and Resident #9, care planning occurrence for Resident #1 and Resident #9, notify the Director of Nursing (DNS) and the Executive Director (ED). Due to LPN #4's ( Unit Manager) noted failures, LPN#4 (Unit Manager) was placed on suspension on 12/7/12 regarding Resident #1 and Residents #9's incident. Subsequently, written disciplinary action and re-education on abuse and reporting , abuse coordinator, behavior management program, incident investigation, documentation, one on one (1:1) utilization, resident assessments and care planning were completed on 12/13/12. On 9/17/12 at approximately 2:30 p.m. Social Service (SS#1) interviewed Resident #9. At that time Resident #9 stated that she was OK. Resident #9 was pleasant with no recollection of the 9/17/12 incident. On 9/18/12 SS#1 again interviewed Resident #9. At that time Resident #9 was pleasant with no recollection of the 9/17/12 incident. SS #1 failed to document the 9/17/12 and the 9/18/12 interviews with Resident #9 in the medical record. The DNS and ED were notified of inappropriate behavior/sexual contact between Resident #1 and Resident #9 on 12/6/12. On 12/6/12 the facility initiated an investigation concerning inappropriate sexual contact between Resident #1 and Resident #9. This investigation was initiated by the DNS and ED. The facility substantiated that inappropriate sexual contact was made by Resident #1 to Resident #9. On 12/6/12 at approximately 2:30 p.m. the Abuse Coordinator in the facility was changed from SS#1 to Executive Director. Executive Director and Director of Nursing were in serviced on reporting procedures and regulations by Facility Vice President on 12/11/12. On 12/6/12, SS#1 interviewed Resident #9 and at that time Resident #9 was noted to be pleasant with no recollection of the 9/17/12 incident. On 12/6/12, SS#1 was suspended pending investigation. SS#1 was issued corrective counseling on 12/13/12 for the failure to document Resident #9's interviews and failure to report incident. Subsequently, SS#1 received re-education on 12/13/12 including abuse and reporting, documentation of incidents/investigations, Medical Director (MD) and Responsible Party (RP) Notification, resident assessment and care planning, behavior management program and one on one (1:1) utilization. On 12/6/12 Resident #9's care plan was updated to include "potential to be abused". Resident #9's Responsible Party (RP) was notified on 12/8/12 that Resident #1 had placed his hand inside of Resident #9's shirt on 9/17/12. On 10/2/12 Resident #1 returned to the facility from the BHU with recommendations to follow up with his Physician for medical conditions and psychiatric services. The facility failed to document notification to Physician of BHU recommendation. Resident #1's 10/2/12 readmission orders [REDACTED]. On 10/2/12 Resident #1 returned to the facility from the BHU and at that time was placed on a "Behavior Monthly Flow Record" for "Danger to others". The facility failed to update Resident #1's care plan on 9/17/12 related to inappropriate sexual contact with Resident #9. On 10/10/12 Resident #1's care plan was updated to include "Inappropriate sexual behaviors". Resident #1 was observed for potential "Danger to others" behaviors with documentation on the "Behavior Intervention Monthly Flow" record from 10/2/12-12/7/12. Resident #1 was evaluated by NP on 10/18/12 with no new recommendation. Resident #1 was monitored for "Danger to others" behaviors until discharged from the facility on 12/7/12. Review of the "Behavior Intervention Monthly Flow" records dated, 10/2/12-12/7/12, revealed no documented behaviors noted or negative outcomes. On 12/7/12 at 1:35 p.m. Resident #1 was placed on 1:1 with CNA #2 until 3:00 p.m. At 3:00 p.m. CNA #3 began 1:1 observation of Resident #1 until 6:40 p.m. which was when Resident #1 was transferred and discharged to the BHU. The 1:1 was documented with no negative behaviors. On 12/21/12 the BHU notified the facility that Resident #1 will return on 12/21/12. Upon return, Resident #1 will be placed on 1:1 observation with a staff member until the interdisciplinary teams deems the need to make changes. Upon return, the facility will enter into a behavior contract with Resident #1. This contract will include but is not limited to; No sexual gestures, comments or sexually inappropriate behavior will be allowed. The care plan, assessments, behavior monitoring flow record and other risk evaluations will be initiated upon return to the facility. All recommendations and orders on return from BHU will be reviewed with the NP/MD for further orders. On 12/10/12 all current cognitive residents were interviewed and resident questionnaire completed to determine if they had been abused. A body audit was initiated on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. There