Every finding on record at Orchard Health and Rehabilitation

Based on interviews, record reviews, and review of the policy titled, Abuse Prohibition, the facility failed to ensure one cognitively impaired resident (R48) was free from sexual and physical abuse from one resident (R121) who had a history of sexually inappropriate behaviors, and history of being agitated and hostile. The sample size was 36. On 3/31/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The Senior Director of Clinical Standards, Director of Quality and Regulatory Services, Director of Nursing (DON), and Assistant Administrator were informed of the Immediate Jeopardy (IJ) on 3/31/2025 at 10:45 am. The noncompliance related to the IJ was identified to have existed on 9/28/2024 when R121 sexually and physically abused R48 inside her room. A Credible Allegation of Compliance was received on 3/31/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed as of 4/1/2025. The facility remains out of compliance while the facility continues management level oversight as well as continuing to develop and implement a Plan of Correction. (POC). This oversight process included the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to Abuse, Neglect, and Exploitation, and the behavioral health needs of residents. Findings include: The facility policy titled Abuse Prohibition, undated, stated it is the intent of this center to actively protect each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 3. Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. 4. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Once an injury or event is identified as suspicious and may constitute abuse, the center will follow the investigation procedures. Identification of patients whose behavior is abusive to other patients. If a patient is identified in one of the following categories, a thorough assessment will be completed to include any identified situations or factors that triggers abusive behavior. Patients whose personal histories render them at risk for abusing other patients. Patients who have displayed abusive behavior toward other patients. ii. From the assessment, intervention strategies will be developed on the care plan or behavior management plan to prevent occurrences including monitoring for factors that trigger abusive behavior for this patient. 1.Record review of the Electronic Medical Record (EMR) for R48 revealed the following diagnoses, but not limited to, schizoaffective disorder, bipolar disorder, Alzheimer's, and major depressive disorder. Record review of the prior Significant Change Minimum Data Set (MDS) assessment for R48 dated 10/2/2024 assessed a Brief Interview Mental Status Score (BIMS) of seven, which indicates moderate cognitive impairment (a score of seven out of 15). R48 was also assessed on the MDS assessment as being independent for ambulation, requiring supervision to partial moderate assistance for Activities of Daily Living (ADLs). R48 resided on B Hall in the facility. Record review of a skin assessment for R48 completed on 9/30/2024 revealed a bruise to the right hip. 2. Record review of the EMR for R121 revealed that he had diagnoses that included, but were not limited to, anxiety disorder, unspecified, and mild intellectual disabilities. A new diagnosis of hypersexuality was identified on 10/23/2023 by the Nurse Practitioner (NP). Record review of the Quarterly MDS Assessment for R121 dated 7/13/2024 revealed that a BIMS score was assessed as a three, which indicates severe cognitive impairment (a BIMS score of three out of 15) and being independent and/or being provided with supervision for ADLs, including ambulation. However, during a psychiatric follow-up visit on 8/21/2024, the physician transcribed a BIMS of seven on this day. R121 resided on C Hall in the facility. A review of Nurse's notes for R121 dated 10/21/2023 revealed, Resident up yelling and going door to door trying to exit. Impulsive, approaching staff stating What you doing? What's your name? I love you! I wanna {sic} make love to you! Trying to enter other resident's rooms. Manic laughing. Is currently standing at nurse station window yelling and laughing stating I wanna {sic) go home! I'm crazy about you! I wanna {sic} make love!. On call nurse notified and she ordered 0.5 mg IM (0.5 milligram intramuscular) Ativan q 6 hours (every six hours). Med pulled from e (emergency)-kit and administered to left glute; resident tolerated well but so far is not effective. Record review of the NP Progress Notes for R121 dated 10/23/2023, documented diagnosis of hypersexuality. The recommendation documented stated hormone treatment, and the R121 is currently receiving Ativan. Record review of Progress Notes dated 12/10/2023 documented Certified Nursing Assistant (CNA) went into R121 room to get the patient up/ R121 got up and punched the CNA in the stomach. Record review of the care plan for R121 last reviewed 6/5/2024, documented an identifying problem of inappropriate sexual Behaviors, verbal behavioral symptoms directed toward others /wandering. The intervention noted was to assess patterns of behavior with behavior monitoring. A review of a psychiatric behavior consult note for R121, dated 8/21/2024, documented an incident of inappropriate, sexually aggressive behaviors displayed by R121. The note stated, staff requested a visit today, staff reports that resident was talking inappropriately in a sexual manner, towards staff, this morning, aeb {sic} wanting sex, trying to kiss a staff member, and stating that he was going to rape her, staff reports that he was hit the nurse in the head, and started kicking her. Recommendation to monitor sexual behaviors and new diagnoses of hypersexuality. A review of a Facility Incident Report Form, dated 9/28/2024, that documented an allegation of resident-to-resident abuse had occurred on 9/28/2024 at 8:40 pm. The form included that the Licensed Practical Nurse (LPN) CC reported an inappropriate act between R121 and R48, with R121 listed as the perpetrator. A further review of the form revealed that the LPN CC heard a scream from R48 room, she entered the room, observed R48 on the floor and R121 on top of her. R121 was observed holding his hands over R48 's mouth and his hands in her brief. She separated the resident, and skin assessments were completed on both residents with no injuries noted. The physician, the responsible parties, and law enforcement were notified. A review of the accompanying investigation that included employee and resident interviews, police reports, and the facility's follow-up summary conclusion revealed evidence that the allegation had occurred. A review of the hospital records for R48 dated 9/28/2024 documented a reported sexually assaulted; she was fondled (contact, hand on the vaginal area. No penetration). The patient complains of mild pain. No blow to the head, loss of consciousness, or alcohol consumed. Not dazed. The patient reports that another nursing home resident pushed her off her bed onto the floor. He placed himself on top of her. He then covered her mouth with his hand and contacted the outer area of her vagina with his opposite hand. SANE evaluation completed on 9/28/2024 at 11:54 pm. Clinical impression: confirmed sexual assault and assault by bodily force. A review of the local police Incident Report dated 9/28/2024 revealed that an officer responded to the facility at approximately 9:30 pm in reference to an aggravated sexual battery. R48's roommate explained that R121 came into their room, grabbed R48, and pushed her down. R48 stated, he stuck his finger up my vagina, and R121 was holding his hand over her mouth. The roommate explained that staff removed R121, but he returned to get his shoe, and staff removed him from the room again before retrieving his shoe. The officer documented the shoe beside the roommate's bed. LPN CC stated to the officer that she witnessed R121 on top of R48 with his hand in the area of her vagina and explained that she then pulled R121 off her. The officer asked R121 several basic questions to assess his mental capabilities, and R121 replied several more times with I don't know. The nursing staff at the facility indicated that they believed R121 was pretending to be mentally incompetent. The Director of Nursing (DON) informed the officer that R121 was on probation. However, the officer later discovered that R121 was on parole. The DON additionally explained that she had been getting reports from staff that R121 had been threatening to rape them over the past couple of weeks. R121 was arrested on 9/28/2024. The officer did respond to the hospital, where he met the SANE nurse, and she explained she had performed a sexual assault exam. At that time, the SANE nurse turned over the sexual assault exam evidence to the officer. Continued review of the EMR for R121 revealed that he was considered a parolee with the Department of Corrections and had the potential to be returned to the Department of Corrections, once determined by the parole board. Interview on 3/25/25 at 12:27 pm with R48 reported that man came into her room and threw her down on the floor and stuck his hand into her diaper and her vaginal area. She stated that the police were called. The man is no longer here, and she couldn't remember his name. R48 stated the man was a resident at the facility. Interview on 3/28/2025 at 12:35 pm with R121's parole officer revealed the resident was sent back to prison after the 9/28/2024 violation. He stated that he was not made aware of any previous incidents with R121, and if made aware, he would have put risk interventions into place. The parole officer stated that facility staff informed him that R121 was doing fine during visits and phone calls. Interview on 3/26/2025 at 2:10 pm with the Administrator reported that she cannot recall the incident with R121 and R48 in detail. She remembers reporting the incident to the State based on what the nurse told her. The nurse reported that resident, R48 stated that R121 had his hand in her vagina. The Administrator further revealed that she thinks what their investigation revealed was not actually the truth. She wrote exactly what R48 said in the Facility Reportable and the 5-Day Report. This was an actual quote, and the staff investigated the incident. The Administrator stated that she was informed that written reports to the State must be based on what the resident (R48) reveals. During an interview on 3/27/2025 at 5:36 pm, the Medical Director (MD) verified being informed by staff of the incident between R48 and R121 on 9/28/2024. The MD confirmed that at the time of R121's admission in 2023, R121 displayed inappropriate sexual behaviors (inappropriate sexual statements towards staff) that had leveled out. The MD reported, I don't recall a time when he was not calm when I interacted with him. The MD reported that usually when they (residents) are on proper medication (med), they will be alright. MD continued to state that if we (referring to medical professionals) are aware of any ongoing sexual behaviors, then we would have to figure out the proper dose of medication because we want them to be their normal self and in control of their behavior. MD reported that an assessment would include trying to figure out the trigger (leading to sexual aggression/behaviors) before we (the medical professionals) add more medications. The MD revealed that the use of Zyprexa for R121 was for his schizophrenia, was not used for sexual aggression, and R121 was being monitored for hormone treatment because the doctor wanted to make sure it was appropriate before starting R121 on progesterone. The facility implemented the following actions to remove the IJ: 1. R48 was assessed for injury, changes in behavior, trauma, and pain on 9/28/2024. NP gave orders to send R48 to the Hospital for evaluation and treatment. The patient was sent to the hospital for evaluation and treatment. MD and family were notified. R48 was discharged back to the center on 9/29/2024 from the hospital. Center nurses began observation on the patient to ensure feelings of safety with no noted distress. Patient had a visit with behavioral health 011 10/1/2024 for a psychosocial support visit. Patient refused to see the behavioral health NP on 10/8/2024. Patient did have visit by hospice on 10/8/2024. Behavior health visit for the patient completed on 3/28/2025. 2. Rl21 was immediately removed from R48 room by the LPN Charge Nurse and placed on one-on-one observation by a CNA until police arrived at the center to test the patient. Patient R121 was arrested on 9/28/2024. 3. Skin audits were conducted on all residents 9/30/2024 to evaluate for any signs of abuse by the facility charge nurses and nurse managers. R48 noted with bruising to the thigh. No other adverse findings for other patients were audited. 4. Resident with BIMs of 10 and above were interviewed by licensed nursing staff on 9/30/2024. 5. In-service education was initiated on 9/29/2024 for staff and to include abuse prohibition, abuse reporting, burnout, and de-escalation for all staff of the facility. Education was provided by the Administrator, Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director. 6. A Resident Council Meeting was held on 10/29/2024. Abuse & Neglect Prevention to include Residents Rights reviewed by Activities Director. R48 was in attendance at the meeting. 7. Interviews were completed on 28 of 28 residents who are interviewable to identify any concerns for abuse on 3/28/2025 by the Social Services Director, Director of Nursing (DON), Activity Director (AD), and Nurse Managers. All denied any type of abuse or neglect. 8. R48 was interviewed by the Administrator on 3/27/2025. Expressed no problems at this time and was happy and planning to attend activities. 9. On 3/28/2025, a Root Cause Analysis was completed for the Abuse Prevention. Root Cause identified that the center failed to implement interventions to protect the residents as outlined on the behavior health visit. A communication tool was developed to improve the communication between the behavior provider and center to provide notification of any recommendations timely. The behavior provider will meet with the DON, ADON, and or nurse supervisor upon entrance and exit to make aware of any new recommendation and to receive report of new adverse events. Education of this process has been provided to the nurse leadership, SSD, and behavior provider on 3/31/2025 by the DON. 10. Education was provided to 28 of 28 cognitive residents regarding the Elder Justice Act and reporting of abuse by the Social Services Director and the Director of Social Services on 3/31/2025. 11. Education provided on 3/31/2025 to the center leadership team by the Governing Body on abuse prohibition policy to reviewing adverse events during Quality Assurance Performance Improvemen (QAPI), recognizing trends to create proactive measures to reduce further reoccurrences, and utilization of non-pharmacological interventions as warranted for patients to promote safety of all patients. 12. Re-education was completed on 3/29/2025 for staff and to include abuse prohibition, abuse reporting to include physical and sexual aggression, burnout, and de de-escalation for all staff of the facility. Education was provided by the Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director. 11 of 11 RN, 9 of 9 LPN, 23 of 23 CNAs, 4 of 4 CMAs, l of 1 Maintenance, 1 of l Therapy, 2 of 2 Activities, 8 of 8 Dietary, 10 of 10 Housekeeping, Social Services Director 1 of l, 5 of 5 Administrative staff have been in serviced which totals l00%. No staff shall work until they have completed in-service education. No staff shall work until they have completed in-service education. Contract and newly hired associates will be educated upon hire on abuse prohibition, abuse reporting, burnout, and de-escalation by the Nurse Manager, DON, or ADON. 13. Audits started on 3/31/2025 by the social service director to interview 10 residents to ensure. They feel safe, and 10 associates' interviews have been completed to ensure they know the process for reporting and can identify abuse, including sexual and physical aggression. Any noncompliance identified will be addressed by the Administrator assistant and or [NAME] by written education, and incidents identified will be reported following the HFRD reporting protocol. 14. On 3/31/2025, the DON, Financial Controller, and Nurse Managers notified all current non-interviewable resident representatives via written notification on Abuse & Neglect Prevention Policy, and the Elder Justice Act and reporting. 15. An ADHOC QAPI meeting was held with the Medical Director, center leadership, and Governing Body on 3/31/2025 to notify of the deficiencies cited and the interventions implemented to ensure that the deficient practices do not reoccur. The Abuse Policy was reviewed with no needed revisions needed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified by: Record review of Licensed Practical Nurse (LPN) CC 's written statement stated nurse assessed resident, and no visible bleeding noted at this time. ROM (Range of Motion adequate to all extremities, and she could stand with full weight, v/s (vital signs 138/93, 97.6, pulse 107, O2 Sat 95 % (oxygen saturation 95 percentage) on room air. The Administrator and DON aware. Verified by: The hospital record review revealed that R48 returned to the facility on [DATE]. Verified by: Record review of nurse written statement showed dates of each observation (consist of every 15 minutes checks per 12 hours shift) conducted by licensed nursing staff: Documentation revealed that staff observation included interview questions about the resident overall well beings. (Note: R48 returned back to the facility at 6:10 pm from the hospital). 9/29/2024 at 6:10 pm to 7 pm -Registered Nurse (RN) VVV 9/29/2024 at 7 pm to 7 am LPN CC 9/30/2024 at 9:30 am to 6:11 pm by Resident Care Coordinator/LPN HH & DON, 9/30/2024 at 6:11 pm to 7:00 pm, DON 9/30/2024 at 7pm to 7am, LPN CC & LPN DDDD 10/1/2024 at 8:40 am to 4:10 pm, Resident Care Coordinator/LPN HH, Interview with Resident Care Coordinator/LPN HH on 4/3/2024 at 2:08 pm verified that she did not clock out to 6:11 pm on 9/30/2025 and provided observations until 6:11 pm. She stated that Activities/SSD (Social Services Director) was in the room to continue monitoring of R48. She was not sure who provided the observation after she left. Interview with the DON on 4/3/2024 at 2:00 pm, the DON confirmed making observations to monitor resident for safety and welfare checks. Verified by: Record review of {Named} Behavioral Health note dated 10/1/2024 verified resident was seen by {Named} Nurse Practitioner (NP). Record review of email from {Named} Behavioral Health NP to Director of Nursing (DON). {Named} Behavioral Health NP stated in her email that R48 refused a follow up visit with her. Verified by: Record review of hospice agency documents documented behavior visits by the Chaplain Interview 4/2/2025 with Hospice Administrator [NAME] verified that R48 was seen by the Chaplain 10/2/2024, 11/20/2024, 12/05/2024, 1/15/2024, 2/20/2024, 3/17/2024. 2. Verified by: Record review of LPN CC written statement verified R121 was removed from the room. Record review of the written statement by Certified Nurse Assistant (CNA) EEEE documented that she provided observations on 9/28/2024. Record review of Police Report dated 9/20/2024. 3. Verified by: Record review of bath sheets and skin assessment forms dated 9/30/2024 documented R48 's skin assessments/bath sheet including the other facility residents based on the facility census. R48's bath sheet and skin assessment noted a bruise to resident 's thigh. 4. Record review of facility form titled Quality Improvement Data Collection GRID excel sheet documented the following question asked to the resident Have you had any encounter with any other resident that made you uncomfortable? A total of 40 residents were interviewed including resident R48. A list of 26 residents which included the same residents were also questioned by the Resident Care Coordinator LPN HH. 5. Verified by: Record review of facility education form titled What is abuse dated 9/29/2024.The content of the training included a PowerPoint handout titled Preventing and Responding to Resident to Resident Mistreatment. 85% of the facility staff were interviewed during the abatement process. The staff was knowledgeable about abuse process and how to work with difficult residents. Also verified the above education by the following staff interview on 4/2/2025 at with Certified Nursing Assistant (CNA) II, Dietary JJ, Dietary KK, Dietary LL, Dietary MM, Dietary Manager, EVS PP, EVS QQ, EVS RR, Assistant Activity Director, Dietary [NAME] SS, Laundry TT, Floor Tech/EVS UU, Environmental Services (EVS) Supervisor, Health Care Navigator, CNA XX, CMA/CNA ZZ, Resident Care Coordinator WW, Unit Manager GG, LPN DDD, CNA BB, LPN Wound care nurse, RN charge nurse EEE, LPN charge nurse EE, LPN HHH, CNA FFF, CNA GGG, CNA III, 4/3/2025 at 8:15 pm LPN QQQ, LPN CC, CNA UUU, CMA/CNA LLL, RN/Charge nurse RRR, CMA/CNA NNN, CNA MMM, EVS TTT, EVS SSS, CNA OOO, RN KKK, CNA PPP, RN/Charge Nurse VVV, RN WWW, RN/Weekend Supervisor XXX, CNA YYY, CNA ZZZ, RN/Weekend Supervisor AAAA, RN/Charge Nurse BBBB, RN CCCC. 6. Record review of Resident Council Minutes dated 10/29/2024, documented questions were added and addressed to the residents Do you feel safe?. Do you know who to tell if you do not feel safe?, Do you know about physical, mental, and sexual abuse. The questions were reviewed with the residents in attendance. 7. 28 of 28 residents were interviewed by the above-mentioned staff. The form listed y (yes) or n (no). 8. Record review of handwritten document by Administrator documented a conversation conducted with R48 by the Administrator for 3/27/2025.The written statement documented Visited with R48 this morning. She told me about the incident and what the man did, and that she went to the hospital and he went to jail. She verbalized being safe here at the facility. She was eating her breakfast and had almost cleaned her plate, and drank her juice and other beverages. She seemed happy and was planning on attending activities. 9. The form list the 5 WHY's (1. Why -The center failed to implement nonpharmacological interventions that were recommended by the behavior health provider after behavior health visits. 2. Why. There was lack of communication with the behavioral health provider to identify the findings and recommendation of the visit to include any pharmacological and/or non-pharmacological interventions for behavioral management. This includes the recommendation for Gradual Dose Reduction (GDR)s for the patients that were approved by the provider. 3. The center changed behavioral health providers, and the process and expectation was not re-established for communication of visits. Root cause: 1. lack of process, 2. change in behavior health support (based on a new behavior provider that was onboard, there were a gap, familiar with the building systems, billing systems, and familiar with resident and their diagnoses/behaviors. 3. Recommendation for the GDRs for the population of the center (Ensure that GDR was effective in coordinating with the resident care/disease process, stabilizations). 10. Verified by: The list of residents revealed that training was provided to 28 residents. Residents' names and signatures are noted on the form. The content included was Elder Abuse. 11. Verified by: Record review of the facility education form titled Abuse Prohibition/Abuse Investigation dated 3/28/2025. Also verified the above education by the following staff interview on 4/2/2025 with the DON, Administrator, ICP, Health Information Management (HIM), Director of Rehabilitation, Social Worker, Human Resources. 12. Verified by: 3/29/2025 for staff education and to include abuse prohibition, abuse reporting to include physical and sexual aggression, burnout, and de-escalation for all staff of the facility. Also verified the above education by the following staff interview on 4/2/2025 at with Certified Nursing Assistant (CNA) II, Dietary JJ, Dietary KK, Dietary LL, Dietary MM, Dietary Manager, EVS PP, EVS QQ, EVS RR, Assistant Activity Director, Dietary [NAME] SS, Laundry TT, Floor Tech/EVS UU, Environmental Services (EVS) Supervisor, Health Care Navigator, CNA XX, CMA/CNA ZZ, Resident Care Coordinator WW, Unit Manager GG, LPN DDD, CNA BB, LPN Wound care nurse, RN charge nurse EEE, LPN charge nurse EE, LPN HHH, CNA FFF, CNA GGG, CNA III, 4/3/2025 at 8:15 pm LPN QQQ, LPN CC, CNA UUU, CMA/CNA LLL, RN/Charge nurse RRR, CMA/CNA NNN, CNA MMM, EVS TTT, EVS SSS, CNA OOO, RN KKK, CNA PPP, RN/Charge Nurse VVV, RN WWW, RN/Weekend Supervisor XXX, CNA YYY, CNA ZZZ, RN/Weekend Supervisor AAAA, RN/Charge Nurse BBBB, RN CCCC. 13. Verified by: Audit contents 1. Abuse Types, Reporting, Audits dates 4/2/2025, 4/3/2025, 4/4/2025. 14. Verified by: Included a letter provided to residents defining abuse and how to report listing information, Administrator contact number, State and Local Agencies, and Confidential Reporting Channels. 15. Verified: Review of a form titled, QAPI Committee Attendance dated 3/31/2025 at 2:30 pm with signatures documented all staff in attendance for the QAPI meeting. The list included 17 facility staff and three corporate staff including the Senior Director of Clinical Standards, Divisional [NAME] President, and the Director of Quality & Regulatory Services. The signature page documented that the Medical Director attended via phone. Review of the signature page revealed there was no signature to indicate that the Activities Director or the Assistant Activity Director were in attendance. Review of a Resident List revealed 22 residents identified with sexually inappropriate behaviors were discussed, and documented two referrals were made for {Named} Behavioral Health services on 3/31/2025 and seen on 4/1/2025. confirmed attendance of the QAPI meeting held on Monday, 3/31/2025; LPN GG, LPN HH, Senior Director of Clinical Standards, Assistant Activities Director. All corrective actions were completed on 3/31/2025. The facility alleges IJ removal 4/1/2025.

Based on resident and staff interviews, record review, and review of the facility's policies titled, Behavior Health, and Abuse Prohibition, the facility failed to ensure one of eight residents (R) (R121) received behavioral health services that promoted psychosocial well-being, met the resident's needs, and included individualized approaches related to nonpharmacological interventions to address worsening sexual behaviors and sexual aggression. The deficit practice provided the opportunity for R121 to sexually and physically abuse R48. On 3/31/2025, a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Senior Director of Clinical Standards, Director of Quality and Regulatory Services, Director of Nursing (DON), and Assistant Administrator were informed of the Immediate Jeopardy (IJ) on 3/31/2025 at 10:45 am. The noncompliance related to the IJ was identified to have existed on 9/28/2024 when R121 sexually abused R48 inside her room. An acceptable Removal Plan was received on 4/1/2025. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on 4/1/2025. The facility remained out of compliance while the facility continued management level staff oversight as well as developed and implemented a Plan of Correction (POC). This oversight process included the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to Abuse, Neglect, and Exploitation, and the behavioral health needs of residents. Findings included: Review of the facility's policy titled, Behavior Health, review date 12/27/2024 revealed, Intent: It is the intent of this center for each patient to receive the necessary behavioral health care and services to attain or maintain their highest practical physical, mental, and psychosocial well-being based on the comprehensive assessment and plan of care. Guidelines: The center will provide behavioral healthcare and services to include Pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated. Training to include .Implementing person-centered care approaches designed to meet the needs of the individual patient .Mental health and social service needs . Patients who display or who are diagnosed with a mental disorder, psychological adjustment difficulty . receive appropriate treatment and services to address the problem .concerns identified will be assessed and care planned; changes should be documented, including frequency of occurrence and potential triggers; concerns, follow-up assessment and potential modifications are discussed with the interdisciplinary team. Review of the facility's policy titled, Abuse Prohibition, review date 12/27/2024 revealed, Intent: It is the intent of this center to actively preserve each patient's right to be from mistreatment, neglect, abuse . The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse . Guideline: Definitions: For the purposes of this policy, the following definitions apply . Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Identification of possible abuse, neglect or exploitation: Identification of injuries or events that are suspicious and may constitute abuse. In attempting to identify any type of abuse or neglect the following signs and symptoms of abuse will be examined as to whether it is suspicious and may constitute abuse . Sexual abuse: An at-risk adult's report . It will be the responsibility of any associate receiving the complaint of alleged abuse .to inform the administrator or designee immediately. The [NAME] will identify, correct and intervene in situations in which abuse, neglect . is more likely to occur. This will include an analysis of: The assessment, care planning, and monitoring of patients with specialty needs and behaviors which might lead to conflict or neglect, such as patients with a history of aggressive behaviors, patients who have behaviors . Review of the medical record revealed that R121 was admitted on [DATE] with diagnoses (Dx) of but not limited to catatonic schizophrenia and anxiety disorder. The primary psychiatric diagnosis was adjustment disorder with mixed disturbance of emotions and conduct. A new diagnosis of hypersexuality was identified on 10/23/2023 by the Nurse Practitioner (NP). There were no physician orders or interventions to monitor for sexual behaviors or sexual aggressiveness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C assessed R121 with a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Section D-Mood was coded as little interest or pleasure in doing things, feeling down, depressed or hopeless, feeling tired or having little energy, and trouble concentrating on things. Section E-No behaviors exhibited Section I-Diagnoses included anxiety disorder, schizophrenia, and other included other sexual dysfunction. Review of the care plan revealed there was no problem/care area or interventions specific for sexual abuse, sexual aggression, or sexual behaviors. Inappropriate sexual behavior was only documented under the category for behaviors and under evidenced by. There were no interventions specific to sexual behaviors or sexual aggressiveness. There was no revision to the care plan after documentation of sexually aggressive behaviors identified. Review of the care plan, updated 8/23/2024, revealed R121 had a care area/problem for Behaviors related to catatonic schizophrenia, anxiety, and mild intellectual disability-onset 2/6/2024. The Behaviors care plan was updated 8/20/2024 related to psychosocial, activity and environmental factors. The Behaviors care plan evidenced by included but not limited to, inappropriate sexual behaviors, inappropriate vocalizations, impulsiveness, anxiety, and verbal behavioral symptoms directed toward others-onset 10/23/2023; Rejects care, treatments, and medication(s)-onset 10/28/2023; Level 2 PASRR-onset 12/18/2023; restlessness-onset 1/25/2024; agitation-onset 6/24/2024; pharmacological-onset 8/20/2024. Interventions for behaviors included: Provide activities of choice, redirect patient as needed, conduct behavior assessment as needed onset 10/23/2023, reviewed 6/5/2024. Provide privacy for resident appropriate to maintain self-esteem-onset 10/25/2023, reviewed 6/5/2024. Analyze key times, places, circumstances, triggers, and what deescalates behavior-onset 1/18/2024, reviewed 6/5/2024. Administer medications for a clearly defined goal aimed at specific target behavior for which the drug is effective, assess patterns of behavior with behavior monitoring tool, be an active listener and allow for expression of feelings without censure, involve the person in the activities based on their preferences and cognitive functioning, maintain a tolerant, calm manner, remove patient from stressful situations-8/20/2024. Every 15-minute observation x 3 days-8/21/2024. Labs-onset 8/23/2024. Review of facility documentation, a written statement by LPN (Licensed Practical Nurse) QQQ, R121's nurse the night of the incident of alleged sexual abuse of R48 revealed, 9/28/2024 8:40-Event the nurse documented that she was summoned to [R48's] room and upon arrival noted R121 on top for a female resident (R48) fully clothed. Female resident (R48) yelling out help Instructed by LPN CC to get off that woman. Writer assisted R121 up and to his room and asked him why he was on that woman and in her room, [R121] stated I didn't know. At 8:50 pm [Named] (R121) was noted attempting to return to R48's room. A 1:1 monitoring CNA (Certified Nursing Assistant) posted outside R121's door for observation. The DON was notified and arrived at the facility. Local police were notified, and a deputy arrived at the facility. R121 was taken into custody and transported to jail. A review of documentation by the [Named] behavioral health services NP and visits confirmed by the DON revealed that R121 was seen on 12/8/2023, 3/5/2024, 6/4/2024, and 8/21/2024. The behavioral health visit note dated 8/21/2024 under the history of present illness and assessment, included R121's primary psychiatric diagnosis was adjustment disorder with mixed disturbance of emotions and conduct, and was documented as worsening. R121 was talking inappropriately in a sexual manner with staff, wanting sex, trying to kiss a staff member, and stated that he was going to rape her. Staff reports he hit a nurse in the head and was kicking, and he paces all the time. Past medical history included hypersexuality. Impulse control and insight/judgement were both poor. BIMS score was seven, and the psychotic symptoms were delusions. Under recommendations, it was documented that R121's parole officer had visited recently, and staff felt he may be a trigger because R121 had some behavioral issues after the last time his parole officer visited him. Recommendations included for staff to speak with the parole officer and ask if he could speak with the nurse instead of coming to the facility, since R121 is not appropriately able to answer questions. R121 was placed on q15 (every 15) minute checks. Also, an order was given to start Haloperidol 5 mg (milligram) po (by mouth/orally) q6hrs (every 6 hours) prn (as needed for) agitation x (for) 14 days. If he is displaying inappropriate behaviors, staff to try to redirect or distract him with an activity, staff to encourage communication with family unless this is distressing to him, staff to offer support and reassurance as needed. Staff to promote good sleep hygiene by dimming the lights, and reducing noise levels as able during bedtime hours, and discouraging daytime naps. If he becomes a danger to himself or others, send him to the Emergency Department (ER) for psychiatric evaluation. A review of documentation revealed no evidence that nonpharmacological interventions for sexual behaviors were implemented or documented based on behavioral health services recommendations on 8/21/2024. Review of facility documentation of the Offence/Incident Report dated 9/28/2024 from 9:00 pm to 9:20 pm by the local county Sheriff's Office revealed a report of Aggravated Sexual Battery of a named victim [R48] by R121. Additional information included the complainant's name, subjects who were interviewed, and evidence. Further review revealed it was reported to the officers by the DON that R121 had been threatening to rape them over the past couple of weeks. An interview with LPN CC revealed that she responded after hearing a commotion and that she witnessed R121 on top of R48 with his hand in the area of her vagina. She explained that she then pulled R121 off R48. Interview with various licensed staff on 3/28/2025 from 11:30 am to 12:30 pm revealed examples of nonpharmacological interventions for sexual behaviors or sexual aggressiveness that staff gave included, try to redirect, watch them, increased monitoring, depends on the situation but keep an eye on the aggressor, remove the resident from the hall, involve in activities, try to calm them down, talk with them, notify family if available, maybe family could come visit and try to reach the resident, interventions are in the book, they ask residents their preference and don't force them or make them do something if they don't want to, separate residents, keep residents safe, notify the doctor, move to another unit/hall to get away from other residents to keep them safe and make sure the perpetrator did not have access to the victim, one-on-one monitoring/ supervision, and if not improving in 24 to 48 hours notify the physician, report to the nurse supervisor, social worker, Administrator, and/or DON. Care plans are not on the POC system. Therefore, CNAs don't have access to interventions, so the nurse lets the CNA know what the interventions are, what the resident needs to be monitored for, or if any revised or new interventions are added. The staff acknowledges what nonpharmacological interventions are for residents. However, these interventions were not implemented for R121. Interview on 3/27/2025 at 5:36 pm with the Medical Director revealed he recalled an event between R121 and R48, the male on top of the female, an actual assault or attempted rape by the male (R121). The interview revealed R121 was evaluated to determine why it happened, what was going on with him, must figure out the proper dosage of medication to be therapeutic at the same time have the resident function and be themselves, and try to figure out triggers before adding more medication (meds). The interview confirmed that he and the nurse practitioner reviewed behavioral health notes, the psychiatric team is responsible for dose-reducing meds, and they are discussed with facility staff. When asked if R121's meds were appropriate, and if olanzapine (Zyprexa) would increase R121's sexual drive. The interview revealed that the use of Zyprexa for R121 was for his schizophrenia, was not used for sexual aggression, and R121 was being monitored for hormone treatment because the doctor wanted to make sure it was appropriate before starting R121 on Progesterone. He confirmed the olanzapine (Zyprexa) was prescribed for the schizophrenia and not anything sexual. Interview on 4/2/2025 at 11:42 am with the [Named] behavioral health NP confirmed R121 did have sexual behaviors, was sexually inappropriate and aggressive with a staff member, had made sexual comments to a nurse, attempted to kiss a nurse, and the sexual assault incident with R48. I'm very conservative with meds, we try nonpharmacological interventions first. I always try to start with nonpharmacological interventions first, and if they don't work, I start with the lowest dosage of medication. Recommended interventions include redirecting, discouraging the behavior, encouraging the resident to get involved in activities, trying to redirect with an activity, encouraging communication with family unless they are not involved or it is distressing to the residents, and offering support as needed. If they become verbally or physically aggressive, observe the source of the conduct. Encourage good hygiene, observe for hallucinations and delusions, allow safe space to pace, observe for pacing, manic, depression, and sexual aggression. Interview on 4/1/2025 at 9:58 pm, the DON confirmed behavioral health notes, confirmed that R121 was seen by the behavioral consultant on several scheduled visits to the facility, and non-pharmacological interventions were in place on the care plan. The facility implemented the following actions to remove the IJ: 1. R121 was discharged from the facility on 9/28/2024 and was arrested at 9:30 pm and did not return to the facility. 2. The Assistant Administrator, DON, Division [NAME] President, and the medical director reviewed the facility's policy titled Behavioral Health on 3/31/2025. No revisions were indicated through review. 3. On 3/31/2025 an audit was completed by DN (Divisional Nurse) for residents with sexual inappropriate behaviors complete of all patients. A review of the plan of care was completed to ensure that nonpharmacological interventions were captured for two of 21 residents that exhibited behaviors in past 30 days. A referral was initiated as appropriate by the DON. 4. In-service education was initiated on 3/31/2025 for RNs (Registered Nurse(s) and LPN(s) and was completed on 3/31/2025 and included identifying behavioral health needs, updating the plan of care and implementing interventions in the plan of care as outline in the facility's Behavioral Health Policy to include nonpharmacological interventions. CNAs provided education on abuse reporting to include sexual inappropriate behaviors on 3/31/2025. Education was provided by the DON, Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director. 11 of 11 RNs, nine of nine LPNs, 23 of 23 CNAs, and four of four CMAs (Certified Medication Tech) have been in serviced which totals 100%. No staff shall work until they have completed in-service education. No new hires as of 3/31/2025. 5. An audit tool was developed by DON on 3/31/2025 to review patients with inappropriate behaviors to ensure they have a non-pharmacological intervention noted on care plan. Any noncompliance noted will be addressed through written education by assistant administrator and/or DON. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified by review of the electric health record (EHR) showed R121's status was discharge. Review of the MDS schedule reported a Discharge return not anticipated assessment dated [DATE]. Interview with staff, the DON, and review of documentation confirmed R121 was removed from the facility in handcuffs by the Sheriff's deputy on 9/28/2025. Observations during the survey period confirmed R121 was not in the facility. An interview on 3/27/2025 at 2:00 pm with the Administrator revealed the Parole Officer confirmed R121 was back in prison because of probation violation. 2. Verified by review of documentation revealed a QAPI (Quality Assurance Performance Improvement) meeting was held on 3/31/2025, and the sign-in sheet had signatures of the Assistant Administrator, DON, Division [NAME] President indicating they were in attendance. Interview on 4/3/2025 at 1:55 pm with the Senior Director of Clinical Standards confirmed the DN attended; and the Medical Director attended via phone. The Behavior Health policy was reviewed, and no revisions were made to the policy. Interview with the DON on 4/3/2025 at 4:20 pm confirmed attendance of Assistant Administrator, DON, Division [NAME] President, and the Medical Director via phone and the policy was reviewed with no revisions. 3. Verified by review of a list of residents revealed 12 residents on a list receiving [Named] Behavioral Health Services. Ten residents were seen for routine visits, and two residents had acute episodes with referrals made on 3/31/2025 for [named] behavioral health. Interview on 4/3/2025 at 4:20 pm with the DON confirmed all care plans of residents identified with sexual behaviors were checked for non-pharmacological interventions. She had made referrals for [named] behavioral health services on 3/31/2025 for two residents with acute episodes in the past 30 days, and they were seen by the [named] behavioral health NP on Tuesday 4/1/2025. 4. Review of documentation revealed a list of 20 nursing staff with their title and confirmed inservice education with licensed nurse staff, RN's and LPN's on 3/31/2025 and included review of the Behavior Health guidelines, and identifying behaviors for patients, updating the care plan, implementing interventions, and non-pharmacological interventions. A list of nursing staff with their title was included and verified 20 licensed practical or Registered nurses. Review of documentation confirmed CNA inservice education completed on 3/31/2025 and included review of the behavior health guidelines, and identifying behaviors for patients, updating the care plan, implementing interventions, and non-pharmacological interventions. A list of nursing staff with their title was included. Verified: Review of documentation revealed a list of 20 nursing staff with their title and confirmed licensed nurse staff received inservice education on 3/31/2025 and included review of the behavior health guidelines, and identifying behaviors for patients, updating the care plan, implementing interventions, and non-pharmacological interventions. Interview on 4/3/2025 at 1:55 pm with the Senior Director of Clinical Standards confirmed the education was completed, audits were completed, and she had reviewed them. Interview with the DON on 4/3/2025 at 4:20 pm confirmed education had been completed with all staff, no staff will be able to work until they complete inservice education on abuse, confirmed abuse was already included in orientation, and on Work-Day training on Relias, and confirmed there was no new hires staff. Also verified the above education by the following staff interview on 4/2/2025 at with Certified Nursing Assistant (CNA) II, Dietary JJ, Dietary KK, Dietary LL, Dietary MM, Dietary Manager, EVS PP, EVS QQ, EVS RR, Assistant Activity Director, Dietary [NAME] SS, Laundry TT, Floor Tech/EVS UU, Environmental Services (EVS) Supervisor, Health Care Navigator, CNA XX, CMA/CNA ZZ, Resident Care Coordinator WW, Unit Manager GG, LPN DDD, CNA BB, LPN Wound care nurse, RN charge nurse EEE, LPN charge nurse EE, LPN HHH, CNA FFF, CNA GGG, CNA III, 4/3/2025 at 8:15 pm LPN QQQ, LPN CC, CNA UUU, CMA/CNA LLL, RN/Charge nurse RRR, CMA/CNA NNN, CNA MMM, EVS TTT, EVS SSS, CNA OOO, RN KKK, CNA PPP, RN/Charge Nurse VVV, RN WWW, RN/Weekend Supervisor XXX, CNA YYY, CNA ZZZ, RN/Weekend Supervisor AAAA, RN/Charge Nurse BBBB, RN CCCC. 5. Verified by review of an audit tool titled, Quality Improvement Date Collection Grid assessed/monitored four areas: 1. Any noted sexual inappropriate behavior. 2. If so, were non-pharmacological interventions implemented. 3. Care plan updated. 4. Was change in condition completed? Review of completed audit tools titled, Quality Improvement Date Collection Grid confirmed audits were completed on 4/1/2025, 4/2/2025, 4/3/2025. Four areas were assessed with no non-compliance identified. Review of a list of residents revealed 12 residents on a list receiving {Named} Behavioral Health Services. Ten residents were for routine visits, and two residents had acute episodes, referrals were made on 3/31/2025 and seen by CHE on Tuesday 4/1/2025. (A previous interview with NP (Nurse Practitioner) FFFF revealed she made visits every Tuesday). Interview with the DON on 4/3/2025 at 4:20 pm confirmed audits were initiated and ongoing. 6. Verified by review of a form titled, QAPI Committee Attendance dated 3/31/2025 at 2:30 pm with signatures documented all staff in attendance for the QAPI meeting. The list included 17 facility staff and three corporate staff including the Senior Director of Clinical Standards, the Divisional [NAME] President, and the Director of Quality & Regulatory Services. The signature page documented that the Medical Director attended via phone. Review of the signature page revealed there was no signature to indicate that the Activities Director (AD) or the Assistant Activity Director were in attendance. Review of a Resident List revealed 22 residents identified with sexually inappropriate behaviors were discussed, and documented two referrals were made for [named] behavioral health services on 3/31/2025 and seen on 4/1/2025. Interview on 4/3/2025 at 1:30 pm with the Assistant Activities Director revealed the AD was out on Monday, March 31, 2025, the day the QAPI meeting was held, and confirmed she attended the QAPI meeting in the AD's place. She revealed they discussed residents with sexual behaviors, reviewed a list of residents, and discussed their behaviors and the policy for Behavioral Health. Interview on 4/3/2025 at 1:55 pm with the Senior Director of Clinical Standards confirmed they reviewed the Behavioral Health policy and revealed they did not make any changes to the policy. Further interview confirmed all steps in the plan of correction had been initiated and further audits were scheduled as indicated. Interview on 4/3/2025 at 2:06 pm with LPN HH confirmed attendance of the QAPI meeting held on Monday, 3/31/2025, and verified attendance and her name on the sign-in page. Further interview confirmed they discussed the Behavioral Health policy and confirmed the list of residents on the form titled Resident List was reviewed related to sexual behaviors. She revealed how they came up with the names on the list. They were not all current or new residents, but also included residents who had sexual behaviors in the past. She confirmed all the residents (22) on the list were reviewed/discussed for sexually inappropriate behaviors, documented if they had behavior monitoring in place or not, two new referrals were made on 3/31/2025, and revealed both were seen by the [named] behavioral health NP on Tuesday, 4/1/2025. Interview on 4/3/2025 at 2:10 pm with LPN GG confirmed attendance of the QAPI meeting held on Monday 3/31/2025 and verified attendance and her name on the sign-in page. She also confirmed they reviewed the Behavioral Health policy, discussed all the residents on the list, and two new referrals were made 3/31/2025. Both residents were seen 4/1/2025 by [named] behavioral health service NP. All corrective actions will be completed on 3/31/2025. The immediate jeopardy will be removed on 4/1/2025. Cross-reference F600

Based on record review, staff interviews, review of the Administrator and Director of Nursing job descriptions, and review of the policy titled Abuse Policy, the facility Administration failed to provide protective oversight to attain the highest practicable physical and psychosocial well-being of the residents. Specifically, the Administration failed to take appropriate action on allegations of resident-to-resident physical and sexual abuse for resident (R) R48 by resident (R) R121; and failed to establish and implement written policies and procedures for feedback, data collection, and monitoring, including adverse event monitoring for Quality Assurance Performance Improvement (QAPI). The failures of the Administration to take appropriate action are likely to lead to future allegations of abuse not being identified. The facility census was 161. On 3/31/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The Senior Director of Clinical Standards, Director of Quality and Regulatory Services, Director of Nursing (DON), and Assistant Administrator were informed of the Immediate Jeopardy (IJ) on 3/31/2025 at 10:45 am. The noncompliance related to the IJ was identified to have existed on 9/28/2024 when R121 sexually and physically abused R48 inside her room. A Credible Allegation of Compliance was received on 4/1/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed as of 4/1/2025. The facility remains out of compliance while the facility continues management level oversight as well as continuing to develop and implement a Plan of Correction. (POC). This oversight process included the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to Abuse, Neglect, and Exploitation, and the behavioral health needs of residents. Findings include: Review of job summary for the Administrator revealed, responsible for day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients. Operates the Nursing Center in accordance with the established guidelines of the organization and in compliance with federal, state, and local regulations. Enforces the Nursing Center guidelines. Maintains a working knowledge of current licensure standards and the survey process. Acts as a liaison between the Nursing Center and regulatory agencies, patient advocacy groups, and fiscal intermediaries. Assumes responsibility for procedural guidelines relative to the prevention and reporting of patient abuse. Reviews, investigates, and arbitrates patient complaints and grievances, and makes available to the supervisor written reports of action taken. Contributes to the work of committees, workgroups, project management, and other collaborative efforts of the System. Review of job summary for DON revealed responsible for planning, organizing, developing and directing the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and/or the Medical Director, to provide appropriate care. Directs, evaluates, and supervises patient care and initiates corrective action as necessary. Evaluates patient care as related to individualized patient needs, family involvement, and the physician's plan of care for the patient. Maintains a working knowledge of current licensure standards and the survey process. Reports problems to the Administrator, conducts daily patient rounds, and initiates corrective action as necessary. Directs and provides implementation of educational programs, quality assurance program, and infection control program Operates the nursing department in accordance with the organization established guidelines, and in compliance with federal, state, and local regulations, demonstrates appropriate/effective supervisory skills that include fair and uniformly applied corrective actions administered without regard to race, color, creed, national origin, age, sex, religion, handicap or marital status. 1. Administration failed to protect resident (R) 48's right to be free from sexual assault by not monitoring, supervising, and effectively addressing the sexually aggressive behavior of R121, a resident who had been displaying sexually aggressive behaviors. This deficient practice resulted in R48 being sexually and physically assaulted. Cross-reference: F600 2. Administration failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of seven residents (R) (R121) reviewed for behavioral care services. Specifically, the facility did not complete a thorough investigation (monitoring) of residents with inappropriate behaviors to ensure they have a non-pharmacological intervention implemented. Cross-reference: F740 3. Administration failed to ensure concerns were identified and QAPI plans implemented related to the abuse prevention system, including resident-to-resident physical and sexual abuse, and implementing all components of the abuse policies. Cross-reference: F867 A review of the local police Incident Report dated 9/28/2024 revealed that an officer responded to the facility at approximately 9:30 pm in reference to an aggravated sexual battery. R48's roommate explained that R121 came into their room, grabbed R48, and pushed her down. R48 stated, he stuck his finger up my vagina, and R121 was holding his hand over her mouth. The roommate explained that staff removed R121, but he returned to get his shoe, and staff removed him from the room again before retrieving his shoe. The officer documented the shoe beside the roommate's bed. LPN CC stated to the officer that she witnessed R121 on top of R48 with his hand in the area of her vagina and explained that she then pulled R121 off her. The officer asked R121 several basic questions to assess his mental capabilities, and R121 replied several more times with I don't know. The nursing staff at the facility indicated that they believed R121 was pretending to be mentally incompetent. The Director of Nursing (DON) informed the officer that R121 was on probation. However, the officer later discovered that R121 was on parole. The DON additionally explained that she had been getting reports from staff that R121 had been threatening to rape them over the past couple of weeks. R121 was arrested on 9/28/2024. The officer did respond to the hospital, where he met the SANE nurse, and she explained she had performed a sexual assault exam. At that time, the SANE nurse turned over the sexual assault exam evidence to the officer. Interview on 3/25/2025 at 12:27 pm with R48 reported that man came into her room and threw her down on the floor and stuck his hand into her diaper and her vaginal area. She stated that the police were called. The man is no longer here, and she couldn't remember his name. R48 stated the man was a resident at the facility. Interview on 3/26/2025 at 2:10 pm with the Administrator reported that she cannot recall the incident with R121 and R48 in detail. She remembers reporting the incident to the State based on what the nurse told her. The nurse reported that the resident, R48 stated that R121 had his hand in her vagina. The Administrator further revealed that she thinks what their investigation revealed was not actually the truth. She wrote exactly what R48 said in the Facility Reportable and the 5-Day Report. Further interview with the Administrator on 3/28/2025 at 1:44 pm revealed that the QAPI team did not change any procedures after months of abuse allegations, but did tell nursing staff to report immediately to the Director of Nursing (DON) and Administrator. The Administrator stated that her phone number is posted on the nursing station wall if she is not at the facility for the night shift. The Administrator revealed there are several sexual abuse allegations, resident-to-resident and staff-to-resident, but at this time, no other processes or procedures were changed after resident R121 sexually abused resident R48. Interview on 4/1/2025 at 9:58 pm, the DON confirmed behavioral health notes, confirmed that R121 was seen by the behavioral consultant on several scheduled visits to the facility, and non-pharmacological interventions were in place. However, there was no evidence that nonpharmacological interventions for sexual behaviors were implemented or documented. The facility implemented the following actions to remove the IJ: 1. Police was notified by DON regarding the incident for R121 and an arrest was made on 9/28/2024 at 9:30 pm. 2. On 03/31/2025- Ad hoc QAPI and performance improvement plan (PIP) was developed and initiated by the Director of Quality and Regulatory Services (DOQRS). The meeting discussion included plan development and citations issued for F-835, F-867, F-600, and F-740. In attendance to the meeting were: Division vice president, Administrator, Division nurse, Director of nursing, licensed nurse, Medical director, Social Service, Financial controller, Maintenance Director, Resident assessment instrument nurses, Wound care nurse, Environmental services director, Activity director, health information manager Environmental/ laundry supervisor, Admission nurse, HR Partner service, scheduler, for the accident. The Medical Director was made aware on 3/31/2025 by the Director of Nursing. The existing Abuse policies were reviewed and concluded no revisions were needed. 3. On March 28, 2025, the 2025 Division [NAME] President provided education to the Administrator on job description to include roles, responsibilities, and duties to ensure the safety of all residents. Education provided on the abuse prohibition policy to include reviewing adverse events during QAPI, recognizing trends to create proactive measures to reduce further reduce reoccurrences to ensure the safety of all residents. Administrator 1 of 1. 4. Corrective action for other residents having the potential to be affected by the same deficient practice. 5. All residents who reside in the center have the potential to be impacted by the deficient practice. 6. Systemic changes were made to ensure that the deficient practice would not recur. 7. Starting on March 25, 2025, oversight was provided by the Divisional Nurses {DN), Program Director of SSD, and Divisional [NAME] President (DVP) to ensure the Administrator and the DON were informed about and adhered to the Abuse policy in their day-to-day operations. On 3/28/2025, the administrator was placed on administrative leave pending investigation, and oversight was provided by the Senior Director of Clinical Services (SRDCS). On March 31, 2025, oversight was provided by the Senior Director of Clinical Services (SRDCS), Program Director of SSD, and Director of Quality and Regulatory Services (DQRS). Education was provided to Administrator Assistant on 3/31/2025 by DVP to ensure the day to day operations were being followed to include adhering to the Abuse policy, QAPI education was also provided to the leadership team to include monitoring and follow-up for adverse events and being proactive by tracking and trending to identified what resources are needed to be proactive when inappropriate behavior is noted by Director of Quality and Regulatory Services and Sr Director of Clinical Standards. DVP, Sr. DCS, and DORQ confirmed that education had been completed with staff on abuse, including intervening to protect a patient from further abuse. On March 31, 2025, DVP and/or DN completed a review to ensure that audits were completed for F600, F867, and F740, ensuring that patients were safe, and that staff understood the education on non-pharmacological interventions for inappropriate sexual behavior, and QAPI review completed as indicate on reportable for trends. Audits will continue until the removal of IJ. 8.Quality Assurance Plans were implemented on 3/31/2025 to monitor facility performance, ensuring that corrections are implemented and remain permanent. An audit tool was developed and initiated by the Assistant Administrator and is being used daily to monitor the implementation of the Plan of Correction. The Assistant Administrator, Director of Nursing, or Assistant Director of Nursing will be responsible for ensuring the completion of this tool. The audits will be validated by the Governing body to include DVP, SrDCS, DOQR, and/or DN. The results of the monitoring completed under this plan of correction will be submitted monthly to the QAPI committee for review and further follow-up. The Audit tool will continue until the QAPI committee deems it is no longer necessary. Any noncompliance noted will be addressed through written education by the Divisional [NAME] President. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1.Verified by Record Review on 4/3/2025 at 12:47 pm. Offense/Incident Report revealed that the DON called the local county sheriff's office regarding the incident. It stated that the local sheriff reported to the facility and that R121 was arrested for aggravated sexual battery on 9/28/2024 at 9:30 pm. There were no concerns identified. 2.Verified by interview and record review. On 4/3/2025 at 1:10 pm the record review revealed that a Quality Assurance/Performance Improvement (QAPI) meeting was held on 3/31/2025 at 2:30 pm and the Skilled Nursing Services: Abuse Prohibition - Reporting and Investigating was reviewed on 3/28/2025. Review of the sign-in The sheet revealed that a certain staff member's signature was not listed. Interview at 1:20 pm with the Senior Director of Clinical Standards, stated that she and Director of Regulatory and Quality wrote version the removal plan and made some mistakes. She stated that the removal plan state that the administrator did not attend the meeting; however, the assistant administrator attended the meeting in her place. She stated that the Division Nurse was herself; however, Division Nurse attended the meeting on the phone. Interview with Assistant Activities Director, verified that she attended the meeting in the place of the Activities Director and did not sign into the meeting. Interview at 2:08 pm with LPN GG and LPN HH, stated that they attended the QAPI meeting on 3/31/2025, verified their signature on the sign-in sheet, and were educated on the Abuse Policy. Interview on 4/3/2025 at 2:35 pm with the Assistant Administrator stated that she attended the QAPI meeting and verified her signature. She stated that the abuse policy was reviewed, and they found no changes needed to be made to the policy. 3.Verified by interview and record review. Interview on 4/3/2025 at 2:35 pm with the assistant Administrator stated that she attended the Administrator's in-service and education which was held on 3/28/2025. She stated that the Divisional [NAME] President gave the in-service education and explained to the Administrator everything that she needs to do regarding investigating and reporting. She stated that the Divisional [NAME] President went off the facility's policy. Record review revealed that an in-service Quality Assurance/Performance Improvement (QAPI) meeting was held on 3/31/2025 at 2:30 pm and the Skilled Nursing Services: Abuse Prohibition - Reporting and Investigating was reviewed on 3/28/2025. Review of the sign-in sheet revealed that a certain staff member's signature was not listed. Interview at 1:20 pm with Senior Director of Clinical Standards, stated that she and Director of Regulatory and Quality wrote Version the removal plan and made some mistakes. She stated that the removal plan state that the administrator did not attend the meeting; however, the assistant administrator attended the meeting in her place. 4.Verified by Interview and Record Review on 4/3/2025. Interview at 2:08 pm with LPN GG and LPN HH, stated that they have Quality Improvement Data Collection Grid to use as the corrective action to monitor residents that may have been potentially affected by the incident. Record review revealed that all the residents had been monitored and tracked using the Quality Improvement Data Collection Grid. The Administrator, the DON (3/28/2025), and Administrator Assistants (3/31/2025) were informed about and adhered to the day-today operations of monitoring and reporting abuse to ensure residents were safe. 5.Verified by Interview and Record Review on 4/3/2025. Interview at 2:08 pm with LPN GG and LPN HH, stated that they have Quality Improvement Data Collection Grid to use as the corrective action to monitor residents that may have been potentially affected by the incident. Record review revealed that all the Residents were monitored using the Quality Improvement Data Collection Grid. The Administrator, the DON (3/28/2025), and Administrator Assistant (3/31/2025) were informed about and adhered to the day-today operations of monitoring and reporting abuse to ensure residents were safe. 6.Verified by Interview and Record Review on 4/3/2025. Interview at 2:08 pm with LPN GG and LPN HH, stated that they have Quality Improvement Data Collection Grid to use as the corrective action to monitor residents that may have been potentially affected by the incident. Record review at 3:40 pm revealed that the systematic changes that were made to ensure that deficient practices would not occur were the following: Quality Improvement Grid; Baseline Review - nonpharmacological interviews; and monitoring and tracking of residents with inappropriate behaviors. 7.Verified by Interview and Record Review on 4/3/2025. Interviewed the DON and ADON at 4:25 pm revealed that they were informed and implemented the Abuse policy in their day-to-day operations. They stated that they are completing the Quality Improvement Data Collection Grid every day to monitor, track, and followup inappropriate behaviors and submit the form to the assistant Administrator. They stated that after receiving the form, the assistant Administrator will submit it to the Senior Director of Clinical Services. They stated that the educate the staff on abuse individually or by a group. They stated that if they educate them as a group, they would have it in the morning or in the afternoon located in the lobby. They stated that they have three different shifts, so staff is educated around the clock. They stated that they monitor the residents by reviewing any initial events, notes or change in conditions during the clinical meeting and will complete the proper assessment if needed. Interview at 4:55 pm with the Senior Director of Clinical Services revealed that the Administrator and the DON were informed about and adhered to the Abuse policy in their day-to-day operations. She confirmed that on 3/28/2025, the Administrator was placed on administrative leave pending investigation. She confirmed that education was provided to the Administrator Assistant on 3/31/2025 to ensure the day-to-day operations were followed, including adhering to the Abuse policy. She confirmed that QAPI education was also provided to the leadership team to include monitoring and follow-up for adverse events by tracking and trending for inappropriate behavior. She confirmed that education had been completed with staff on abuse, including intervening to protect a patient from further abuse. She also confirmed that on March 31, 2025, a review was completed to ensure that audits were completed for F600, F867, and F740, ensuring that patients were safe, and that staff understood the education on nonpharmacological interventions for inappropriate sexual behavior. She confirmed that audits will continue until the removal of IJ. Review if the records at 4:05 pm revealed that the Quality Improvement Data Collection Grid is completed daily. It revealed that on 3/28/2025, the administrator was placed on administrative leave pending investigation. Record review revealed that all the residents had been monitored using the Quality Improvement Data Collection Grid. Record review revealed that an in-service Quality Assurance/Performance Improvement (QAPI) meeting was held on 3/31/2025 at 2:30 pm, and the Skilled Nursing Services: Abuse Prohibition - Reporting and Investigating was reviewed on 3/28/2025. A record review revealed that an audit was completed to ensure that audits were completed for F600, F867, and F740. 8.Verified by Interview and Record Review on 4/3/2025. Interviewed the DON and ADON at 4:25 pm revealed that they were informed and implemented the Abuse policy in their day-to-day operations. They stated that they are completing the Quality Improvement Data Collection Grid every day to monitor, track, and follow-up inappropriate behaviors and submit the form to the Assistant Administrator. They stated that after receiving the form, the Assistant Administrator will submit the form to the Senior Director of Clinical Services. They stated that they educate the staff on abuse individually or in a group. They stated that if they educated them as a group, they would have it in the morning or the afternoon, located in the lobby. They stated that they have three different shifts, so staff are educated around the clock. They stated that monitor the residents by reviewing any initial events, notes, or changes in conditions during the clinical meeting and will complete the proper assessment if needed. Interview at 4:55 pm with the Senior Director of Clinical Services revealed that the Administrator and the DON were informed about and adhered to the Abuse policy in their day-to-day operations. She confirmed that on 3/28/2025, the Administrator was placed on administrative leave pending investigation. She confirmed that education was provided to the Administrator Assistant on 3/31/2025 to ensure the day-to-day operations were being followed to include adhering to the Abuse policy. She confirmed that QAPI education was also provided to the leadership team to include monitoring and follow-up for adverse events by tracking and trending for inappropriate behavior. She confirmed that education had been completed with staff on abuse, including intervening to protect a patient from further abuse. She also confirmed that in March 31, 2025, a review was completed to ensure that audits were completed for F600, F867, and F740, ensuring that patients were safe, and that staff understood the education on non-pharmacological interventions for inappropriate sexual behavior. She confirmed that audits will continue until the removal of IJ. On 4/3/2025 verified by record review of an audit titled, Quality Improvement DATA Collection Grid. Indicators: 1. Any noted sexually inappropriate behavior. 2. If so, were non-pharmalogical interventions implemented 3. Care Plan updated. 4. Was change in conditions completed? This tool will indicate whether the indicator was met, three residents were identified no to all indicators and was implemented on 4/3/2025, 4/2/2025, and 4/1/2025. On 4/3/2025 verified by interview with DON that audits will be continued until QAPI committee deems to no longer need audits. DON also confirmed that audits are implemented daily and reported to Administrator Assistance. She explained that the IJ tags are audited based on expectations of monitoring for tracking of residents with inappropriate behavior. All corrective actions were completed on 3/31/2025. The facility alleges that the IJ was removed on 4/1/2025.

Based on staff interview, facility document review, and review of the facility policy titled, Quality Assurance/Performance Improvement, the facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program regarding the facility's Performance Improvement Plan (PIP) for Sexual Abuse. This had the potential to affect all residents of the facility. On 3/31/2025, a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Senior Director of Clinical Standards, Director of Quality and Regulatory Services, Director of Nursing (DON), and Assistant Administrator were informed of the Immediate Jeopardy (IJ) on 3/31/2025 at 10:45 am. The noncompliance related to the IJ was identified to have existed on 9/28/2024 when R121 sexually abused R48 inside her room. An acceptable Removal Plan was received on 4/1/2025. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on 4/1/2025. The facility remained out of compliance while the facility continued management level staff oversight as well as developed and implemented a Plan of Correction (POC). This oversight process included the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to Abuse, Neglect, and Exploitation, and the behavioral health needs of residents. Findings include: Review of the facility policy titled, Quality Assurance/Performance Improvement Plan Revised April, 2,2001 revealed, The Center's Quality Assurance - Performance Improvement (QAPI) Process is a systemic organized approach to quality assurance and performance improvement. The process is designed to be systematic, comprehensive, data-driven, proactive approach to performance management and improvement utilizing the five elements of QAPI of 1) design and scope 2) governance and leadership 3) feedback, data analysis and systematic action. The QAPI Process supports the center's mission and vision. It is the aim of the QAPI Process to take a consistent, proactive approach to continually improving the way our center cares for and engages with our patients, associates and other customers so that we may realize our vision to be the leader in long term care by improving the care and services to enhance the quality of life of the patients we serve. On April 1, 2025, a record review of a section of the policy titled, Governance and Leadership revealed that the facility failed: 4. To identify and prioritize problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. 5. To implement an Action Plan addressing gaps in systems, and are evaluated for effectiveness; and 6. To create clear expectations that are set around safety, quality, rights and choice, and respect. On March 28, 2025, a record review of QAPI minutes revealed on June 28, 2024, July 31, 2024, August 26, 2024, October 15, 2024, December 19, 2024, and January 15, 2025 allegations of some form of sexual abuse/ abuse were made to the facility for resident to resident or staff to resident. At the bottom of the listed meeting minutes, notes state, QAPI team, no noted changes in procedure. A record review on March 28, 2025, titled Performance Improvement Projects (PIP) revealed, PIPs are charted and implemented through the QAPI committee based on priority as aligned with key customer expectations, center strategic objectives, and resource availability. At least annually, a PIP that focuses on high-risk or problem areas should be charted. Concurrent PIPs team should include a PIP Project Leader to lead the team, contain scope, focus on PIP objective and manage within available timeframe, PIP team members should include representatives from various departments/units'/ shifts as affected and associates who work with system/process on daily basis. During the PIP team charter, each PIP project leader will be charged with leading the team in the root cause analysis to determine the underlying causes of issues, rather than applying quick fixes that address symptoms only. The PIP Team leader is responsible for documenting the work of the PIP team, which should include highlights of the teamwork progress made and lessons learned. PIP documents will be maintained as part of the QAPI records. The PIP team leader should provide updates on PIP's work to the QAPI committee. The copy committee retains the right to recharter or discontinue PIPs. The Administrator is responsible for ensuring that PIP team members are enabled to meet and carry out PIP team functions for performance improvement purposes. On March 28, 2025, a record review of the facility's PIP dated November 11, 2024, December 12, 2024, and December 10, 2024, provided by the facility revealed a problem with residents inappropriate touching, resident to resident abuse, and resident staff abuse. Documentation was found on March 31, 2025. The PIP consisted of the problem statement and the root cause, with goals identified, no baseline data, or barriers established. Completion date marked as ongoing. No further information was provided to the survey team. Residents were not identified in the PIP on the Quality Assurance Event form. An interview on March 28, 2025, at 1:44 pm with the Administrator revealed that the QAPI team did not change any procedures after months of abuse allegations, but did tell nursing staff to report immediately to the DON and the Administrator. The Administrator stated that her phone number is posted on the nursing station wall if she is not at the facility for the night shift. Further, interview revealed that staff do not begin reporting until it is discussed with the DON and Administrator, so that they can get facts. There are several sexual abuse allegations between residents and staff to residents but at this time, no other processes or procedures have been changed after resident R121 sexually abused resident R48. The procedure for handling sexual abuse is to notify the police, ambulance, family, and physician. We have not changed any procedures. Cross-reference: F600, F740, and F835 The facility implemented the following actions to remove the IJ 1. The QAPI committee met on 3/31/2025 and reviewed the reportable adverse events from February 27, 2025, to March 31, 2025, to determine if any trends were identified. During the meeting the center did note that some behaviors were a result of GDRs and established a conununication tool to provide to the behavioral health provider upon entrance and to schedule an exit meeting after the visit to include review of GDRs. 2. An ad hoc meeting was held by the Director of Quality and Regulatory to review F-835, F-867, F-740, and F-600, and a performance improvement plan was developed. For F600 the policy for abuse education was reviewed to include response to sexual abuse, Non-Pharmacological Interventions to manage behaviors, Patient interviews completed on 3/31/2025 by social service director to interviewIO residents to ensure they feel safe and IO associates interviews to ensure they know process for reporting and can identify abuse to include sexual and physical aggression. Audit will continued until IJ removed. F867 - QAPI education was provided to include trending RCA to analyze resources needed to decrease or prevent reoccurrence. Communication tool was developed and implemented on 3/31/2025 by DON to improve the communication between the behavior provider and center to provide notification of any recommendations timely. The behavior provider will meet with the DON, ADON, and/or nurse supervisor upon entrance and exit to make aware of any new recommendation and to receive report of new adverse events. Nurse Managers will update the patient care plan with any non-pharmacological interventions to the patient care plan. For F740 an audit tool was developed by DON on 3/31/2025 to review patients with inappropriate behaviors to ensure they have a non-pharmacological interventions noted on care plan. Audit will continued until lJ removed. Education of this process has been provided to the nurse leadership and behavior provider on 3/31/2025 by the DON. Any noncompliance will be brought back through QAPI process and addressed tlu [NAME] the PDSA framework to identify RCA tlu-[NAME] the QAPI committee. For F835 a daily review for oversight will be completed by the Divisional [NAME] president and/or Senior Director of Clinical Standards to ensure that audits were completed for F600, F867, and F740, ensuring that patients were safe and that staff understood the education on non pharmacological interventions for inappropriate sexual/physical behavior, and QAPI review completed as indicate on reportable for trends. Any noncompliance noted will be addressed through written education by the Divisional [NAME] President. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. On 4/3/2025 at 12:55 pm verified by record review of a 5-way tool was used during QAPI meeting that held on 3/31/2025 at 2:30 pm. The tool determined that root causes were a result Gradual Dose Reduction (GDR)s of some behaviors. They established a communication tool with titled {Named} Visits Communication dated 4/1/2025. The tool is broken into 4 identified components routine visits, acute episode, GDR and Added to PAR. {Named} visit. On 4/3/2025 verified by interview with facilities Management Supervisor who revealed that he attended the QAPI meeting on 3/31/2025 at 2:30pm. On 4/3/2025 at 1:48 pm DON revealed that she was in the QAPI meeting that was held on 3/31/2025 and a discussion of all IJ tags and they discussed behaviors and GDR reviews. On 4/3/2025 at 3:45 pm verified by record review of QAPI minutes were reviewed along with attendees sign in sheets all QAPI committee was present except for Administrator. On 4/3/2025 at 3:45 pm verified by record review revealed that on March 28,2025, the governing body held in service education to the Administrator, the divisional vice president, educated her on the process to follow when reporting abuse, the QAPI role, responsibilities, and her duties as the Administrator to ensure the safety of the patients. On 4/3/2025 at 2:27 pm LPN GG confirmed that she attended QAPI meeting during the meeting they discussed the IJ tags. On 4/3/2025 at 2:27 pm LPN HH confirmed that she attended QAPI meeting they discussed the communication tool that they will be utilizing with {Named} Behavioral Health monitor residents with sexual behaviors and behaviors. 2. On 4/3/2025 at 2:02 pm verified by record review of an education titled, Behavior Health Process dated 3/31/2025, presented by Senior Director of Clinical Standards. On 4/3/2025 at 2:08 pm Licensed Practical Nurse (LPN) GG confirmed that she was educated on the process of an audit that will be conducted as the {Named} Behavioral Health enters and exits the facility. In further interview she revealed that they will identify residents that are acute episode and routine visits. The communication between {Named} Behavioral Health and nursing staff will increase to ensure that residents are being identified if medications are changed or if interventions are added for sexual behaviors or behaviors. On 4/3/2025 at 2:27 pm LPN HH confirmed that she attended QAPI meeting and she was educated on 3/31/2025 titled, Behavior Health Process presented by Senior Director of Clinical. In further interviews she revealed that this audit has been conducted since 4/1/2025 the indicators: 1.Were there any self-reportable for sexually inappropriately behaviors submitted? 2. If so, was there an RCA completed to identify trends? LPN GG revealed that no reports were reported to nursing leadership on 4/1/2025, 4/2/2025, or 4/3/2025. A record review conducted on 4/3/2025 at 2:47 pm of the Quality improvement Data Collection Grid was implemented by nursing staff submitting information to assistant Administrator and reviewed by Senior Director for 4/1/2025, 4/2/2025 and 4/3/2025.The results self-reportable for sexually inappropriate behaviors were submitted no reports. On 4/3/2025 Certified Nursing Assistant (CNA) BB revealed that she is aware that they must report any sexual abuse behaviors for all residents she works on the memory unit. An observation was conducted on 4/3/2025 at 3:33 pm on memory unit residents were singing and calm in TV room no sexual behaviors were seen or heard. Staff were involved with residents and CNAs and Nursing staff are monitoring residents. Residents were observed in TV room CNAs were in room observing residents. On Hall C residents were seen in halls chatting with one another no sexual abuse seen or heard on halls. Residents are communicating with each other no issues found. Nursing staff are visible and monitoring and interacting with residents. On 4/3/2025 at 3:53 pm an audit of reportable in the last 30 days has been identified on 3/31/2025 of 6 residents that were identified with the date of incident and nature of incident. All corrective actions were completed on 3/31/2025. The Facility alleges IJ Removal 4/1/2025.

Based on observations and staff/resident interviews, the facility failed to ensure that privacy curtains provided full visual privacy for two residents (R) (#56 and #59) of 31 sampled residents. Findings include: 1. Observations on 7/12/2021 at 10:30 a.m., 7/13/2021 at 12:00 p.m., 7/14/2021 at 11:00 a.m. and 7/15/2021 at 9:15 a.m. of R#56 revealed the privacy curtains did not provide full visual privacy. 2. Observations on 7/12/2021 at 10:31 a.m., 7/13/2021 at 12:01 p.m., 7/14/2021 at 11:01 a.m., and 7/15/2021 at 9:17 a.m. of R#59 revealed the privacy curtains did not provide full visual privacy. During an interview on 7/13/2021 at 9:08 a.m., R#56 revealed her preference is to have privacy curtains that provide full coverage. She reported not wanting to be exposed to others when attempting to provide self-care or dress herself. R#56 described the task of using the bathroom to dress and undress as an inconvenience for herself. She further stated certified nursing assistants (CNAs) and licensed nursing staff were aware of the gap in her curtains (which prevented closure) and that she used the bathroom (shared with four other residents) to dress and undress. However, no one had tried to fix the curtain. During an interview on 7/14/2021 at 1:30 p.m., R#59 reported being aware of the short privacy curtains but always used his bathroom to dress and undress himself to prevent exposure from his roommates and others. He was unaware that his privacy curtains should provide full coverage to prevent exposure to others. R#59 stated that since he did not know about this, he really did not care or think about addressing to staff the issue with the gap in his curtains. R#59 reported being just fine with using the bathroom and no facility staff had attempted to fix his curtains. During an interview and observation on 7/15/2021 at 9:10 a.m., the Environmental Services Supervisor (EVS) was observed attempting to hang privacy curtains on Hall C. The EVS reported that he was informed to hang privacy curtains yesterday and this morning by the Administrator. He reported that the additional curtains were from the facility storage building. Environmental tour and interviews were conducted on 7/15/2021 at 9:22 a.m. through 9:36 a.m. with the Administrator, EVS, Maintenance Supervisor (MS), and the Director Nursing (DON). During the tour, the MS measured the gap in the privacy curtains for R#59 and the gap measurement no less than 24 inches. The privacy curtain gap for R#56 had a width of 32 inches. Interview on 7/15/2021 at 9:30 a.m. with the Administrator revealed being unaware about the gap in privacy curtains which failed to provide full visual privacy. The Administrator further stated that she had not toured the residents' rooms in a long time. She confirmed that the gaps in the curtains were a result of the curtain width measurements, missing curtains, missing hooks, or jams due to curtain rods requiring repairs. The Administrator stated her expectations are for all curtains to provide full visual privacy and staff to report any curtain that needs repair. She stated that Environmental Services are responsible for hanging privacy curtains. During an interview on 7/15/2021 at 9:20 a.m., the DON reported that she was unaware of the issue with privacy curtains which failed to provide full visual privacy for the residents on Hall C. The DON reported that her expectation is for the residents to have privacy curtains in their room that ensure privacy. She reported that she had not looked at any of the rooms identified during the survey for short privacy curtains on Hall C. The DON further stated that her expectations are for the CNA's or licensed nursing staff to report any concerns with short privacy curtains.

Based on observations and interviews, the facility failed to ensure the upkeep of one resident's (R) wheelchair related to rust, dirt, and debris (R#19) and failed to ensure a mattress was free of sagging and indentations for one resident (R#56). The facility failed to ensure that bedside rolling table were free of rust in rooms 26A and 27A. In addition, the facility failed to ensure that two residents' bathrooms were free of strong urine odor (23A and 27A). The facility census was 65. Findings include: 1. Observations on 7/12/2021 at 10:30 a.m., 7/13/2021 at 12:00 p.m., 7/14/2021 at 11:00 a.m., and 7/15/2021 at 9:15 a.m. of room 27A revealed three rolling bedside tables heavily covered in rust. In room 26A there was one rolling bedside table heavily covered in rust. 2. Observations on 7/12/2021 at 10:31 a. m., 7/13/2021 at 12:01 p.m., 7/14/2021 at 11:01 a.m., and 7/15/2021 at 9:16 a.m. revealed R#19's wheelchair was covered with dark brown sticky speckle substances on the wheels and frame of the wheelchair. A closer observation revealed also rust on the tippers of the wheelchair. The wheelchair arm rests were badly torn and cracked. 3. Observations on 7/12/2021 at 10:30 a.m., 7/13/2021 at 12:00 p. m., 7/14/2021 at 11:00 a.m., and 7/15/2021 at 9:16 a.m. revealed R#56 had a mattress that was sagging and worn with indentations. R#56 was observed sitting on her mattress each day. R#56's mattress sagged more and unleveled while sitting on the mattress. 4. Observations on 7/12/2021 at 10:30 a.m. and 2:01 p.m.; 7/13/2021 at 9:41 a.m. and 12:00 p.m.; 7/14/2021 at 11:00 a.m. and 2:01 p.m., and 7/15/2021 at 9:16 a.m. revealed a strong urine odor in room 27A and room 23A. During an interview on 7/12/2021 at 10:33 a.m., R#56 reported that she had requested a mattress replacement by making a verbal request to one of the facility nurses. She could not recall the nurse's name. R#56 stated that her mattress conditions had existed for months. She had expressed her concerns with the nurse that the mattress was very uncomfortable for her. She reported that the nurse never got back with her about a mattress replacement. R#56 reported that she was not sure if the mattress was going to be replaced. Environmental tour and interviews began on 7/15/2021 at 9:30 a.m. and ended at 10:45 a.m. with the Environmental Services Supervisor (EVS), the Administrator, and the Director of Nursing (DON). During the tour on 7/15/2021 at 9:33 a.m., the EVS revealed the following: the rust and strong urine odor in the resident's bathroom in room 27A was a result of cracked tiles and the male residents in the room urinating repeatedly in the cracks. He stated that he was aware of the problem which was identified months ago by himself and his housekeeping staff. He stated to eliminate the problem the tile will have to be replaced. He further stated that the dark brown sticky substances encircling the base of the commode should had been removed. He was not sure if the cleaning products could remove the dark stains. The EVS stated that he has attempted to clean the bathroom on several occasions and confirmed the strong urine odor in room 23A was because of the floor tiles as well. During the tour on 7/15/2021 at 9:31 a.m., the DON revealed that she was unaware of the urine odor in the resident bathrooms. She confirmed that she was not aware of the condition of R#19's wheelchair. The DON confirmed that the wheelchair was in poor condition with rusty wheels and frame. She confirmed that the bedside rolling tables were covered in rust. She stated that there is a staff member who monitors resident mattresses for replacement. The DON stated that R#56's mattress can be replaced today. She further stated that she was unaware of the condition of R#56's mattress. During the tour on 7/15/2021 at 9:33 a.m., the Administrator confirmed that the strong urine odor existed in the residents' bathrooms in room 27A and room 23A. She reported that environmental staff are responsible for cleaning bathrooms daily to prevent urine odor. She was unaware of the cracked and stained tiles in the resident's bathroom. The Administrator confirmed the three rusty bedside tables in room 27A and the one rusty bedside rolling table in room 26A. She reported being unaware of the rusty conditions of the bedside tables. She reported that the bedside tables can be replaced with new rolling tables. The Administrator was able to observe R#19 sitting in his wheelchair in the smoking area. She confirmed that the wheelchair was in poor condition, was badly rusted and needed to be replaced. The Administrator reported that her expectation is for staff to have durable medical equipment that is in good repair including bed mattresses and that bathrooms are free of urine odor.

Based on record review, review of the facility policy titled Skilled Inpatient Services Abuse Prohibition and staff interviews, the facility failed to ensure that three residents (R) (#7, #16, and #53) were protected from resident-to-resident physical abuse, of 31 sampled residents. Findings include: Review of facility policy titled Skilled Inpatient Services Abuse Prohibition dated 2020 documented: It is the intent of this center to actively preserve each patient 's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. We believe that each patent has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. During an initial tour of the facility and interview on 7/12/2021 at 10:41 a. m., R#51 pointed to her shoulder and stated that another resident had physically abused her. R#51 stated that she was in pain. She complained of being physically attacked during a resident-to-resident altercation. R#51 stated that she was upset and wanted something to be done. Later during the initial interview, R#51 was able to identify the other resident involved by her name. Record review revealed R#51 had the following of Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R#51 had a Brief Interview of Mental Status (BIMS) score of 14, indicating cognition intact. Further record review of the Facility Room Census revealed that R#51 had several room changes due to resident to resident altercations (room changes made 8/16/2020, 9/1/2020, and 7/7/2021). Further investigation revealed the following incidents involving R#51: 1. Record review revealed R#7 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R#7 had a Brief Interview of Mental Status (BIMS) score of 99. Review of Facility Incident Report Form dated 2/18/2021 revealed R#51 hit R#1 in the face with a pack of wipes, no injury. Neurological checks were initiated. 2. Review of the clinical record revealed R#53 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Incident Report Form dated 6/20/2021 documented R#53 was in shared bathroom when R#51 came in and began yelling at her to get out. According to residents, R#53 hit R#51 on left side of the face multiple times and R#51 hit R#53 on her back. Redness noted to left side of R#53's face. 3. Record review revealed R#16 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R#16 had a BIMS score of 9. Review of the Facility Incident Report Form dated 7/4/2021 revealed R#16 was watching television (TV) in the tv room and was hit by her roommate, R#51. R#51 was arguing at her, got up and hit R#16 on her arm and in her face. R#16 in return hit her roommate (R#51) back striking her on the arm, leaving her with a redden mark on her right forearm area. No further injuries were noted. Residents were separated and redirected. Both R#51 and R#16 suffered minor injuries. R#51 noted with a reddened area to her deltoid and R#16 had reddened area to her right forearm. Record review documented Physician medications review dated 7/8/2021 for R#51 due to behavior on 7/4/2021. The following physician recommendation were implemented: Increase [MEDICATION(S)] to 250 milligrams (mg) by mouth twice per day for mood stabilization and episodes of agitation. Increase [MEDICATION(S)] to 100 mg by mouth twice per day for [CONDITION(S)]. Record review revealed R#51 received psychiatric counseling services on 7/8/2021 immediately after the resident-to-resident altercation incident that occurred on 7/4/2021 with R#16. Recommendations were implemented to add [MEDICATION(S)] 250 mg at 1:00 p.m. daily. Interview on 7/14/2021 at 2:33 p.m., the Social Service Director (SSD) reported that R#51 rarely has any incidents of abuse, unless she becomes angry with someone. R#51 is receiving counseling services. She does not consider R#51 to be a threat to the general population of other residents. She rarely displays aggressive behavior unless someone gets in her way. She feels that R#51 has control and able to control her rage of anger. Interview 7/15/2021 at 11:04 a.m. with Certified Nursing Assistant (CNA) AA revealed that R#51 never hits staff and will hit those residents who she feels will not hit back. She described the resident as attention seeking, demanding at times, and wanting her way. This resident can be very inpatient. She will initiate a fight if she feels she can win. She feels this resident has self-control of her behavior and aware of her negative behavior. During an interview on 7/15/2021 at 11:21 a.m., Licensed Practical Nurse (LPN) BB reported that R#51 is known to become inpatient and demanding towards others. R#51 has never tried to hit or strike out at staff. She feels R#51 has self-control and is aware of her negative behaviors.

Based on interviews and record review, the facility failed to accurately assess one resident (R) #1, as high-risk for elopement on admission (resident had a known history of elopement and attempted elopement) resulting in the resident successfully eloping on [DATE]. The facility failed to re-assess the resident and his elopement risk after his return. He eloped again on [DATE] with his remains found on [DATE]. The Sample size was six residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately a quarter of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Clinical record review for R#1 revealed the resident had the following diagnoses, including but not limited to: unspecified [MEDICAL CONDITION], generalized anxiety disorder, adjustment disorder, unspecified dementia, [MEDICAL CONDITION], and dementia with behavior disturbance. Review of R#1's Minimum Data Set (MDS) annual review dated [DATE] revealed under Section C - Cognition, that resident is severely cognitively impaired. Under Section E - Behaviors, R#1 is not coded for wandering behavior, but his previous MDS assessments from [DATE] through [DATE] were coded for wandering. Resident also had delusions, exhibited verbal behaviors ,[DATE] days of the review period and exhibited other behaviors ,[DATE] days of the review period. Under section G- Functional Status, the resident required supervision for most activities of daily living, but needed extensive assistance to dress and maintain personal hygiene. Review of 'Interdisciplinary Progress Notes' dated [DATE] recorded by nursing staff revealed an assessment for a fall that occurred on [DATE] with an additional notation that read: 'also, at 4:35 p.m. staff member alerted nurse that (R#1) had left the premises. Nurse writer and 3 other staff members went outside to search for him. Resident had waked (sic) about 1 mile down HWY 46 and was returned to facility by staff member. Resident had no injuries noted to body, appeared to be in no distress. Resident showed nurse writer how he had gotten out. Apparently, while the heating and air service men were working on the unit they left the door open and resident walked outside. Resident stated, I'm sorry, I was just trying to get home'. Continuing review of the 'Interdisciplinary Progress Notes' related to the elopement reveals there was no follow-up documented or re-assessment recommended. Review of R#1's current 'Plan of Care' for wandering/elopement revealed it originated on [DATE] and had not been updated or revised related to the elopement on [DATE]. Problem 004, on page 4 of the plan of care reads as follows: Resident has the potential for leaving the facility grounds due to poor decision making skills. He requires supervision and redirection throughout the day. Under 'Goals', dated [DATE], it reads: Resident will not leave the facility grounds without an escort through next review. There are 4 'Interventions' listed to meet this goal, all dated [DATE], that read as follows: 1. Cue & Redirect as needed 2. Involve resident in activities as a diversion, encouraging resident to attend activities of preference. 3. Observe resident's location & redirect as needed 4. Notify MD (Medical Director) as needed. Under 'Start Date' for the 'Interventions' are two handwritten dates, [DATE] and [DATE], but no additional interventions or revisions are recorded. Interview on [DATE] at 11:10 a.m. with the DON who confirmed that the resident had previously eloped in 2015 under similar circumstances. She further states that the facility made a policy change requiring that the security codes on the doors be changed monthly after R#1's elopement in 2015. There was no follow-up investigation or tracking tool used to measure effectiveness of this intervention and no re-assessment of this resident or other residents at risk for elopement. Continuing interview with the DON revealed the facility had no formal assessment tool for elopement. The DON was not aware that the resident attempted to 'catch' doors before they closed, but was aware that he had entered other resident's rooms and was known to observe staff entering the code to open the secured doors and agrees that these should have been on the resident's care plan. The facility implemented the following actions to remove the Immediate Jeopardy 1. On [DATE] the Regional Nurse (RN), Director of Nursing (DON), Assistant Director of Nursing (DON) and one Resident Care Coordinator reassessed all patients to determine elopement risk using the elopement risk assessment tool. Fifteen out of eighty-one residents were identified as high risk. Care plans for these patients were reviewed and updates made as indicated by Resident Assessment Instrument (RAI) Coordinator, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. 2. On [DATE], the remaining care-plans that had been reviewed for elopement/wandering risk but were not high risk were reviewed for medium and low risk patients and were updated as indicated by RAI Coordinator, Restorative Nurse, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. 3. On [DATE], the Administrator and Director of Nursing educated the RAI Coordinator, Restorative Nurse, Assistant Director of Nursing, and two Resident Care coordinators on ensuring wandering risk, communication of any patient reviewing and revising patient care plans as patient's conditions change and their roles in the interdisciplinary team assessment and care planning process. 4. Education will be provided to licensed nurses on this process. There are currently nineteen on staff. This education will be provided by the Director of Nursing and will be completed by close of business on Friday, [DATE]. The education will begin at 4:00 p.m. and will end at 4:30 p.m. If all 19 licensed nurses do not participate, education will be provided to those who were unable to attend by Director of Nursing via telephone. Each nurse will be required to receive the education prior to providing patient care. 5. Newly hired nurses will be provided education on elopement risk assessment during orientation by the Director of Nursing or Assistant Director of Nursing. 6. Policy review was performed by the Vice President of Clinical Practice on [DATE]. Policy is being revised and will be implemented on [DATE] for center to perform elope risk assessments at least monthly due to patient population. 7. Patients will begin receiving elopement risk assessments at least monthly by licensed nurses with the baseline risk assessments being those performed on [DATE]. 8. All findings were entered into the QAPI program by the Administrator. This will continue to be reviewed by the Quality Assurance Performance Improvement (QAPI) team members during the monthly QAPI meetings until compliance is achieved and sustained. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Elopement Risk Assessment Tool was used for assessment of all residents resulting in 15 high risk residents identified. Elopement Risk Assessment Tool will be the new base-line going forward for assessment and re-admissions. 2. On [DATE] copies of the new care plans were reviewed for all residents in the high, medium, and low risk categories. All care plans had been updated as indicated by RAI Coordinator, Restorative Nurse, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. Review of updated care plans reveals appropriate new interventions have been added. 3. On [DATE] and [DATE], the Administrator and Director of Nursing educated the RAI Coordinator, Restorative Nurse, Assistant Director of Nursing, and two Resident Care coordinators using a printed Power Point tool that expanded on the interventions used for wandering risk, communication, reviewing and revising patient care plans as patient's conditions change and their roles in the interdisciplinary team assessment and care planning process. Review of the training tool on [DATE] at 11:55 a.m., review of the signatures page, and interview with RAI Coordinator confirmed that the training had been done and the RAI coordinator was able to verbalize the training material. 4. All staff have been educated in person or by telephone by [DATE]. Interview with Licensed Practical Nurse (LPN) Charge Nurse RR who confirms that training on [DATE] and ,[DATE] /17 was completed on [DATE] between 2:30 p.m. and 3:00 p.m. Review of the training sheet and the staff records reveals that all staff have received the specified training either in person or by phone. 5. Interview on [DATE] at 2:40 p.m. revealed that the Director of Nursing or Assistant Director of Nursing have provided a copy of the new elopement risk assessment tool to be incorporated into the training packet for all new nurses. 6. Interview and review with the Vice President of Clinical Practice on [DATE] at 1:35 p.m. reveals that the policy is being revised and will be implemented on [DATE] for the entire center to perform elope risk assessments at least monthly due to the patient population. 7. Interview on [DATE] at 9:15 a.m. with Social Service Director (SSD) who confirms that high risk residents were assessed on [DATE] and will be assessed monthly, all other residents will be assessed quarterly, annually, as needed or based on significant change, and new or re-admissions will be assessed on admission. 8. Review of QAPI plan, tools initiated and staff interviews on [DATE] at 4:40 p.m. with DON, ADON and the RVP confirm this process as of [DATE].

Based on observation and interview, the facility failed to review and revise the care plan, assess the resident's responses to current care plan interventions and failed to get input from the resident or his/her representative regarding the reason for the elopement and possible interventions for preventing a future elopement for one resident (R) #1 of six residents sampled after the resident successfully eloped from the facility on [DATE]. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately ¼ of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Clinical record review for R#1 revealed the resident had the following diagnoses, including but not limited to: unspecified [MEDICAL CONDITION], generalized anxiety disorder, adjustment disorder, unspecified dementia, [MEDICAL CONDITION], and dementia with behavior disturbance. Review of the current of 'Interdisciplinary Progress Notes' reveals no voiced threats of elopement or elopement attempts documented. Review of the historical 'Interdisciplinary Progress Notes' dated [DATE] at 10:15 p.m. and recorded by nursing staff revealed an assessment for a fall that occurred on [DATE] with an additional notation that read: also, at 4:35 p.m. staff member alerted nurse that Mr. (R#1) had left the premises. Nurse writer and 3 other staff members went outside to search for him. Resident had waked (sic) about 1 mile down HWY 46 and was returned to facility by staff member. Review of the current Plan of Care for R#1 for wandering/elopement revealed that was developed on [DATE] and had not been updated or revised related to the elopement on [DATE]. Problem 4, on page 4 of the plan of care reads as follows: Resident has the potential for leaving the facility grounds due to poor decision making skills. He requires supervision and redirection throughout the day. 'Goals', dated [DATE], were documented to be: Resident will not leave the facility grounds without an escort through next review. There are four 'Interventions' documented to meet this goal, all goals dated [DATE], and documents the following: 1. Cue & Redirect as needed 2. Involve resident in activities as a diversion, encouraging resident to attend activities of preference. 3. Observe resident's location & redirect as needed 4. Notify MD (Medical Director) as needed. On the residents care plan documented under 'Start Date' for the 'Interventions' are two handwritten dates, [DATE] and [DATE], and revealed that there were no new interventions documented after the resident eloped in 2015 and revealed that the resident's care plan had not been revised or updated since 2015. Interview with the Administrator and the Regional Vice-President on [DATE] at 10:45 a.m. revealed that R#1's [DATE] elopement was discussed during the scheduled Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] at 12:00 p.m. No changes were recommended to R#1's plan of care. Interview on [DATE] at 11:10 a.m. with the DON who confirmed that the resident had previously eloped in 2015 under similar circumstances. The DON revealed that she was aware that the resident had entered other resident's rooms and was known to observe staff entering the code to open the secured doors and agrees that these should have been addressed on the resident's care plan. Post survey interview with the Administrator on [DATE] at 11:29 a.m. revealed that the previous Administrator, Regional Vice-President and the DON did not believe that in 2015 there was anything that could have been done that wasn't done, and that there had not been any changes to the resident, so there was no need to re-vise or update the resident's care plan. Post investigation interview with the DON on [DATE] at 11:48 a.m. revealed that R#1 was impulsive, needed cueing and re-directing, and to be kept engaged and active. These interventions were already included in the residents care plan in 2015, so there were no new interventions to add after the resident eloped in 2015, so his care plan had not been revised or updated. During this same interview, the DON revealed that R#1 was already care planned for elopement and the interventions in place were still appropriate. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], each patient was reassessed by Director of Nursing, Assistant Director of Nursing, RAI Coordinator, and Resident Care Coordinator to determine current level of risk using an Elopement Risk assessment tool between 4:00 p.m. and 6:00 p.m. Care plans for these residents were reviewed and updates made as needed (some residents who were previously noted as low risk, are now considered high risk). Specific interventions implemented include: Redirect resident if he/she becomes agitated when possible, Notify Medical Doctor (MD) for further interventions when needed, if resident voices wanting to leave facility notify social services or charge nurse as needed, observe for suspicious behaviors of a possible attempt such as hanging in doorways or pushing on doors, talk with resident and attempt to redirect if noted to be confused about whereabouts as needed, redirect resident if possible, try to determine cause for agitation, involve resident in activities as will tolerate to redirect attention and thoughts, involve in activities such as bingo and music related, activities for diversion, praise resident for good behavior and engage in conversation, try different staff members that resident might relate to better to become calmer, consult with psychiatrist for further interventions, talk with resident about past experiences to provide diversion. 2. Education was provided to the RAI Coordinator, Director of Nursing, Assistant Director of Nursing, two Resident Care Coordinators, and RAI Coordinator on [DATE] by Regional Vice President and Administrator, care plan must demonstrate and contain, Admission/Readmission care plans, Acute Care Plans, Patient at Risk (PAR), MDS/CAA, all areas noted on the Care Area Assessment (CAA) summary to proceed to care plan must be reflected in the care plan, other assessments must be considered in the are planning process to assure all relevant issues are addressed, consultation recommendations should be considered for incorporation into the plan of care, individualized programs that assist to maintain highest level of function should be incorporated into care plans, other areas to consider, and strengths/preferences/desires. 3. Education will also be provided by the Director of Nursing or Assistant Director of Nursing to all licensed nurses on how to revise a care plan when updates are needed. There are currently 19 licensed nurses on staff. This education will be provided and completed by close of business on [DATE]. Education will begin at 4:00 p.m. and conclude at 4:30 p.m. Each nurse will be required to receive the education prior to providing patient care. Education will be provided to those unable to attend by the Director of Nursing via telephone. 4. Newly hired nurses will be provided education on care plan revisions during orientation by Director of Nursing, Assistant Director of Nursing, or the RAI Director. 5. Care plan meeting will be attended by the regional nurse consultant and/or Regional RAI consultant to monitor process and determine if additional education is needed. This will occur for the next 3 months. 6. All findings were entered into the Quality Assurance Performance Improvement (QAPI) by the Administrator. This will continue to be reviewed by the QAPI team at monthly QAPI meetings. It will continue to be reviewed until compliance is achieved and sustained. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review revealed that the Elopement Risk assessment Tool was used to update relevant care plans. The Director of Nursing, the Assistant Director of Nursing, RAI coordinator, and Resident Care Coordinator were interviewed on [DATE] at 11:00 a.m. and validated that on [DATE] the residents were assessed for an elopement risk with an Elopement Risk Assessment tool between 4:00 p.m. and 6:00 p.m. Fifteen out of 81 residents were identified as high risk. Record review revealed that the care plans for those patients that had a high, medium, and low risk of elopement had care plan revisions with interventions updated as needed. Specific interventions implemented include: Redirect resident if he/she becomes agitated when possible, Notify MD for further interventions when needed, if resident voices wanting to leave facility notify social services or charge nurse as needed, observe for suspicious behaviors of a possible attempt such as hanging in doorways or pushing on doors, talk with resident and attempt to redirect if noted to be confused about whereabouts as needed, redirect resident if possible, try to determine cause for agitation, involve resident in activities as will tolerate to redirect attention and thoughts, involve in activities such as bingo and music related, activities for diversion, praise resident for good behavior and engage in conversation, try different staff members that resident might relate to better to become calmer, consult with psychiatrist for further interventions, talk with resident about past experiences to provide diversion. 2. Using the education tool dated [DATE] and [DATE]. The RAI Coordinator, Director of Nursing, Assistant Director of Nursing, and Resident Care Coordinators were interviewed on [DATE] at 11:00 a.m. and validated that education was received on [DATE] and [DATE] by the Regional Vice President and Administrator related to what each care plan must demonstrate and contain, Admission/Readmission care plans, Acute Care plans, Patient at Risk (PAR), MDS/CAA, all areas noted on the CAA summary to proceed to care plan must be reflected in the care plan, other assessments must be considered in the care planning process to assure all relevant issues are addressed, consultation recommendations should be considered for incorporation into the plan of care, individualized programs that assist to maintain highest level of function should be incorporated into care plans, other areas to consider, and strengths/preferences/desires. 3. The Director of Nursing and the Assistant Director of Nursing were interviewed on [DATE] at 11:00 a.m. and validated that education was provided on [DATE] to all licensed nurses on how to revise care plan when updates are needed. Staff interviews on [DATE] at 11:00 a.m., of the Assistant Director of Nursing, RAI Coordinator, and Resident Care Coordinator validated that the education was provided on [DATE] by the Director of Nursing on how to revise a care plan when updates are needed. Record review revealed that care plans had been updated and revised. 4. Interview with the Director of Nurses, Assistant Director of Nurses, and RAI Director on [DATE] at 11:00 a.m. and validation received that education would be provided on care plan revisions during orientation to newly hired nurses. Record review revealed that new hire packets contained education on the elopement risk assessment. 5. Interview on [DATE] at 11:00 a.m. confirmed, care plan meetings will be observed by the above noted individuals for no less than three months for attendance of concerned/interested parties, changes in status, new planning interventions, etc. Interview conducted with Regional Nurse Consultant on [DATE] at 11:00 a.m. and validation received that care plan meeting will be attended to monitor process and determine if additional education is needed. This will occur for the next 3 months. Record review revealed that the policy was reviewed by the Vice President on Clinical Practice on [DATE]. Policy being revised to be implemented on [DATE] for center to perform elopement risk assessments at least monthly. 6. Record review revealed that the first QAPI was held on [DATE] and[DATE] and will continue as needed, no less than monthly. Interview conducted with the Regional Vice President on [DATE] at 11:00 a.m. and validation received that all finding will be entered into the QAPI and will continue to be reviewed by the QAPI team at monthly QAPI meetings. It will continue to be reviewed until compliance is achieved and sustained.

Based on interviews and record review, the facility failed to provide a secure environment for one resident (R) #1 of six residents sampled with a known history of elopement and elopement attempts. After a successful elopement from the facility on [DATE], the facility failed to address the resident's risks after the elopement, failed to assess for and evaluate those risks, and failed to implement interventions to reduce those risks. R#1 was able to successfully elope a second time and was found, deceased , four days after the elopement. The sample size was 6 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately a quarter of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Clinical record review for R#1 revealed the resident had the following diagnoses, including but not limited to: unspecified psychosis, generalized anxiety disorder, adjustment disorder, unspecified dementia, schizophrenia, and dementia with behavior disturbance. Review of R#1's Minimum Data Set (MDS) annual review dated [DATE] revealed under Section C - Cognition, that resident was severely cognitively impaired. Under Section E - Behaviors, R#1 is not coded for wandering behavior, but his previous MDS assessments from [DATE] through [DATE] were coded for wandering. Resident also had delusions, exhibited verbal behaviors ,[DATE] days of the review period and exhibited other behaviors ,[DATE] days of the review period. Under section G- Functional Status, the resident required supervision for most activities of daily living, but needed extensive assistance to dress and maintain personal hygiene. Review of the 'Interdisciplinary Progress Notes' dated [DATE] at 10:15 p.m. and recorded by nursing staff revealed an assessment for a fall that occurred on [DATE] with an additional notation that read: also, at 4:35 p.m. staff member alerted nurse that Mr. (R#1) had left the premises. Nurse writer and 3 other staff members went outside to search for him. Resident had waked (sic) about 1 mile down HWY 46 and was returned to facility by staff member. There were no injuries noted to body. Appeared to be in no distress. Resident showed nurse writer how he had gotten out. Apparently, while the heating and air service men were working on the unit they left the door open and Mr. (R#1) walked outside. Resident stated, I'm sorry, I was just trying to get home. Review of R#1's current 'Plan of Care' for wandering/elopement revealed it originated on [DATE] and had not been updated or revised related to the elopement on [DATE]. Interview with the Administrator on [DATE] at 1:40 p.m. revealed that R#1 eloped from the facility on [DATE] sometime after 10:45 a.m. Staff discovered the resident was missing at approximately 1:30 p.m., searched the facility, and notified the Administrator at 1:45 p.m. The Administrator alerted the local police and a search for the resident was initiated. Continuing interview with the Administrator revealed that the resident had successfully eloped previously on [DATE]. Exterior tour and interview on [DATE] at 11:35 a.m. with the Engineering and Safety Manager QQ reveals that all gates are padlocked with the exception of the front gate which is secured with a maglock. The fencing is approximately 4 ½ feet tall, there are two types of fence, but no large gaps in between them. Engineering and Safety Manager QQ confirms that this is the same fencing that was in place in 2015. Engineering and Safety Manager QQ states that he never observed R#1 hanging around the secured doors, trying to get out of the building or trying to leave the secured exterior, but that the resident was known to observe the door codes. When asked how the facility addressed this, the Engineering and Safety Manager QQ stated that the door codes were changed when it was reported to him. Interview on [DATE] at 3:05 p.m. with Activities Director KK who confirmed that resident was with her for activities on [DATE]. Activities finished at 10:30 a.m. but that R#1 stayed with her to visit, until approximately 10:45 a.m. Activities Director KK revealed that she believed the resident exited through the secure door of the hall next to the dining room. That is where R#1 put his wheelchair prior to activities. Activities Director KK confirmed that R#1 did not need the wheelchair to ambulate, but was encouraged to use it because of his unsteady gait. Activities Director KK revealed that R#1 would have been able to see the contracted staff out the dining room window during that mornings activities, and also stated that when resident's family visited, he wanted to go home with them. Once they left, he was easily re-directed due to his short-term memory loss. Activities Director KK confirmed that he was pretty happy most of the time, liked to watch television, enjoyed smoke breaks and was involved with everything. He had problems with some residents when he wandered into their rooms. He was curious and impulsive and said that he wanted to learn to drive and get a car. He was aware that the doors locked and would try to catch them before they closed. Activities Director KK states that she never reported this because it was not new behavior for this resident. Interview with the Administrator and the Regional Vice-President on [DATE] at 10:45 a.m. revealed that R#1's [DATE] elopement was discussed during the scheduled Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] at 12:00 p.m. No changes were recommended to R#1's plan of care, at that time. The facility implemented monthly checks of the secured doors for functionality and security as an intervention and the door codes were changed as a precaution. Changes to the secured code for the doors occur 'as needed'. Monthly monitoring logs continue to be maintained of the secured door checks, but no monitoring of the efficacy of this intervention was recorded. Interview on [DATE] at 11:10 a.m. with the DON revealed that she confirmed that the resident had previously eloped in 2015 under very similar circumstances to the residents elopement on [DATE]. In 2015 the contractors were there to make repairs on the air conditioning units and the resident exited the building through the open gate. The DON further revealed that R#1 paid attention to the door codes and that he was probably able to let himself out. She further states that the facility made a policy change requiring that the secured doors be checked monthly after R#1's elopement in 2015. Further interview revealed that there was no follow-up or tracking tool used to measure the effectiveness of this intervention and that there was not a re-assessment completed for this resident or any of the other residents at risk for elopement. Continued interview with the DON revealed that the facility had no formal assessment tool to assess for risk for elopement, and that elopement risk assessments are not required by the facility and had not been conducted. Further interview with the DON revealed that was not aware that the resident attempted to 'catch' doors before they closed, but was aware that he had entered other resident's rooms and was known to observe staff entering the code to open the secured doors. Interview on [DATE] at 1:27 p.m. with the Georgia Bureau of Investigation's officer YY who confirmed that resident's remains were located on [DATE] by the Sheriff's department a short distance from the facility with no apparent foul play involved. Interview on [DATE] at 1:35 p.m. with Certified Nursing Assistant (CNA) EE who reveals she noticed the resident was not in the dining room in his spot and that his tray was still on the cart and notified R#1's assigned CNA. She also states that she noticed the air conditioning contractors working because you could see them out the dining room window. She confirmed that activities are performed in the dining room and that the resident would have been able to see the air conditioning contracted staff working during activities. Interview on [DATE] at 1:45 p.m. with Engineering and Safety Manager QQ who confirmed that contractors were at the facility on [DATE] between the hours of 9:45 a.m. and 11:45 a.m. working in the attic on the air conditioners. Engineering and Safety Manager QQ also confirms that contractors are allowed to work unsupervised by facility staff. Interview with Maintenance Director NN on [DATE] at 3:15 p.m. revealed that the contractors entered into the attic opening to repair the drip pans on the AC. The gate was open for them to go back and forth for supplies, etc. The Maintenance Director stated that he told the contractors not to let anyone out and cautioned them regarding the residents. The gate was rolled closed, but not locked. Post investigation interview with the Administrator on [DATE] at 11:29 a.m. revealed that Engineering and Safety Manager QQ stated that he is the Regional Manager and is at this facility periodically. As the Safety Manager, he attended the Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] that discussed when R#1 eloped and that is when he became familiar with R#1 and was told that the resident had been known to observe the door codes. Post survey interview on [DATE] at 10:34 a.m. with the owner of the HVAC company revealed that they arrived at the facility around 10:00 a.m. and completed their work at 12:00 p.m. He stated that they saw and spoke to no residents while they were working. The HVAC owner revealed that once they were completed he walked to the Administrator's office with the invoice and let her know they were finished. He stated that he walked back towards the dining area to use the that door to exit and the door had a key pad and needed a key code. A nurse was near-by and the nurse quietly told him the code to the key pad to exit out of the door. The HVAC owner stated that no residents were near him or the nurse when he had asked for and was given the code to the key pad. He revealed that when he exited the facility he did not see anyone outside. The HVAC owner revealed when they exited the gate that surrounds the facility they locked the gate before leaving the grounds. The facility implemented the following actions to remove the Immediate Jeopardy: Emergency Preparedness for Missing Patient Implemented on [DATE] by Administrator. 1. On [DATE] at 3:15 p.m., the Director of Nursing and Assistance Director of Nursing made rounds and made sure that every patient was accounted for. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, RAI Director, and both Resident Care Coordinator's recognized all patients who were at high risk for elopement. A current resident listing was printed and an elopement assessment was completed on each patient to determine if the patient was at high risk, medium risk, or low risk for elopement. 3. On [DATE], the Director of Nursing, Assistant Director of Nursing, and RAI Director reviewed care plans for every patient in the center and started making revisions where necessary. On [DATE], the RAI Director finished necessary care plan revisions. 4. On [DATE], the Administrator, Director of Nursing, and Regional Vice President held a mandatory staff meeting at 7:00 a.m. Education was provided to staff on how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits (there are a total of 7 entry/exit doors). All exit doors currently have a keypad that requires a protected key code to be entered in order to exit the center. Codes are changed monthly and as needed. Use of alarm placed on door that is suspected patient exited (if alarm were to sound, employee is to go with another employee to complete rounds of the outside of building to verify no one left the building, come back inside of the facility and account for every patient to ensure no one exited building), emergency preparedness in the event of a missing person, zone defense rounds (defense rounds include a list of every patient and all 7 entry /exit doors. The nurse assigned to the resident will verify that the resident is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure, and CNA care plan utilization (CNA care plan specifically for CNA's, example: Do they have a walker? Do they require assistance in toileting? 4 of 5 RNs, 13 of 14 LPNs, 28 of33 CNAs, 7 of 7 Dietary, 7 of 9 Housekeeping, 1 Service Director, 1 of 1 Financial Controller, 1 of 1 Human Resource Manager, 1 of 1 Admission Coordinators, 1 of 1 Administrator, and 1 of 1 Medical Record Manager have been in serviced, which is 87.2% of total staff. 5. There were staff that were unable to attend due to as needed (PRN) status (1 total), part-time status (3) and unable to attend who are full-time (4 total). These staff will be educated by Administrator, Director of Nursing, or Assistant Director of Nursing on how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits, use of alarm placed on the door where patient is suspected to have exited (if alarm were to sound, employee is to go with another employee to complete rounds of the outside of the building to verify no one has the left building, come back inside of facility and account for every patient to ensure no one exited building), emergency preparedness in the event of a missing person, zone defense rounds, ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure), and CNA care plan utilization (CNA care plan specifically for CNA, example: Do they have a walker? Do they require assistance in toileting?) 6. Interventions implemented by the facility include: Staff member sat and monitored door #5 that suspected patient exited on [DATE], (log kept) a door alarm was placed on door #5, [DATE]. Administrator and Engineering Safety Manager assessed the building entrances and exits to determine any risk factors for elopement (made sure that all gates were locked and doors were secure), Administrator interviewed the owner of the Heating, Ventilation, and Air Conditioning (HVAC) company on [DATE] and owner stated that he did not see the resident nor speak to the resident and confirmed that the additional 4 HVAC employees did not see or speak to the resident. On [DATE], all door codes were changed. Ad-hoc (impromptu) QAPI meeting held on [DATE] to determine mechanisms for preventing further occurrence (attendants include Administrator, Director of Nursing, Financial Controller, Assistant Director of Nursing, MDS Coordinator, Infection Control Nurse, Education Nurse, Food Service Manager, Social Service Director, Facility Management Supervisor, Environmental Services Supervisor, Patient Care Coordinator, Regional Vice President, Human Resource Manager, Regional Engineering Safety Manager, and Recreational Therapist), Assessments performed on all residents on [DATE]. All residents assessed per DON on [DATE] to determine if any additional residents are at high risk (findings did show that some residents who were previously considered low risk are now considered high risk) and resident specific interventions implemented as needed by RAI Director, on [DATE] RAI Director implemented specific interventions as needed for those residents recognized to be at high risk for elopement (Interventions include: Redirect resident if he/she becomes agitated when possible, Notify MD (DON spoke with him on Friday and discussed doors and QAPI) for further interventions when needed, if resident voices wanting to leave facility notify social services or charge nurse as needed, observe for suspicious behaviors of a possible· attempt such as hanging in doorways or pushing on doors, talk with resident and attempt to redirect if noted to be confused about whereabouts as needed, redirect resident if possible, try to determine cause for agitation, involve resident in activities as will tolerate to redirect attention and thoughts, involve in activities such as bingo and music related, activities for diversion, praise resident for good behavior and staff members that resident might relate to better to further interventions, talk with resident about past experiences to provide diversion). Gates are documented checked twice a day to insure all gates are locked. All staff received education on [DATE] presented by the Administrator, Director of Nursing, and Regional Vice President on how to observe gates and make sure gates are locked at all times during the day. Facility follows same protocol for weekends and holidays. There are currently seven entry/exit doors. A temporary alarm was placed on suspected exit door #5 on [DATE], the remaining six doors will have a temporary alarm placed by the close of business [DATE]. Installation of permanent key pads with an alarm that alarms if door is opened longer than thirty seconds or if door is forced open will begin [DATE]. Anticipated completion date is Tuesday, [DATE]. Temporary alarms will remain on doors until all permanent alarms are placed and working. Door alarms are checked hourly during zone defense rounds completed by nurses responsible for residents located on that hall. All doors are locked and have a keypad that requires a protected code in order to be opened. The entire facility is surrounded with a fence that includes locked gates that must be unlocked in order to exit. Gate checks are completed twice a day to insure all are securely locked 7. The Administrator and the Director of Nursing will monitor the collected elopement data (elopement data is gathered from the elopement assessment tool providing information on does the patient attempt to elope? Do you see the patient attempting to get out the doors? Are you aware of the patient leaving the center without informing staff? Does the patient wander aimlessly? Does the patient express the desire to go home? Is the patient easily redirected? Are there any interventions that you find helpful with redirecting the patient when they may be seeking an exit?) Using the Elopement assessment tool (the elopement assessment tool asks the following questions on every resident to determine elopement risk: Do they attempt to elope? Do you see the patient attempting to get out the doors? Are you aware of the patient leaving the center without informing staff? Does the patient wander aimlessly? Does the patient express the desire to go home? Is the patient easily redirected? Are there any interventions that you find helpful with redirecting the patient when they may be seeking an exit?) for 6 weeks and review monthly during QAPI. New admissions and re-admissions will have an elopement risk assessment (elopement risk assessment ask the following: Does this resident have a court-appointed guardian? Does this resident have the cognitive ability to make relevant decisions? Does this resident have a history of escape or elopement? Does the resident have a related diagnosis¿ dementia/depression/mental illness, Does the resident move around freely and independently with or without devices such as he/she wants to leave to go home, wander with or without devices such as he/she wants to 1 eave to go home, Does the behavior include risky behaviors such as trying to open doors) completed on him/her at time of admission to facility. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Interview with the Director of Nursing (DON) and (Assistant Director of Nursing (ADON) on [DATE] at 11:45 a.m. revealed that when R#1 was suspected to be missing from the facility on [DATE], Nursing made rounds and ensured that every patient was accounted at 3:15 p.m. Documentation was provided verifying that rounds were made at that time and that every resident excluding the eloped resident was accounted for. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, Resident Assessment Instrument (RAI) Director, and both Resident Care Coordinator's reviewed all residents who were at high risk for elopement. A current resident listing was printed and an elopement assessment was completed on each resident to determine if the resident was at high risk, medium risk, or low risk for elopement. An interview conducted on [DATE] at 10:38 a.m. with the Director of Nursing, Assistant Director of Nursing, and the Resident Assessment Instrument (RAI) Director and who confirmed that all facility residents were assessed for elopement risk. A current resident listing was provided and Record review revealed that an elopement assessment had been completed on every resident to determine if the resident was at high risk, medium risk, or low risk for elopement. 3. On [DATE], a current resident listing was printed and an elopement assessment was completed on each patient to determine if the patient was at high risk, medium risk, or low risk for elopement. A current resident listing and elope assessment risk for every patient in the center was provided on [DATE] at 10:38 a.m. On [DATE], the Resident Assessment Instrument (RAI) Director finished necessary care plan revisions and provided copies of the care plan revisions for residents assessed as high or medium risk. 4. A meeting was held with Administrator, Director of Nursing, Regional Vice President, Resident Assessment Instrument (RAI) Director coordinator on [DATE] at 10:35 a.m. who confirmed their presence in this meeting or that they were reached by telephone and that how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits. Summary of the training tool was provided for reference. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA at 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 am, CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by Administrator. Door codes for 7 doors (all facility exit doors) were changed on [DATE] at 3:00 p.m. Monthly code changes were confirmed during interview with Regional Engineering and Safety Manager on [DATE] at 12:10 p.m. and were again confirmed by the facility Maintenance Director on [DATE] at 10:38 a.m. Observation revealed that the temporary alarm mounted on door #5 was functional for both access and egress. Tour of the Gate perimeter and door rounds with the facility Maintenance Director on [DATE] 10:38 a.m. confirmed that gate rounds are made hourly and keypad doors have been monitored and recorded since at least 2015. Code changes are made monthly or as needed and are recorded. Both the Regional Engineering and Safety Manager and the Maintenance Director were able to articulate the new Zone Access Tool process and support this new tool. Interview on [DATE] at 9:50 a.m. the DON with who confirmed that Door #5 that an alarm was placed on door #5 on [DATE] at 2:05 p.m. and that the alarm is functional. Staff have been trained in the new Zone Defense tool and know what to implement if the alarm were to sound unexpectedly. An interview on [DATE] at 9:55 a.m. with LPN RR who revealed she would go with another employee, complete rounds of the outside of building to verify no one left building and come back inside and account for every patient to ensure no one exited building. She was able to explain emergency preparedness in the event of a missing person, zone defense rounds (defense rounds include a list of every patient and all 7 entry/exit doors. The nurse assigned to that resident will verify that the resident is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure). CNA's also participate and are responsible for care plan utilization of the CNA care plans, like identifying if the missing resident uses a walker, can walk unassisted, has a beard, etc. 5. Of the staff unable to attend on [DATE], two were on medical leave, one is a PRN employee, and three are part time and did not attend. All of these employees have since been trained as of the end of the day on [DATE]. This is evidenced by the sign in sheets and confirmed with interviews on [DATE] with the Director of Nursing and Assistant Director of Nursing on [DATE] at 10:38 a.m. 6. Review of the log book reveals that door #5 was secured and monitored until the door alarm was placed on [DATE] at approximately 5:00 p.m. In the event of a missing person, emergency preparedness zone defense rounds are initiated that include a checklist of every patient and review of all 7 entry/exit doors. The nurse assigned to that patient will verify that patient is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and CNA care plan utilization such as specific resident CNA care plans: Does resident have a walker? Do they require assistance in toileting? Observation of Mock zone defense rounds on [DATE] beginning at 8:30 a.m., at 9:25 a.m. and again at 10:10 a.m. revealed that participating staff included housekeeping JJJ, KKK, LPN's Z, and AAA, CNA FFF, and activity director DD, maintenance LLL. Other staff observed and were asked questions about the process. Staff who were unable to participate were called and interviewed over the phone for the Zone Defense Tool including the following questions: in the event of a missing person, what protocol is followed? When are emergency preparedness zone defense rounds initiated and what do they include? Is there a check list of every patient and review of all 7 entry/exit doors? What does the nurse assigned to that patient do, how are the gates divided, checked and validated as secure? After all safety meas(TRUNCATED)

Based on interviews and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed the residents and the physical environment for elopement risks. The sample size was 6 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately ¼ of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Observations, clinical records review, and staff interviews revealed that the facility was not in substantial compliance during the Abbreviated Extended Survey conducted [DATE] through [DATE]. Refer to the following deficiencies for specific details of the noncompliance. Cross reference to F278: Based on interviews and record review, the facility failed to accurately assess one resident (R) #1, as high-risk for elopement on admission (resident had a known history of elopement and attempted elopement) resulting in the resident successfully eloping on [DATE]. The facility failed to re-assess the resident and his elopement risk after his return. Cross reference to F280: Based on observation and interview, the facility failed to review and revise the care plan, assess the resident's responses to current care plan interventions and failed to get input from the resident or his/her representative to assess the reason for the elopement and develop new interventions to prevent future elopement attempts for one resident (R) #1. Cross reference to F323: Based on interviews and record review, the facility failed to provide a secure environment for one resident (R) #1 of six residents sampled with a known history of elopement and elopement attempts. After a successful elopement from the facility on [DATE], the facility failed to address the resident's risks after the elopement, failed to assess for and evaluate those risks, and failed to implement interventions to reduce those risks. R#1 was able to successfully elope a second time and was found, deceased , four days after the elopement. Interview with the Administrator and the Regional Vice-President on [DATE] at 10:45 a.m. revealed that R#1's [DATE] elopement was discussed during the scheduled Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] at 12:00 p.m. and no changes were recommended to R#1's plan of care. Post survey interview with the DON on [DATE] at 11:48 a.m. revealed that Facility does not believe any other interventions were necessary, no changes were made, so nothing was required follow-up. Residents were not assessed or re-assessed for elopement risks and no care plan revisions were made for R#1 related to elopement or elopement risk after R#1 eloped in 2015. The facility implemented the following actions to remove the Immediate Jeopardy 1. On [DATE] at 1:45 pm the Administrator initiated the Emergency Preparedness Missing person plan after being informed that staff could not locate patient R#1. The Administrator assumed the Incident Commander role and organized search teams to search the center, surrounding outside area and local areas surrounding the center. The Administrator directed the Director of Nursing and Assistant Director of Nursing to visually account for all residents in the center and all residents were accounted for. The Administrator directed the Maintenance Director to check all exit doors and gates to ensure that they were closed and locked. The Administrator directed the Regional Nurse to assist the Director of Nursing, Assistant Director of Nursing, and three Resident Care Coordinators to re-assess all residents for Elopement Risk. All residents were assessed for elopement risk and grouped according to high, medium and low risk status. All care plans have been reviewed and revised, if indicated, for all high and medium risk elopment status. 2. On [DATE] at 2:00 p.m. the Administrator notified the Candler County Sheriff's Office. The Sheriff's Office was on site at 2:15 p.m. and assumed the Incident Commander role and began to lead an extensive search for the patient that included: - A three-mile radius ground search using trained medical staff, law enforcement agents, K-9s. - A five to seven-mile radius air search using drones, two planes and a Helicopter with infrared capability. - Facility Staff placed calls and provided search description and pictures of R#1n to local emergency room s on Friday and Saturday; confirmed by RVP. - Facility Staff and volunteers searched on foot and car in surrounding areas; Confirmed by RVP, everyone was participating. - Facility staff and volunteers distributed flyers to private homes in area and local/surrounding businesses. - Flyers were faxed to local and surrounding emergency room s, Fire Departments, EMS and Private Ambulance/Transport Companies. ([DATE], [DATE] and [DATE] done by Human Resource Associate and patient transition directors) 3. On [DATE], the Administrator contacted R#1 physician and family. The Administrator provided contact information and updated status on law enforcement investigation. 4. On [DATE], the Administrator posted staff members at the exit door that was suspected that the resident exited until an audible alarm was placed on the door at approximately 5:00 p.m. Education provided included: In the instance that the alarm goes off, an employee is to get with another employee (go in pairs) and make rounds outside of the building, once inside the building, every patient is to be accounted for. Remaining staff members were educated on [DATE] by Administrator and Director of Nursing. 5. On [DATE], the Administrator called and Ad-hoc (imppromptu) QAPI meeting with the Director of Nursing, Assistant Director of Nursing, Financial Controller, MDS Coordinator, Food Service Manager, Social Services Director, Resident Care Coordinator, Maintenance Director, Environmental Services Supervisor, Human Resource Manager, Recreational Therapist, Regional Engineering and Safety Manager, Regional Vice President and Regional Nurse to review the incident, investigation measures and next steps. 6. On [DATE], the Administrator implemented a 1. Visitor Sign In/Out procedure. 2. Visitors will be given a document upon signing in that provides education regarding the safety and security of our patients. This will be an ongoing procedure. 7. On [DATE], the Regional Vice President 1. provided education to the Administrator on job description, roles and responsibilities and duty to ensure that the center uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient. 2. The Regional Vice President and the Regional Nurse provided education to the Administrator on the Wandering Patient Protocol (patient behavior should be reviewed with patient, responsible party, family members and interdisciplinary team; the center cannot inhibit the patient's leaving the center if he/she so chooses without a court-appointed guardian; the center should initiate efforts to protect the patient from injury; the center may have a door alarm system; Notify Administrator and Director of Nursing, local law enforcement, responsible party, attending physician; and Emergency Preparedness Plan for Missing Patients (Notify Administrator ASAP, Form Search Teams, Thoroughly search the premises, Notify the patient representative, notify the attending physician, notify the appropriate agencies). The Regional Vice President re-educated the Administrator on her role in the Quality Assurance Performance Improvement process. The Regional Vice President, Regional Nurse and Administrator reviewed the residents was performed to determine moving forward. In an effort to prevent reoccurrence of elopement, the Administrator was educate by the RVP and regional support teams on proper ways to ensure patient safety. 8. On [DATE], the Administrator and Director of Nursing provided education to center staff on elopement prevention and response - 4 of 5 RN' s, 13 of 14 LPN's, 28 of 33 C.N.A's, 1 of 1 Admissions Director, 7 of7 Dietary Staff, 7 of 9 Environmental Services, 1 of 1 Maintenance Director, 3 of 3 Activities, 1 of 1 Social Services, 1 of 1 Social Service Director, 1 of 1 Financial Controller, 1 of 1 Human Resource, and 1 of 1 Medical Records. Education provided included: How to assess the patient (focus on determine resident's purpose for attempting to leave), how to identify those at risk for elopement and identifying them, patient care plan (activity and social programs to occupy patients), Communication (resident sign in/out), Emergency Preparedness (Notify Administrator ASAP, Form Search Teams, thoroughly search the premises, Notify the patient representative, notify the attending physician, notify the appropriate agencies). 9. On [DATE], the Regional Vice President and Regional Engineering and Safety Manager made thorough environmental rounds to identify any potential risk factors and areas addressed as indicated. There were no noted potential risk factors or areas. All gates were locked and all doors were secure. The Regional Vice President and Regional Engineering and Safety Manager reviewed findings with the Administrator. 10. On [DATE] the Ad-hoc (impromptu) QAPI team will review the investigation to date and all interventions implemented to determine and additional mechanisms for preventing further occurrence. All findings will be entered the QAPI program and will be reviewed until compliance is achieved. The regional vice president will continue to provide ongoing education to the Administrator and any abnormal findings related to patient safety will be entered in the QAPI program until compliance is achieved. If any abnormal findings concluded, regional vice president will re-educate administrator and perform disciplinary action if needed. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Interview on [DATE] at 4:00 p.m. with Administrator revealed that she had initated the Emergency Preparedness on [DATE]. Record review revealed that Administrator completed actions per the Emergency Preparedness Missing Person Plan. Interview on [DATE] at 11:15 a.m. with DON and ADON revealed that they had accounted for all residents residing in the facility. Record review revealed that DON and ADON visually accounted for all patients in the center using the resident roster. Interview on [DATE] at 11:30 a.m. with Maintenance Director revealed they had ensured all exit doors and gates were closed at locked on [DATE]. Record review revealed that the Maintenance Director checked all exit doors and gates. Interview on [DATE] at 3:45 p.m. with Administrator revealed that the residents were re-assessed for Elopement Risks. Record review revealed that DON and ADON re-assessed all patients for Elopement Risk. Interview on [DATE] at 11:00 a.m. with DON, ADON, RAI Director, and RCC revealed that all residents were assessed for elopement risk and grouped according to status and care plans had been revised if indicated on [DATE] and [DATE]. Record review revealed that R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#12, R#13, R#14, R#15, and R#16 care plans have been updated and revised. Record review revealed on [DATE] the Administrator initiated the Emergency Preparedness Missing person plan, was the Incident Commander, and organized teams to search the center, surrounding area, and that all staff participated. All residents were accounted for except R#1, The DON/ADON re-assessed all residents for Elopement risk and grouped the residents according to risk of elopement for medium and high risks. 2. Interview on [DATE] at 2:05 p.m. with the Sheriff's Deputy and Georgia Bureau of Investigation and confirmed with the Administrator and Regional Vice President on [DATE] at 4:45 p.m. revealed Candler County Sheriff's Office Investigation Reports were contacted on [DATE] and that the investigation was pending. Record review revealed Candler County Sheriff's Office Investigation Reports were contacted on [DATE] and that the investigation was pending. 3. Interview on [DATE] at 4:00 p.m. with Administrator and Regional Vice President confirmed that the resident's family and physician were notified on [DATE]. Record review revealed that Administrator notified resident's sister and resident's physician on [DATE] at 2:00 p.m. 4. Interview on [DATE] at 11:00 a.m. with Regional Vice President, DON, CNA SSS, CNA CCC and CNA YY revealed that they had been educated on what to do when the door alarms went off. Record review revealed that staff members were posted by the door until audible alarm was placed on the door on [DATE] at 5:00 p.m. and that education was provided to the staff of the installation of the alarm and what to do if the alarm went off. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 a.m., CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by the Administrator. 5. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE]. 6. Interview on [DATE] at 11:45 a.m. with Regional Vice President revealed that visitors need to sign in and out of the facility. Record reviewed revealed visitors are required to sign in and out and patient safety education is being provided to visitors as they are signing in. 7. Interview on [DATE] at 9:20 a.m. with the Regional Vice President revealed they provided education to the Administrator on her job description, roles and responsibilities and duty to ensure that the center uses its resources effectively and efficiently. Record review revealed that Administrator was re-educated by Regional Vice President. 8. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans, and how to assess the patient, how to identify those at risk for elopement and identifying them, patient care plan, Communication, Form search teams, thoroughly search the premises, notify patient representative, and physician, and the appropriate agencies. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA at 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 a.m., CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by Administrator. 9. Interview on [DATE] at 4:00 p.m. with Regional Vice President revealed environmental rounds had been completed to ensure all doors and gates were locked. Record review revealed that environmental rounds were made by Regional Vice President and Regional Engineering and Safety Manager were completed on [DATE] and all gates were locked and doors were secure. 10. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE] and that findings will be reviewed until compliance is achieved and the Regional Vice President will continue to provide ongoing education to the Administrator. 10. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc (impromptu) QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE] and that findings will be reviewed until compliance is achieved and the Regional Vice President will continue to provide ongoing education to the Administrator.

Based on record review, and interviews, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed, developed, and implemented plans to correct quality deficiencies regarding quality of care related to an effective infection control program. This failure resulted in actual harm for R#7 who had a [DIAGNOSES REDACTED]. R#7 continued to have a rash and or itching from April 2017 through July 2017 and consequently was diagnosed , by the dermatologist, as having a recurrence of scabies in July 2017. The facility census was 84 residents. Findings include: Deficient areas that were identified through observations, interviews, and record review during the Recertification and extended survey are examples of how the facility's QAPI program failed to function. Refer to the following deficiencies for specific details of the noncompliance that was not addressed by the facility Quality Assurance Committee, including: F441: Effective Infection prevention and control program F490: Effective Administration/Resident Well Being F520: Quality Assurance & Performance Improvement Interview with the Medical Director and the Administrator on 8/10/17 at 9:57 a.m. revealed that they had attended a Quality Assurance and Performance Improvement (QAPI) meeting that morning to discuss the residents with scabies. Continued interview with the Medical Director revealed he had been the facility's Medical Director for seven years. The Medical Director stated that he attended the QAPI meetings every quarter and participated in policy reviews and revision. Continued interview revealed that he did not remember if he was notified about R#7's scabies infection in January 2017, but that staff would not notify him unless he was the resident's attending physician. Interview on 8/12/17 at 4:41 p.m. with the Administrator revealed that the issue of scabies was discussed in December 2016 and that he acknowledged that some residents had scabies, at that time, and had received treatment. The Administrator reported that he was not sure how many residents at that time had scabies. It was further reported that even though scabies was identified there were no written interventions in place to determine the root cause of the issue. The only thing in place at the time was the policy and protocols for scabies. The Administrator further revealed that he does not remember other dates that scabies was discussed but he was aware that Resident #7 had tested positive for scabies previously. The Administrator reported that the current Medical Director did not want to provide treatment to any residents that were not displaying symptoms of or had a positive scabies diagnosis. The Administrator acknowledged that the lack of the policy being implemented when scabies was diagnosed ultimately rests on him. The Administrator reported that in the future there would be weekly skin assessments. Cross refer F441

Based on observation and clinical record review, resident and staff interviews, the facility failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being of each resident; specifically, the facility failed to ensure that there was an effective infection control program, failed to monitor and track residents with suspicious rashes and with scabies to prevent reinfection and to prevent further infection to other residents and staff. This failure resulted in actual harm for R#7 who had a [DIAGNOSES REDACTED]. R#7 continued to have a rash and or itching from April 2017 through July 2017 and consequently was diagnosed , by the dermatologist, as having a recurrence of scabies in July 2017. The facility's census was 84 residents. Findings: F441: The facility failed to investigate and identify the root cause of the scabies infection for R#7 in January 2017 to prevent recurrence of the scabies infection in July 2017 and failed to prevent the spread of the infection to his roommate R#63. The facility failed to properly implement transmission based precautions to prevent the spread of scabies infection to other residents, staff or visitors; and failed to develop an effective infection prevention and control program that included heightened surveillance and specific steps to identify potentially suspicious rashes for scabies infections for nine (9) residents (R#7, #32, #63, #44, #53, #11, #48, #49 and #30) reviewed for rashes, three of these residents (R#7, R#63, and R#30) actually tested positive for [DIAGNOSES REDACTED]. This failure resulted in actual harm for R#7 who had a [DIAGNOSES REDACTED]. R#7 continued to have a rash and or itching from April 2017 through July 2017 and consequently was diagnosed , by the dermatologist, as having a recurrence of scabies in July 2017. The sample size was thirty (30) residents. F490: The facility failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being of each resident; specifically, the facility failed to ensure that there was an effective infection control program, failed to monitor and track residents with suspicious rashes and with scabies to prevent reinfection and to prevent further infection to other residents and staff F520: The facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to skin care and assessments for 84 of 84 residents and there was no evidence that the Director of Nursing (DON) was present for all QA meetings. On 8/7/17 the facility reported that only one resident (Resident #7) in the facility had any skin issues. On 8/8/17 the facility conducted 100% body audits of all residents and found the following: 1. Resident #49 had rash to right leg, face, arms 2. Resident #30 red slightly raised area, closed (tested positive for scabies on 8/14/17) 3. Resident #44 moderate to severe rash with closed areas scattered mainly on chest, abdomen back, bilateral upper extremities 4. Resident #63 pustules (tested positive for scabies on 8/9/17) 5. Resident #32 rash 6. Resident #11 skin rash predominantly on chest, neck, face with scan scattered areas on extremities, all closed areas 7. Resident # 7 multiple pustules scabs confirmed scabies follow up on 8/17/17. 8. Resident #48 scaly areas 9. Resident #53 identified as scaly pustules per last dermatology visit. (Review of chart, revealed last dermatologist assessment in February 2017) Interview with Medical Director and the Administrator on 8/10/17 at 9:57 a.m. revealed that the facility was investigating the root cause of the scabies infection for R#7 and #63. When asked if staff had been assessed as the potential source, the Administrator stated that staff were investigating now. Further interview with the Administrator revealed that he had heard that there were two staff who had scabies over a year ago, but did not know what interventions the facility put in place at that time. Interview on 8/12/17 at 4:41 p.m. with the Administrator revealed that the issue of scabies was discussed in December 2016 when residents, at the time, were identified with scabies and received treatment. The Administrator reported that ultimately the failure of the facility to implement interventions in July 2017, after Resident #7 was diagnosed with [REDACTED]. Cross refer F441

Based on observations, record review, review of the Centers for Disease Control and Prevention Resources for Health Professionals: Scabies in Institutional Settings, a facility policy titled, Scabies-Treatment Recommendations, review of the new facility policy, effective August 2017, titled Infectious Diseases-Scabies and Care of Patient with Scabies and staff interviews the facility failed to investigate and identify the root cause of the scabies infection for R#7 in January 2017 to prevent recurrence of the scabies infection in July 2017 and failed to prevent the spread of the infection to his roommate R#63. The facility failed to properly implement transmission based precautions to prevent the spread of scabies infection to other residents, staff or visitors. The facility failed to develop an effective infection prevention and control program that included heightened surveillance and specific steps to identify potentially suspicious rashes for scabies infections for nine (9) residents (R#7, #32, #63, #44, #53, #11, #48, #49 and #30) reviewed for rashes, three of these residents (R#7, R#63, and R#30) actually tested positive for scabies. This failure resulted in actual harm for R#7 who had a [DIAGNOSES REDACTED]. R#7 continued to have a rash and or itching from April 2017 through July 2017 and consequently was diagnosed , by the dermatologist, as having a recurrence of scabies in July 2017. The sample size was thirty (30) residents. Findings include: 1. Professional Reference According to the Centers for Disease Control (CDC) and Prevention Resources for Health Professionals: Scabies in Institutional Settings, human scabies was caused by an infestation of the skin by the human itch mite which was almost always passed by direct, prolonged, skin-to-skin contact with a person who was already infested. Institutions such as nursing homes were often sites of scabies outbreaks. When a person was infested with scabies the first time, symptoms usually did not appear for up to 2 to 6 weeks after being infested; however, an infested person could spread the scabies during that time even though he did not have symptoms. A common early symptom of scabies was severe itching as well as a pimple-like (papular) itchy rash. The intense itching of scabies leads to scratching that can lead to skin sores which can sometimes become infected with bacteria which in turn can lead to an inflammation of the kidneys. Institutions needed to have an active surveillance program for early detection of infested patients and staff. Institutions should maintain a high index of suspicion that undiagnosed skin rashes may be scabies even though characteristic signs and symptoms are absent. Skin scrapings of suspected cases should be obtained and examined by a person who was trained and experienced in identifying scabies mites for a definitive diagnosis. Consultation with an experienced dermatologist should be utilized in differentiating skin rashes and confirming the [DIAGNOSES REDACTED].g. handwashing, avoidance of direct skin-to-skin contact), early and complete treatment and follow-up of cases, and [MEDICATION NAME] treatment of [REDACTED]. A scabies outbreak suggests that transmission has been occurring within the institution for several weeks to months. 2. Facility Policies According to a facility policy, located in the Infection control log book, titled, Scabies-Treatment Recommendations, (no date) a 100% skin audit should be performed for residents with rashes/suspected infection. Patients with confirmed/suspected infection should be treated along WITH their roommates. After the resident was treated, showered the next morning, placed in clean clothes and their room deep cleaned, the resident should stay in their room for 24 more hours. According to a new facility policy, effective August 2017, provided by the ADON on 8/9/17 at 10:57 a.m., titled Infectious Diseases-Scabies and Care of Patient with Scabies, staff should initiate contact precautions before treatment and for 12 to 24 hours after initiation of effective therapy, avoid direct skin-to-skin contact with suspected or conformed scabies cases and wear gloves and gowns for all direct resident care. Residents with scabies should be confined to their room for 12 to 24 hours after treatment if possible. The facility should have an active program for early detection, treatment and implementation of appropriate isolation and infection control practices. The facility should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies (i.e., no itching) are absent. Skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Although, the new facility policy addressed the treatment of [REDACTED]. 3. Resident (R) #7 Review of the medical record for R#7 revealed that he was admitted [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE], revealed R#7 had a Brief Interview for Mental Status (BIMS) score of six, which indicated the resident was cognitively impaired. He was noted to be ambulatory with supervision and had delusions and other physical behaviors such as scratching himself that occurred one to three days during the review period. According to the Interdisciplinary Notes (IDPNs) dated 10/25/15, 11/20/15, 1/25/16, 1/29/16 and 12/29/16, R#7 used his wheelchair to ambulate up and down the hallways often greeting others while attempting to grab their hands. Additionally, he was noted to be actively involved in activities and self-propelled himself throughout the facility. Care Plans According to R#7's comprehensive care plan dated 2/3/16, R#7 had a rash on his trunk and extremities, with an intervention for staff to treat with [MEDICATION NAME] cream ( a scabicidal medication) and [MEDICATION NAME] cream (a corticosteroid). The care plan note (no date) documented that the rash resolved. The care plan was updated and revealed R#7 had a rash on 3/18/16, with an intervention for staff to treat as ordered. The care plan note (no date) documented that this rash resolved. Further review of the care plan revealed R#7 had a rash on 10/4/16 with an intervention for staff to treat as ordered. The care plan note documented that the rash resolved on 3/22/17. According to the Acute Care Plan dated 7/10/17, R#7 had a rash on his torso, buttocks and feet and included interventions for staff to provide treatment as ordered and observe for signs of infection. According to an Acute Care Plan dated 7/20/17, R#7 had a [DIAGNOSES REDACTED]. The Acute Care Plan was revised on 8/8/17 to include contact precautions (no time frame given) and to follow-up with the physician as needed. February 2016 Review of the Interdisciplinary Note (IDPN) dated 2/3/16 (no time indicated), revealed that R#7 complained of itching and was noted with a red rash on his back, abdomen and legs. The resident's attending physician was notified and ordered [MEDICATION NAME] cream be applied to the resident's entire body at bedtime, rinsed off the medication in the morning and to reapply the [MEDICATION NAME] in one week for a rash. Additionally, [MEDICATION NAME] cream was ordered to be applied to the resident's extremities and trunk twice a day for itching. The IDPN note dated 2/4/16 at 3:00 a.m., revealed that at approximately 2:00 a.m., the resident stated he was anxious because I can't stop itching and staff administered [MEDICATION NAME] (a sedative) one (1) milligrams (mgs.) to the resident which allowed him to rest. According to the Treatment Administration Record (TAR) for February 2016 staff applied the [MEDICATION NAME] cream on 2/3/16 and 2/10/16 and the [MEDICATION NAME] cream as ordered and the rash had resolved on 2/12/16; however, staff continued the [MEDICATION NAME] cream for itching. Although staff applied the scabicide to the resident as ordered by the physician, there was no indication that staff obtained a skin scraping to positively identify scabies mites as per CDC recommendations. There was no indication that staff initiated contact precautions for 24 hours after the resident's treatment with the scabicide at that time in order to prevent potential spread to the resident's roommates, other residents and staff, as outlined in the facility policy above. There was no indication that staff investigated the root cause of the resident's potential scabies infection. March 2016 Review of the IDPN dated 3/18/16 (no time) revealed R#7 was noted with multiple red papules to his bilateral extremities and torso. The physician was notified and ordered [MEDICATION NAME] to be applied and repeat the treatment in seven (7) days. Additionally, [MEDICATION NAME] cream was ordered for itching. On 3/20/16 at 3:14 p.m., the rash was noted to spread to his groin and neck and the resident was noted to be scratching himself with his fingernails. According to the Treatment Record for March 2016, staff applied [MEDICATION NAME] on 3/18/16 and 3/25/16, and continued to apply the [MEDICATION NAME] cream twice a day for itching. Further review revealed the rash was resolving on his stomach and he had decreased itching. Although staff applied the scabicide to the resident, there was no indication that staff obtained a skin scraping to identify scabies mites for a definitive [DIAGNOSES REDACTED]. There was no indication that staff initiated contact precautions for 24 hours after the resident's treatment with the scabicide, in order to prevent potential spread of scabies to the resident's roommates, other residents and staff as outlined in the facility policy. There was no indication that staff attempted to identify the root cause of the continuation of the resident's suspicious rash. April 2016 Review of the Treatment Record notes dated 4/6/16, 4/13/16 and 4/19/16 revealed that R#7 did not have a rash; however, continued review of the Treatment Record revealed staff continued to apply the [MEDICATION NAME] cream for itching. Review of the Treatment Record note dated 4/27/16 revealed that the [MEDICATION NAME] cream was discontinued because the resident's itching had resolved. June 2016 Review of the Situation/Background/Assessment/Recommendations and Notify (SBAR) form, dated 6/21/16, revealed R#7 had an itchy red rash between his fingers, on his trunk (front and back) and arms. The physician was notified and ordered [MEDICATION NAME] cream to be applied twice a day for seven days for contact dermatitis. According to the IDPN dated 6/29/16 at 1:15 p.m. the rash continued and staff made an appointment for the resident to see a dermatologist on 7/14/16 because the rash was not improving. However, review of the 7/2016 Treatment Record revealed the rash resolved on 7/8/16 and the dermatology appointment was canceled. Review of the TARs for 6/2016 revealed that staff applied [MEDICATION NAME] cream twice a day from 6/21/16 to 6/28/16. July 2016 Review of the SBAR dated 7/22/16, revealed the resident was noted to have several red and raised bumps on his hands, torso and legs. The physician was notified and ordered [MEDICATION NAME] to be applied from head to toe at bedtime and to wash off the medication in the morning. Continued review revealed staff was supposed to reapply the [MEDICATION NAME] in one week, if the rash had not cleared. However, review of the Treatment Record for July 2016, revealed that the [MEDICATION NAME] was not applied on 7/22/16. Review of the IDPN dated 7/23/16 at 1:30 p.m. revealed the physician was notified about the resident's recurring rash and told staff it was likely eczema and ordered staff to schedule an appointment with the dermatologist and discontinued the [MEDICATION NAME]. An appointment for R#7 to be assessed by the dermatologist was scheduled for 8/15/16. According to the IDPNs dated 7/28/16 at 3:15 p.m. the on-call physician was notified about the resident's rash on his bilateral upper extremities and trunk and the resident's complaints of intense itching at times. The on-call physician ordered staff to apply [MEDICATION NAME] for two treatments. Continued review revealed that contact precautions were initiated for possible scabies. Review of the Treatment Records for 7/2016 revealed that the [MEDICATION NAME] was applied on 7/29/16. August 2016 According to the IDPN dated 8/15/16 (no time), the dermatologist diagnosed the resident with eczema and ordered staff to apply [MEDICATION NAME] cream twice a day. However, the resident had recently been treated twice with [MEDICATION NAME] on 7/29/16 and 8/5/16. According to the August 2016 Treatment Record, the second treatment of [REDACTED].#7 on 8/5/16. Additionally, staff applied the [MEDICATION NAME] as ordered and the resident's rash was resolving and he had no complaints of itching on 8/26/16. The [MEDICATION NAME] was discontinued on 8/31/16. October 2016 Review of the SBAR form dated 10/4/16, revealed R#7 was itching and had a rash on his trunk and extremities. The attending physician was notified and ordered staff to apply [MEDICATION NAME] cream to affected areas twice a day as needed (PRN). According to the Treatment Record for October 2016, R#7 required the PRN [MEDICATION NAME] cream four times for itching in 10/2016 (on 10/4/16, 10/5/16, 10/11/16 and 10/18/16). November 2016 Review of the IDPNs for 11/2016 revealed that there was no indication that R#7 had a rash or complaints of itching. However, review of the Treatment Record note dated 11/8/16 revealed that R#7 was observed scratching and he complained of itching. Continued review of the note revealed that staff applied the PRN [MEDICATION NAME] cream on that date. Review of the Treatment Record note dated 11/15/16 revealed that the resident had itchy, raised bumps on his upper extremities, upper torso, buttocks and his right leg and that the PRN [MEDICATION NAME] cream was applied on that date. Review of the Treatment Record note dated 11/22/16 revealed that the resident continued to have the rash on his upper torso and complained of itching. Continued review revealed that the physician was notified on 11/22/16 and ordered staff to apply the [MEDICATION NAME] twice a day routinely. Review of the Treatment Record revealed that staff applied the [MEDICATION NAME] as ordered from 11/22/16-11/30/16. Review of the Treatment Record note dated 11/29/16 revealed that the resident had decreased itching and scratching and the rash was diminishing. December 2016 According to the IDPN dated 12/1/16 (no time), R#7 was transferred from C hall to D hall (secured unit). According to the Nursing Summary dated 12/29/16, R#7 was out of bed daily and used the wheelchair at times but, since moving to D hall the resident ambulated more frequently. According to the Treatment Record for December 2016, staff continued to apply the [MEDICATION NAME] cream twice a day for complaints of itching and a rash on his trunk and extremities. January 2017 According to the SBAR form dated 1/16/17, R#7 now had a rash on his feet and was scratching his feet, groin and torso. The physician was notified and ordered staff to schedule an appointment with the dermatologist, which was scheduled for 1/20/17. On 1/20/17 R#7 returned from the dermatologist at 11:30 a.m., with a [DIAGNOSES REDACTED]. Additionally, the physician ordered [MEDICATION NAME] to be applied to the resident twice a day for two weeks for itching and for staff to repeat the [MEDICATION NAME] treatment in one week. According to IDPN dated 1/21/17 at 3:00 a.m., R#7 had papules and redness noted to his entire body except for the palms of his hands and the soles of his feet. Continued review revealed staff were waiting for the [MEDICATION NAME] to arrive from pharmacy. On 1/21/17 at 1:30 p.m., R#7 was noted out of bed ambulating ad lib (as much and as often as desired) throughout D hall. Additionally, the [MEDICATION NAME] cream was noted to have been washed off that morning. However, the January 2017 Treatment Record revealed staff did not apply the [MEDICATION NAME] to the resident until 1/21/17 at 7:00 p.m., which was 31.5 hours after he had been diagnosed with [REDACTED]. There was no indication that staff initiated contact precautions after the R#7 returned on 1/20/17 at 11:30 a.m., with a [DIAGNOSES REDACTED]. There was no indication that staff attempted to identify the root cause of the continuation of the resident's suspicious rash as per CDC recommendations. Review of the Treatment Record note dated 1/10/17 revealed that the bumps on the resident's abdomen, arms, back and extremities had worsened and that [MEDICATION NAME] cream continued to be applied twice a day. Staff continued to apply the [MEDICATION NAME] cream twice a day as ordered and staff applied a second treatment of [REDACTED]. Additionally, the Line Listing of Resident Infections for January 2017, revealed that 15 residents (R#2, R#54, R#A, R#17, R#12, R#55, R#24, R#13, R#B, R#53, R#C, R#21, 66, and R#32 and R#63, (Note: R#32 and R#63 were roommates of R#7) on the D hall where R#7 resided were treated [MEDICATION NAME] with [MEDICATION NAME] on 1/20/17. February 2017 Review of the Consultant Report dated 2/16/17 revealed that the resident was assessed by the dermatologist that day and was negative for scabies. Review of the Treatment Record for February 2017 revealed there was no rash or itching/scratching noted. Staff continued to apply the [MEDICATION NAME] cream to R#7 twice a day. March 2017 Review of the Treatment Record for March 2017 revealed that the [MEDICATION NAME] was discontinued on 3/21/17. April 2017 Review of the SBAR dated 4/4/17 revealed that the resident had a rash on his lower extremities and trunk. The physician was notified and ordered staff to apply [MEDICATION NAME] cream twice a day. Review of the IDPNs dated 4/5/17- 4/6/17 revealed that the resident was observed scratching his bilateral lower and upper extremities at times. Review of the Treatment Record for April 2017, revealed staff applied the [MEDICATION NAME] cream as ordered. May 2017 Review of the SBAR dated 5/5/17 revealed that the resident continuously scratched his bilateral extremities causing part of the nail of the third toe of his left foot to come off. The physician was notified and ordered staff to administer [MEDICATION NAME] (an [MEDICATION NAME]) 25 milligrams (mg) twice a day as needed for ten days for itching and Triple Antibiotic Ointment (TAO) every day for seven days or until resolved to prevent infection. Review of the Medication Administration Record and Treatment Record for May 2017 revealed that staff administered the [MEDICATION NAME] and applied the TAO and [MEDICATION NAME] cream as ordered. June 2017 Review of the Nursing summary dated 6/12/17 revealed that the resident was out of bed daily on D hall with the wanderers' group, would touch/grab staff at times, continued to pick at skin and toenails, ate meals in the D hall dining room and was observed to reach his hand in his brief and scratch his bottom at times. According to the Treatment Record note dated 6/24/17, R#7's rash was improving and the resident did not have any itching or scratching. Review of the Treatment Record for June 2017 revealed R#7 was bathed daily and the [MEDICATION NAME] cream applied twice a day as ordered July 2017 Review of the Treatment Record note dated 7/6/17 revealed that the resident's rash on his hands, feet, upper and lower torso had flared up and he was scratching himself. Review of the Treatment Record revealed that staff had continued to apply the [MEDICATION NAME] cream twice a day as ordered. Review of the SBAR dated 7/9/17 revealed R#7 had an itching rash on his bilateral upper and lower extremities, groin and buttock. The resident's left lower extremity was noted with 2+ pitting edema and warm. The right lower extremity was noted with 1+ edema. R#7 continued to receive the [MEDICATION NAME] cream with no improvement. The physician was notified and ordered staff to administer [MEDICATION NAME] 25 mg twice a day as needed for itching and to consult with a dermatologist. Review of the IDPN dated 7/10/17 at 3:00 a.m., revealed that R#7 was noted scratching his bilateral lower extremities especially his left foot. The rash was noted on his bilateral lower and upper extremities, torso, groin and buttock and the skin was red, swollen and warm to touch. On 7/10/17 at 2:47 p.m. he was noted to be out of his room and sitting in the D Hall solarium (day room). Review of the Physician orders [REDACTED]. Review of the IDPN dated 7/12/17 (no time) revealed R#7 was noted to be in the day room on D hall. On 7/20/17 at 12:30 p.m., R#7 returned from his dermatology appointment at 10:00 a.m. with a [DIAGNOSES REDACTED]. Review of the IDPN dated 7/20/17 at 1:15 p.m. revealed that staff placed the resident on contact precautions for 24 hours. Review of the IDPN dated 7/21/17 at 3:00 a.m. revealed that staff were waiting for the [MEDICATION NAME] cream to arrive from the pharmacy and that the resident continued to have a rash on his bilateral lower and upper extremities and torso. Review of the IDPN dated 7/21/17 at 3:00 p.m. revealed that R#7 was sitting in the D hall solarium (dayroom), scratching multiple times and stated I'm itching. Continued review revealed that staff were still waiting for the [MEDICATION NAME] cream to arrive from pharmacy. Review of the IDPN dated 7/22/17 at 1:05 p.m. revealed that R#7 was noted to be in the D hall dining room after eating his lunch and continued to scratch at his rash. Further review revealed that the [MEDICATION NAME] was expected to arrive from the pharmacy that day. Review of the IDPN dated 7/23/17 at 11:15 a.m. revealed that the resident was sitting in the D hall solarium (day room) at the present time and continued to complain of itching. Continued review revealed that a rash was noted on his upper and lower extremities and his torso. Review of the Treatment Record for July 2017 revealed that staff did not apply the first application of [MEDICATION NAME] cream to the resident until 7/22/17, on the 7:00 p.m. to 7:00 a.m. shift, which was approximately 57 hours after the resident returned to the facility with a [DIAGNOSES REDACTED]. from the dermatologist in order to prevent the potential spread of scabies to the resident's roommates, other residents and staff. Instead staff allowed the resident to sit in the D hall day room on 7/21/17 at 3:00 p.m. and the dining room on 7/22/17 at 1:05 p.m. prior to the initial [MEDICATION NAME] treatment provided 7/22/17 on the 7:00 p.m. to 7:00 a.m. shift. There was no indication that staff initiated 24-hour contact precautions after the resident was treated with the [MEDICATION NAME] on the 7:00 p.m. to 7:00 a.m. shift on 7/22/17 and allowed the resident to sit in the D hall solarium (day room) on 7/23/17 at 11:15 a.m. On 7/23/17 at 11:15 a.m., staff deep cleaned the resident's room including his mattress and bedframe. On 7/31/17 (no time) R#7 was noted to be pacing in the hallway that morning in distress, pulling on his clothes and scratching. Review of the Treatment Record for July 2017 revealed staff applied the second treatment of [REDACTED]. Although scabies symptoms do not appear for 2 to 6 weeks after a person has been infested, there was no indication that staff investigated any potential direct skin-to-skin contacts that the resident may have had prior to the recurrence of scabies on 7/20/17 in order to heighten surveillance of a potential scabies outbreak. There was no indication that staff attempted to identify the root cause of the recurrence of R#7's scabies infection in order to prevent future recurrence. August 2017 Review of the IDPN dated 8/6/17 at 11:15 a.m., revealed R#7 was scratching with bleeding noted on his back, buttock and feet, he had increased agitation and aggression and attempted to grab other residents and staff at that time. Continued review revealed that the previous [MEDICATION NAME] treatment appeared to be ineffective. The physician was notified on 8/6/17 and ordered staff to apply [MEDICATION NAME] cream from the resident's neck to the soles of his feet every seven days until the scabies infection was resolved. However, review of the Treatment Record for August 2017 revealed that staff did not apply the [MEDICATION NAME] until 8/7/17 on the 7 p.m. to 7 a.m. shift. Review of the IDPN dated 8/7/17 at 6:30 a.m., revealed that R#7 continued to remove his clothing and scratch at his torso, arms, buttocks and legs. It was noted that he had a rash on his entire body with several open scratches with dried blood. Further review revealed that the resident continued to grab other residents and staff after being told repeatedly to keep his hands to himself. On 8/9/17 at 7:00 a.m. R#7 continued to have a crusted rash on his torso, bilateral arms and bilateral legs. Continued review revealed that the physician ordered contact precautions initiated on 8/8/17 and to continue the application of the [MEDICATION NAME] cream every seven days until the resident was seen by the dermatologist on his follow-up appointment 8/17/17. Review of the IDPN dated 8/9/17 (no time), revealed that R#7 was noted to continuously scratch at the rash to his body, remove his clothes and rub his body against the door frame. Review of the Treatment Record for August 2017, revealed that staff did not apply the [MEDICATION NAME] until 8/7/17 on the 7:00 p.m. to 7:00 a.m. shift. There was no indication that staff initiated contact precautions after obtaining the physician's orders [REDACTED]. 4. Observations Observation on 8/7/17 at 12:30 p.m., revealed that R#7 was observed sitting in a cloth chair in the dining room with other residents. The resident stated at that time I'm itching! and was noted with red papules on his neck, arms, hands and legs. The resident was wearing shorts and a short-sleeved shirt at the time. Observation of R#7's room on 8/7/17 at 12:40 p.m. revealed that there was no cart with personal protection equipment (PPE), i.e., gowns, gloves, outside the resident's room or a sign on the door documenting any type of precautions. Observation on 8/8/17 at 9:30 a.m. revealed R#44 (BIMS=99, severely cognitively impaired), R#66 (BIMS=3, cognitively impaired) and R#21 (BIMS=99, severely cognitively impaired), all residents who resided on C hall, were observed sitting in the D hall day room with the residents from D hall. Observation on 8/8/17 at 11:10 a.m. revealed R#53 (BIMS=3, cognitively impaired) who resided on D hall was observed in the D hall day room sitting in a wheelchair. R#53 had his shirt raised and he was scratching his abdomen. The resident's abdomen had a rash with red papules. The CNA who was supervising the residents in the day room at that time stated that the resident had been scratching his abdomen for a while now. Continued observation, at this time, revealed R#32 (BIMS=99, severely cognitively impaired), a roommate of R#7, was also in the day room and had a red rash on his arms and neck. R#63 (BIMS=unable to determine due to severe cognitive impairment), who was also a roommate of R#7, was observed with a rash on his abdomen and upper chest area. R#44, who resided on C hall was observed scratching a red rash on his face, neck, chest and arms. Observation on 8/8/17 at 11:35 a.m., R#7 ambulated unsupervised to room D-30 and sat on another resident's bed (A bed) and then sat on the B bed. R#7 then got up and ambulated unsupervised to room D-32 and sat on that resident's bed (A bed). The resident then ambulated to the day room. While R#7 was observed sitting on other residents' beds unsupervised, staff were observed in the day room with other residents. Observation on 8/8/17 at 12:40 p.m., R#7 was sitting in the dining room in a different cloth chair than the chair he sat in the previous day. Observation on 8/8/17 at 2:10 p.m., R#48 (BIMS=4, cognitively impaired) was observed sitting in the day room with other residents on A hall. R#48 was scratching his chest and a red rash was on his face, neck, chest and arms. Observation on 8/8/17 at 3:35 p.m., R#11 (BIMS=7, some cognitive impairment) was observed in his bed on the D hall scratching his neck. R#11 was observed at that time with papules on his face and neck. Observation on 8/8/17 at 3:55 p.m. R#49 (BIMS=14, alert and oriented) was sitting in the A hall scratching a red rash on her neck. The red rash was on her face and arms as well. R#49 stated that she has had a rash for a little while. Observation on 8/9/17 at 8:59 a.m. R#7, R#63 and R#32 were sitting in plastic covered chairs in the D hall day room with other residents and three staff. R#63 got up and ambulated down the hall with staff supervision. A cart with PPE was outside the resident's room and housekeeping staff, wearing gloves and gowns, were deep cleaning his room at that time. Observation on 8/10/17 at 8:30 a.m. a Contact Precautions sign was noted on the room door for R#7, #32 and #63. A cart with PPE was outside the room door in the hall. Each of the residents was observed in their own bed and CNA JJ was observed sitting in the room wearing a gown and gloves. CNA JJ stated at that time that prior to the survey, she wore gloves and washed her hands before and after the provision of care for the resident. She stated that she had placed his soiled linens and clothing in clear bags and placed the bags in the soiled linen closet. Continued interview revealed that now she wears gloves and a gown and bags his soiled linens/clothing in a clear bag but, takes it directly to the laundry and tells laundry staff that the articles needed to be washed separately. 5. Other affected Residents Review of the Resident Census and Condition of Residents Form CMS- 672 revealed that the facility census on 8/7/17 was 84 residents and that only one (1) resident (R#7) in the facility had a rash; however, on 8/7/17 and 8/8/17 during the initial portion of the survey, eight residents (#7, #32, #63, #44, #53, #11, #48 and #49) were identified by surveyors with rashes. On 8/9/17 at 10:18 a.m. the ADON provided Skin Assessments fo

Based on observations, and staff interview, the facility failed to ensure that one of one (1 of 1) ice machine was maintained in a sanitary manner, to prevent the spread of infection. Findings include: Observations of the ice machine on 9/15/14 at 6:45 p.m. and 9/16/14 at 1:40 p.m. revealed that the facility had only one (1) ice machine which was located outside of the main dining area. It had copious amounts of a dark brown substance on the plastic shield inside the ice compartment. Observation on 9/17/14 at 9:35 a.m. with the Dietary Manager revealed copious amounts of a dark brown substance on the plastic shield inside the ice compartment. The Dietary Manager verified the presence of the dark brown substance and revealed that she is responsible for cleaning the ice machine but could not recall the last cleaning. Review of kitchen cleaning schedule revealed cleaning dates for the ice chests and carts but no evidence of a schedule for the ice machine.

Based on observations, Medication Destruction Policy, Controlled Medication Administration Policy, and staff interview the facility failed to ensure expired medications were disposed of in a timely manner in one of two (1 of 2) medication storage rooms, and one of three (1 of 3) medication carts; and failed to ensure that Controlled Medications were reconciled accurately for two (2) random residents in one of three (1 of 3) medication carts. Findings include: 1. Observations of the medication storage room (Main Nurse Supply Room A/B Hall) on 09/17/14 between 1:30 p.m. and 2:30 p.m. revealed the following medications were found to be expired: -Four (4) unopened bottles of Certavite Multivitamin (MVI) and Mineral Liquid Supplement 236 milliliter (ml) bottles with an expiration date of July, 2014. -Four (4) unopened bottles of Aspirin Enteric Coated 325 milligram (mg) Tablets with an expiration date of July, 2014 -Two (2) unopened bottles of Senexon Liquid- Natural Vegetable Stimulant Laxative 237ml bottles with an expiration date of August, 2014 -Thirty (30) packs in one (1) unopened box of Juven Nutrition Powder with an expiration date of May 1, 2014 During interview with Licensed Practical Nurse (LPN) "AA" on 9/17/14 at 2:20 p.m. she verified the medications were expired. 2. Observation of the medication cart (A/B Medication Cart) on 09/17/14 between 1:30 p.m. and 2:30 p.m. revealed one (1) opened bottle of Senexon Liquid- Natural Vegetable Stimulant Laxative 237 ml bottle which was half empty, with an expiration date of July, 2014. Review of the Facility policy titled " Medication Destruction " revealed that discontinued medications, medications left in the nursing center after a patient's discharge, and expired medications are to be destroyed. 3. Review of the Controlled Drug Record Form for two (2) residents receiving controlled substances revealed -one (1) resident, receiving Hydrocodone-APAP 5/325 mg, had seventeen (17) tablets available but reconciliation revealed that the medication package had a total of eighteen (18) tablets not used. -one (1) resident receiving, Lorazepam 1 mg tablet, had forty-five (45) tablets available, but reconciliation revealed that the medication package had a total of forty-four (44) tablets not used. Interview with LPN "BB" on 9/17/14 at 2:00 p.m. she verified that the medication was expired, and that the controlled medications were not reconciled accurately. Review of the Facility policy titled " Controlled Medication Administration " number three (3) revealed that at each shift change, a physical inventory of all controlled mediation is conducted by two (2) licensed nurses and is documented on a Controlled Drug Sheet Audit Report.

Based on observations, record review and staff interviews the facility failed to maintain safe water temperatures of one hundred and twenty degrees Fahrenheit (120 F) to prevent accidents in resident bathrooms on three (3) of four (4) halls. Findings include: Observations during initial tour of the facility on 9/15/14 between 7:00 p.m. and 7:30 p.m. revealed the following hot water temperatures: - The "D" hall common bathroom water temperature was one hundred and twenty-two (122) degrees Fahrenheit (F) -The water temperature in room B-17 was one hundred and twenty three point seven (123.7) degrees F Interview on 10/01/14 at 10:45 a.m., during the Quality Assurance process, with the Assistant Director of Nursing (ADON) revealed that there were three (3) residents in room B-17 and that all three (3) were able to use the sink in the bathroom independently. Review of the weekly water temp and equipment log revealed that water temperatures were monitored on each hall and the common bath weekly with no evidence of temperatures elevated above 120 degrees F

Based on observations and record review, it was determined that the facility failed to provide appropriate interventions to prevent foot injuries for two residents (#24 and "A") who were transported in wheelchairs from a sample of 31 residents. Findings include: 1. Resident #24 had [DIAGNOSES REDACTED]. There was a care plan since at least 9/27/12 to address his/her risk for foot injury due to a refusal to wear shoes. There was an intervention for staff to protect the resident's feet from injury especially when propelling him/her in a wheelchair. However, it was observed on 11/12/12 at 1:00 p.m. and on 11/13/12 at 8:25 a.m., 8:50 a.m. and 1:30 p.m., that staff was propelling (pushing) the resident in his/her wheelchair without the footrests in place. The resident was observed to only have been wearing socks on his/her feet. As the staff propelled (pushed) the wheelchair forward, the resident's feet were dragging underneath the wheelchair with his/her toes being curled under towards the floor. 2. During a random observation on 11/13/12 at 8:35 a.m., staff were propelling resident "A" in a wheelchair. Staff had not put footrests on the wheelchair. As the staff was propelling (pushing) the wheelchair with the resident seated in it, it was observed that the resident's feet were dragging along the floor.

Based on observation and record review, it was determined that the facility failed to implement care plan interventions to protect the feet from foot injury during transport for one resident (#24) from a total sample of 31 residents. Findings include: Resident #24 had a care plan since at least 9/27/12 to address his/her risk for foot injury due to his/her refusal to wear shoes. There was an intervention for staff to protect the resident's feet from injury especially when propelling (pushing)him/her in a wheelchair. However, it was observed on 11/12/12 at 1:00 p.m. and on 11/13/12 at 8:25 a.m., 8:50 a.m. and 1:30 p.m., that staff were propelling (pushing) the wheelchair with the resident seated in it but they had not put the foot rests in place. Staff had put socks on the resident's feet The resident's feet were being dragged underneath the wheelchair and his/her toes were curled under towards the floor. See F323 for additional information regarding resident #24.

Based on observations, and resident and staff interviews, it was determined that the facility failed to ensure an environment free from flies on four of four halls (A, B, C, and D) and in the dining room. Findings include: 1. During an observation and resident interview on 5/16/11 at 2:12 p.m., there were flies on the face of resident "C." At that time resident "C" stated that there was a bad problem with flies and that they were even worse when it rained. 2. During an observation and resident interview on 5/16/11 at 2:21 p.m., there were flies on two residents and on the overbed table in room A3. 3. On 5/16/11 at 2:38 p.m., while the resident in room A2-C was lying on the bed, there were two flies observed on the resident's bed and the overbed table. 4. On 5/18/11 at 9:30 a.m., there was a fly on the head of resident "D" as he/she sat in the wheelchair outside of the A Hall shower room. 5. On 5/18/11 at 12:50 p.m., there were flies on the residents and furniture in the common area on the D Hall. 6. On 5/19/11 at 9:00 a.m., flies were in the A and B Hall corridors and in the B Hall dining room. 7. On 5/18/11 at 12:15 p.m., during observation of medication administration, a fly was crawling on the bed covers and on the resident in room 23B. On 5/17/11 at 12:15 p.m., the Dietary Manager stated that the door exiting the dining room at the end of the B hall was used frequently throughout the day. The facility's pest control policy revealed services had been provided by Ecolab on 4/21/11 for flies, mice and cockroaches. The Ecolab representative identified a one-quarter inch or greater gap in the laundry room door which "would allow pests to enter the area." Observation of the double doors in the laundry room on 5/19/11 at 9:00 a.m. with the Housekeeping Supervisor revealed that the door was not completely closed. Once closed and latched, there was a gap between the doors through which the outside environment could be seen. On 5/19/11 at 9:40 a.m. and 11:30 a.m., the single door exiting the clean side of the laundry room was open even though there was a sign on the door instructing staff to keep that door closed at all times. There was a screen door in place but, the top section of the screen was missing.