were no negative outcomes. During the 12/10/12 interview of cognitive residents, Resident #20 stated that she believed she had been previously abused within the facility but currently feels safe and is not afraid of anyone within the facility. An investigation was initiated by the abuse coordinator (ED). A follow up interview was conducted by the ED as part of this investigation. Resident #20 stated that she had been grabbed on her wrist by Resident #1 in the past with no known date of occurrence. On 12/13/12 Resident #20 denied any current concerns since Resident #1 has been discharged . On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. Facility staff also re-in serviced 26 staffs members on abuse reporting. On 12/13/12 the facility notified the state agencies (State Survey Agency and Attorney Generals Office), resident #20's RP and the Physician of the alleged occurrence. The facility was not able to substantiate inappropriate physical contact or abuse. The SSD will visit Resident #20 daily for two (2) days starting 12/13/12 and weekly for two (2) weeks. Resident #20's care plan was updated. Abuse Coordinator will visit with resident #20 once weekly for four weeks starting 12/13/12 to further ensure residents remains comfortable with addressing any issues identified. The NP made rounds and ordered a psychiatric consult due to her observation of Resident #20 attention seeking behaviors. On 12/13/12 there were 41 male residents in the facility. 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. There were no males with physical behavior symptoms directed toward others. On 12/6/12 the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". This policy includes abuse/neglect, staff treatment of [REDACTED]. The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. This change was posted at all three (3) nurse's stations, the time clock and at a central location on wing 1. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The Abuse Coordinator is to be notified for all suspected or reported abuse and neglect. This in-service also included, protecting the victim and one on one monitoring of perpetrator. No employee will be allowed to return to work until they have been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12 the SDC initiated in-servicing licensed nursing staff on assessments, body audits and care planning, notification to MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing twenty four hour report. In Serviced: Assessments Policy - purpose is to identify and document the residents condition/status in efforts to develop a plan of care. Care Plan Policy - purpose is to identify problems and needs that will assist the Interdisciplinary team in providing care. Accident and Incident Policy - purpose is the guide of documenting and investigating occurrences that involve residents. Behavior Management Committee Policy - Purpose is the guide that is used to identify and track behavior(s) that are displayed routinely that may affect the resident(s). Abuse Prevention Policy - Purpose is to define the facilities commitment to protect the residents from abuse from anyone. Notification to MD/RP Policy - Purpose is to inform MD/RP of change in resident's condition. On 12/11/12 the SDC initiated in-servicing for licensed nursing staff concerning resident assessment, documentation, physician/RP notification and following MD orders. On 12/13/12 the interdisciplinary team were in-serviced on the facility behavior management program. On 12/13/12 the DNS in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. Starting 12/11/12 the social service department will visit Resident #9 twice a day for four (4) days, then three (3) times a week for two (2) weeks. The Abuse Coordinator initiated twice a week rounds starting 12/10/12 for four (4) weeks to ensure accessibility to residents and staff on abuse reporting. On 12/13/12 the DNS initiated monitoring of any allegation of abuse and neglect through review of any incident logs for five (5) days per week for four (4) weeks. The results of the findings were reported to the ED. All components of deficiencies cited and corrective action taken thus far were reviewed by the Quality Assurance Committee on 12/12/12 by committee members and facility Medical director. A follow up Quality Assurance meeting was held on 12/14/12 to discuss additional action taken and the conclusion of Resident #20's allegation of abuse and the reporting process. A Quality Assurance Committee meeting was held on 12/20/12 with committee members and the Facility Medical Director to further review polices (no policy changes were noted) and the facilities allegation of compliance as well as monitoring/audit reports with no findings of recurrence of deficient practice. We are alleging that the allegation is removed as of 12/21/12 of all Immediate Jeopardy deficiencies cited." The aforementioned information is quoted in the AoC. Review of the AoC conducted from 12/27/12 at 11:30 a.m. through 12/28/12 at 5:30 p.m., revealed the following information was validated: On 12/6/12, the Staff Development Coordinator (SDC) began in-servicing all staff on the facility policy "Abuse Prevention". The in-services also included the change in the Abuse Coordinator in the facility from the Social Service Director to the Administrator. In the Administrator's absence the Director of Nursing is designated as the Abuse Coordinator. The in-service also included protecting the victim and one on one monitoring of perpetrator. No employee was allowed to return to work until they had been in-serviced on abuse/neglect and change of Abuse Coordinator. On 12/10/12, the SDC in-serviced licensed nursing staff on assessments, body audits and care planning, notification of MD/RP of change in resident status (behaviors), incident reporting and documentation on the nursing 24 hour report. On 12/10/12, the facility interviewed all current cognitive residents and a resident questionnaire was completed to determine if they had been abused. Body audits were initiated by the facility staff on 12/10/12 on 80 non-cognitive residents based on their Brief Interview for Mental Status (BIMS) score to determine if any signs of abuse were prevalent. On 12/11/12, the Social Service Department (SSD) began visiting Resident #9 twice a day for 4 days, the 3 times a week for 2 weeks. The Abuse Coordinator initiated twice a week rounds on 12/10/12. On 12/11/12, the Staff Develop Coordinator (SDC) in-serviced licensed nursing staff on resident assessment, documentation, physician/RP Notification and following MD orders. On 12/13/12, the facility notified the state agencies (State Survey Agency and Attorney General's Office), Resident #20's Responsible Party and the Physician of the alleged occurrence. The SSD visited Resident #20 daily for 2 days starting 12/13/12 and weekly for 2 weeks. Resident #20's care plan was updated. The Abuse Coordinator visited Resident #20 once weekly beginning 12/13/12. Also on 12/13/12 41 of 41 male residents were reviewed for any physical behavioral symptoms directed toward others. On 12/13/12, the interdisciplinary team was in-serviced on the facility behavior management program. On 12/13/12, the DON in-serviced the unit managers to ensure compliance on hospital return physician orders [REDACTED]. On 12/14/12, 19 cognitive residents throughout the facility were re-interviewed to ensure no other abuse allegations existed. On 12/14/12, the DON and Regional Clinical Operations Nurse initiated in-servicing on care planning and investigation procedures. Facility staff re-in-serviced 26 staff members on abuse reporting. Interviews of 13 residents individually on 12/27/12 and 12/28/12 and review of Resident Questionnaires provided by the facility verified that the facility had spoken with each resident regarding abuse/reporting on 12/10/12. The facility performed body audits on 80 non-cognitive residents to determine if any signs of abuse were present as verified by record review of body audits. Interviews of 28 staff members from all 3 shifts on 12/27/12 and 12/28/12 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, care planning, documentation, protection of residents, incident investigation, notification of MD/RP, Abuse Coordinator, behavior management program, 1:1 utilization, resident assessments, and following up on reports of suspected/alleged abuse/neglect. These policies were reviewed as well. Staff members included in these interviews were CNAs, nurses, Administrator, Maintenance Director, Dietary Manager, PT/OT staff, Activities Director, housekeeping, and DON. These in-services were conducted by the facility on the following dates: 12/10/12, 12/11/12, 12/12/12, 12/13/12, 12/14/12, 12/15/12, 12/17/12, 12/20/12, 12/21/12, 12/24/12, and 12/26/12. Review of 15 Resident records on 12/27/12 and 12/28/12 revealed no concerns regarding abuse/neglect or care plans. The facility entered into a Behavior Contract with Resident #1 on 12/21/12. Review of this document verified the contract was signed by Resident #1, the Administrator, and the DON on 12/21/12. Resident #1 was discharged from BHU and returned to the facility on [DATE]. Upon his return, Resident #1 was placed on 1:1 observation with a staff member. The facility entered into a behavior contract with Resident #1 on 12/21/12. The care plan, assessments, behavior monitoring flow record and other risk evaluations were initiated on his return. Resident #1 was also moved from Wing II to Wing III. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/21/12 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee.