Every finding on record at Palo Pinto Nursing Center

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 (Resident #18) residents who received a pureed meal reviewed during 1 of 1 lunch meals. The facility failed to ensure Resident #18, who received a pureed diet, was provided the food according to the menu, including a roll on 09/09/2025. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Record review of Resident #18's face sheet dated 09/11/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included anorexia, heart failure and feeding difficulties. Record review of Resident #18's MDS dated [DATE] Section C -Cognitive Patterns revealed a BIMS score of 11 meaning moderate cognitive impairment; Section K Swallowing/Nutritional Status revealed Resident #18 received a mechanically altered diet. Record review of Resident #18's physician orders revealed a start date of 03/15/2024 Pureed texture, moderately thickened honey consistency.Record review of Resident #18's care plan dated 08/06/2025 revealed, Nutritional Status: {Resident Name} is on a puree diet.During an observation and interview on 09/09/2025 at 12:30 PM Resident #18's lunch tray left kitchen without a puree roll. The DM stated Resident #18's meal tray should have had a pureed roll. The DM stated the cook was responsible for ensuring a pureed roll was on Resident #18's tray. The DM stated residents not receiving all the menu items could have affected the residents by possible weight loss. The DM stated what led to failure was that dietary staff were distracted by state surveyor being in the kitchen. During an interview on 09/11/2025 at 11:30 AM [NAME] A stated residents were to get everything listed on the Menu. [NAME] A stated it was her responsibility to ensure all items were on the meal tray. [NAME] A stated residents could have been affected by not getting all of their food could have caused weight loss. [NAME] A stated what led to failure was she got distracted by the chicken waiting for it to get cooked. During an interview on 09/11/2025 at 12:11 PM the ADMN stated her expectation was residents should have received every item that was listed on the menu, and residents who received a pureed meal should have received a pureed roll. The ADMN stated the DM was responsible for ensuring trays contained all food items on the list. The ADMN stated the dietician was responsible for monitoring on her weekly visits. The ADMN stated residents could have been affected by their rights being violated by not receiving all the food they were supposed to receive. The ADMN stated what led to failure was that dietary staff were distracted because the state survey team were in the kitchen. Record review of facility policy titled, Menu Planning, Chef's Special (alternate Menu) or Static Menu dated 02.19.2028 revealed, The menus will be followed and served as written.

In an observation on 09/10/2025 at 3:18 p.m., there did not appear to be any survey results in the lobby nor a sign indicating survey results were available and where to locate them. Survey binder observed to be placed in a bin down a hallway to the right of lobby with small print labeled survey results outside of the binder and on the bin. The survey binder did not have results from investigation visit on 04/10/2025 or most recent recertification visit on 08/20/2024.Resident #10Record review of quarterly MDS dated [DATE] reflected Resident #10 was a [AGE] year-old male who admitted into the facility on [DATE] with diagnoses to include: coronary artery disease (disease that affects the main blood vessels that supply blood to the hear reducing blood flow to the heart muscle), hypertension (high blood pressure), renal disease (kidneys do not work as well as they should) and hyperlipidemia (high cholesterol). Further review reflected Resident #10 had a BIMS of 14 which indicated his cognition was intact.During an interview on 09/09/2025 at 2:46 p.m., Resident #10 was sitting in his room with a family member. Resident #10 and his family member both stated that they were not aware that survey findings were available or where to find them.In an observation and interview on 09/11/2025 at 11:18 p.m., the ADMN verified that the survey binder did not have results from investigation visit on 04/10/2025 or most recent recertification visit on 08/20/2024. She stated her expectation would be for the last survey results and investigation results to be in the survey results binder. She stated she was responsible for making sure the survey results binder was updated. She stated that corporate may monitor required postings which included the survey binder during their annual mock survey. The ADMN stated she had worked for the facility before the last survey and did not know why those results were not in the folder. She stated the effect would be that the residents and visitors would not have access to survey and investigation results without asking for them. She stated the facility was not withholding information intentionally from residents or visitors. She stated the public would be notified of access to those results from the label outside of the bin the binder was kept in. She stated that label was not prominent for visitors. The ADMN stated she would update the binder with the missing results. Record review of facility admission agreement without a date reflected: Resident Rights Under Federal Law.The Resident has a right to examine the results of the most recent survey of the Facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the Facility. Record review of facility policy titled Availability of Survey Results revised on 02/08/2024 reflected: 1. A readable copy of our company's most recent federal and/or state survey report and plan of correction for any identified deficiencies is maintained in a 3-ring loose-leaf binder titled Results of Most Recent Survey.2. The survey binder is located (in the main lobby) and is available for review by interested persons who wish to review information relative to our company's compliance with federal or state rules, regulations, and guidelines governing our company's operation.3. A representative of management is assigned the responsibility of making weekly inspections of the survey binder to ensure that the binder contains current information, is located in its designated area(s), and is readily accessible without one having to ask staff members for the information.4. The facility will maintain reports of any surveys, certifications, and complaint investigations made respecting the facility during the 3 proceeding years, and any plan of correction in effect with respect to the facility. This information will be available for any individual to review upon request.5. The facility shall not alter the survey results unless authorized by the state agency.6. Signs identifying the availability and location of our survey binder and availability of previous survey results are posted throughout the building and public bulletin boards. (See attached Notice.)

Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual completed a training and competency evaluation program for 2 (SNA A and SNA B) of 2 Student Nurse Aides reviewed for nursing services. The facility failed to ensure SNA A and SNA B was certified within the required time. This failure could place residents at risk for receiving inappropriate care from an individual whose skill level was not known. Findings include: Review of the facility's employee files revealed: -SNA A had a hire date of 12/08/2021 and worked full time. An annual EMR/NAR check on 11/08/2024 indicated SNA A did not have a CNA certification number. -SNA B had a hire date of 05/20/2024 and worked full time. An annual EMR/NAR check on 05/30/2024 indicated SNA B did not have a CNA certification number. During an interview on 04/09/2025 at 5:30 PM, SNA A stated he had been working continuously at the facility since 05/30/2024. He stated he performed the duties of a nurse aid on the evening shift and assisted certified nurse's aides with transfers and other patient care tasks. He stated that he had gone to take his certification test, did not have the proper ID, and was turned away. He stated he was not aware of the identification that he needed in order to take the test. He stated he was in the process of getting the proper ID to take the test. He stated the adverse outcome that could result from failure to be certified would be the resident might not get the care that they should receive, and that might affect their health and overall wellbeing. He stated he had not registered to take the test again because of his lack of an ID. SNA B was not interviewed during the investigation (unable to reach by phone. During an interview on 04/10/2025 at 2:47 pm, the DON stated that her expectation would be for the facility to have certified nurse assistants. She stated that she recently took on the responsibility of monitoring and ensuring the CNAs tested and became certified. She stated she didn't know there was a limit on how long SNA A and B could work before becoming certified. She stated no negative effect had occurred to residents due to care received from a non-certified SNA, but an adverse outcome could be that a resident could not receive appropriate care. She stated it was the responsibility of the prior ADON to monitor training and certifications, but going forward it was her responsibility. Record review of a document titled How To Become a Certified Nurse Aide (CNA) in Texas (from website www.hhs.texas.gov)website not dated stated in part: - Complete NATCEP Training (Nurse's aide Certification and Evaluation Training program) - Submit an application through TULIP (Texas Unified Licensure Portal) - NATCEP approval - based on successful completion of training; Successful background check Student not listed on the EMR - Schedule and pass the exam : Student schedules and passes both the written and skills exams Record review of the document provided by the DON titled Job Description For a SNA dated 2010, and signed on 04/18/23 by SNA A stated the following [in part] : Must provide written proof of a completion of 16-hour ADL training by authorized school instructor. Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics . Applicant declaration: I have read the qualifications and requirements of the position of student nurses aide; I understand this position is not permanent but limited to 120 days in which I am required to test and obtain certification. I understand and certify that the foregoing is a non-exhaustive criterion that is consistent with the needs of this facility and is a legitimate measure of the qualifications for a Certified Nursing assistant and relates to the functions essential to a certified nursing assistant.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident # 1) of 5 residents reviewed for infection control, in that: The facility failed to implement Enhanced Barrier Precautions for Resident #1 who had an Enhanced Barrier Precautions sign posted on her room door. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident 1's electronic Face Sheet dated 04/09/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues), MRSA (methicillin resistant staph aureus, a drug resistant bacteria) , clostridium difficile (inflammation of the colon caused by the bacteria clostridium difficile) diagnoses. An observation and interview on 04/10/25 at 9:21 AM revealed CNA C and CNA D entered Resident #1's room to perform incontinent care. There was an Enhanced Barrier Precaution sign on the door, and personal protective equipment outside of the room. CNAs C and D entered the room to provide incontinent care. They did not wear a gown. The DON was standing outside the door because the call light remained on. The CNAs washed their hands, applied gloves, and informed Resident #1 that they were going to do incontinent care. Resident #1 requested the surveyor leave the room for privacy. There were no gowns in the room. In an interview on 4/10/25 at 9:30 AM with CNA C and CNA D, both stated they realized after they got in the room they should have donned a gown to provide any direct patient care. Both stated they were not sure why they didn't put on a gown. CNA C stated she knew the resident had a bowel movement be and was laying crooked in the bed before she entered the room. She stated she did not usually work that hallway, so she wasn't familiar with the residents. She stated she went to get CNA D who was assigned to the hall. She stated they proceeded to the room and provided privacy by shutting the door and pulling the curtain and completed incontinent care. CNA C stated she knew after they had started to perform the incontinent care they had messed up because they didn't put on gowns. She stated she did not know why they did not get gowns when they realized their mistake. She stated she felt like she forgot the gown because they were trying to hurry because the resident was laying crooked in the bed and was upset that she had a bowel movement in the bed. She stated she just thought it was more important to get her cleaned up quickly. Both CNA C and CNA D stated that a negative outcome for the resident that could result from their failure to wear a gown would be the spread of infection. They both stated they did not remember when they last had an in-service on enhanced barrier precautions at the facility. In an interview on 04/10/2025 at 3:30 PM, the DON stated it was her expectation that the CNAs should have worn a gown when performing direct care on a resident on Enhanced Barrier Precautions. She stated they had been in-serviced on enhanced barrier precautions. She stated failure to implement enhanced barrier precautions could result in the spread of multi drug resistant organisms. Record review of the facility's policy titled Infection Prevention and Control Program dated 10/24/2022 stated in part: Enhanced barrier precautions are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multi Drug Resistant organisms to staff hands and clothing. Enhanced barrier precautions are indicated for residents with any of the following: infection or colonization with a multi drug resistant organism when contact precautions do not otherwise apply, wounds and or indwelling medical devices regardless of multi drug resistant organism colonization status

49427 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 2 (Resident #9 and #24) of 24 residents reviewed for care plans. 1. The facility failed to develop and implement a comprehensive care plan for Resident #24 to address the left femur fracture sustained on [DATE] and current transfer status. 2. The facility failed to update Resident #24's Kardex (a brief digital overview of the resident's needs) to reflect she required 2 people to transfer her. As a result, the resident was transferred on [DATE] by a hospitality aide. Resident #24 was sent to the hospital and sustained a femur fracture. 3. The facility failed to develop a comprehensive care plan for Resident #9 to address her non-compliance with asking for assistance with transfers and failed to follow Resident #9 transfer status. As a result, staff were not aware of the transfer status of Resident #9 and she experienced an unwitnessed fall on [DATE], [DATE], and [DATE]. 4. The facility failed to update Resident #9's care plan to address the nasal bone fracture on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:30 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained comprehensive care plans These failures could place residents at risk for not receiving care required to meet their individualized needs and place them at risk for falls and injury. Findings included: Resident #24 Record review of Resident #24's Comprehensive MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (damage to the brain from interruption of its blood supply), dysphagia (difficulty swallowing), and hemiplegia and hemiparesis (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Resident #24's BIMS was 15, which indicated her cognition was intact. The MDS assessment indicated Resident #24 required extensive assistance of one-person physical assistance with transfer, and personal hygiene. GG functional section reflected the resident required substantial /maximal assistance with toilet transfer. Record review of Resident #24 care plan dated [DATE] reflected: Focus: Fall - [Resident #24] has the potential for falls related to . Gait/balance. Goal: The resident will be free of falls through the next review date. Interventions: Transfers with assist of 2 staff. Record review of the Post-Fall Risk assessment dated [DATE] revealed Change in Functional Ability . New Interventions: 2 persons lift with Hoyer. Review of the Provider Investigation report, dated [DATE], for Resident #24 reflected, .Incident date [DATE] at 8:30 PM .description of incident .Resident was being transferred by a non-certified aide and sustained an injury.Nurse assessed resident and noticed evidence of fracture. Resident was transported to hospital by EMS . HA C was suspended. MD and RP notified. Safe survey completed. In-service regarding abuse and neglect and fall prevention .Skin assessment performed on all resident who are unable to be interviewed. Staff educated regarding transfers . Review of the Nurses Notes completed by LVN D and dated [DATE] reflected, . I was called to her room and found her lying in the bathroom floor. HA C stated she was transferring her back to wheelchair when there was a loud pop and she wasn't able to stand, HA C then lowered her to floor and got me. Left leg and foot were turned inward. Action: I notified DON and Doctor. Resident was transferred to the hospital . Review of Resident #24's hospital records, dated [DATE], reflected the following: .Female who presented to the emergency department from nursing home after a fall which occurred at the skilled nursing facility. She stated that she was using the commode when her left leg gave way and she fell . She began to experience pain in the left leg. She had imaging studies done at the local emergency department which revealed a complex comminuted fracture of the distal femur with mild displacement. She was therefore sent here for further management. Pre operation diagnoses: Left extra-articular distal femur fracture. Procedure: Intramedullary nailing of left distal femur fracture. During the course of the patient's operation, surgical assistance was provided. Record review of Resident #24's care plan dated [DATE] did not reflect the fall with the facture and did not reflect the new intervention of 2 persons lift with Hoyer. Record review of Resident #24's MDS Kardex report, dated [DATE], revealed Resident Care . Transfers: Extensive 1 staff . Toileting: Extensive assist 1 staff. In an interview on [DATE] at 9:25 AM, with Resident #56 revealed he was in Resident #24's room during the incident on [DATE]. He stated HA C assisted Resident #24 to the toilet without help of another staff. He stated usually 2 staff helped Resident #24 with transfer. Resident #56 stated HA C went in to help Resident #24 get off the toilet. When she helped get her up and turned her to the wheelchair for the transfer, her knees gave out and there was a loud pop as she was lowered to the ground. Resident #56 stated he yelled for help and the nurse and other staff came in for help, somebody called the ambulance and Resident #24 was sent to the hospital. In an interview on [DATE] at 9:30 AM, Resident #24 stated HA C dropped her on the floor in the toilet. In an interview on [DATE] at 2:42 PM, LVN D stated she was working the evening of the incident when she heard Resident #24's Family Member calling for help in the room. LVN D stated when she walked in, the resident's leg was turned outward and looked to be broken. LVN D stated she assessed the resident. Another staff called the 911. Resident #24 was transferred to the hospital. LVN D stated Resident #24 is 2 persons assist with transfer. LVN D stated hospitality aides were not allowed to transfer residents. In an interview on [DATE] at 3:17 PM, HA C stated on [DATE] at approximately 9 PM she reported to Resident #24's room, resident needed to go to the restroom. HA C stated she assisted Resident #24 to the toilet because the CNA was on break. HA C stated she was able to access the Kardex. When transferring the resident from toilet back to wheelchair, resident used grab bars to assist in standing up, HA C assisted resident with pulling up pants, in the middle of turning the resident's left knee buckled, HA C instructed the resident to try and stand up. Resident #24 reported she could not. HA C stated she heard a loud pop and assisted resident to the floor. Resident #56 called for assistance, the nurse and staff member reported to resident's room. HA C confirmed she was not a CNA (her certificate was expired since 2014), and stated she had to work with a certified nurse aide on the floor at all times. At the time of this interview HA C stated she had received an in-service on transfers of Resident #24 after the fall occurred on the evening of [DATE]. HA C stated she assisted Resident #24 to the toilet without assistance because the CNA was break. In an interview with the DON on [DATE] at 3:30 PM, he stated hospitality aides were not allowed to provide any direct care to residents. He stated HA C should not transfer Resident #24. He stated hospitality aides were in-serviced on job description up on hire. The DON did not provide the in-service on job description for HA C to the surveyor. The DON stated Resident #24 was 2 persons assist with transfer. The DON stated the amount of assistance needed by a resident would be reflected in the Kardex system for nursing staff. The surveyor asked if the care plan populated the Kardex because the Kardex did not show before and after the incident that Resident #24 was a two-person assist for transfer. The DON did not provide any answer. The DON stated he was, and the ADONs, responsible to oversee the care plans for updates and the Kardex to reflect the care plans. Resident #9 Record review of Resident #9's face sheet, printed date [DATE], revealed she was a [AGE] year-old female initially admitted on [DATE], and readmitted on [DATE] with diagnoses of fracture of nasal bones, metabolic encephalopathy (metabolic disorder), sepsis (life threatening complication of infection), muscle weakness, repeated falls, type-2 diabetes (high blood sugar), congestive heart failure, major depressive disorder (persistent feelings of sadness or loss of interest), chronic obstructive pulmonary disease (lung disease causing restricted airflow), and anxiety disorder (persistent feelings of worry or fear). Record review of Resident #9's Quarterly MDS, dated [DATE], revealed she required partial/moderate assistance for transfers, and she had a BIMS score of 15 (intact cognition). Review of Resident #9's MDS Kardex report, undated, revealed she required setup help and supervision for transfers and was not steady when moving from seated to standing, moving on and off the toilet, or with surface-to-surface transfers and the section for accidents and fall risk was blank. Review of Resident #9's care plan revealed there were functional limitations in range of motion or decreased mobility, impaired balance and impaired coordination, dated initiated and revised on [DATE]. Interventions included her transfer status was limited x 1 dated initiated [DATE] and revised [DATE]. Review revealed Resident #9 had the potential for falls related to incontinence, gait/balance problems and was unaware of safety needs, dated initiated [DATE] and revised on [DATE]. Interventions included educate resident to let staff know when she was going to the bathroom so they could check on her date initiated, [DATE]; medication review to be performed by psych for fall eval, dated initiated [DATE]; Resident #9's care plan did not reflect she had a fall on [DATE], [DATE] with fracture, or [DATE]. Review of the incident report dated [DATE] at 9:40 PM, completed by LVN U, revealed Resident #9 had an unwitnessed fall. Resident #9 was found sitting on the floor in the bathroom and stated she had fallen asleep on the toilet and then had fallen and bumped her head and left shoulder on the wall and floor. LVN U assessed Resident #9 for injuries and there were none observed, range of motion was normal, she complained of pain to her left shoulder, displayed no visual signs of pain, and was assisted into her wheelchair and into bed. Review of the incident report dated [DATE] at 2:05 AM completed by RN DD, revealed Resident #9 had an unwitnessed fall. RN DD was called to Resident #9's room by a CNA and witnessed Resident #9 was on her stomach on the floor beside her bed with a considerable amount of blood coming from a laceration above the right eyebrow and from her nose. Resident #9 had urinated in her bed and appeared to have gotten out of bed and fell on her stomach and face. RN DD called 911 and Resident #9 was taken to the hospital around 2:30 AM. Review of Resident #9's hospital visit documentation, dated [DATE] revealed she was seen for a nasal bone fracture, laceration of face, and forehead contusion. Review of Resident #9's the CT report dated [DATE] at 5:26 AM revealed she had a comminuted displaced bilateral nasal fractures (multiple broken nasal bones) and right facial and nasal swelling with lacerations. Review of the Post-Fall Evaluation dated [DATE] at 11:18 AM and signed by ADON A revealed Resident #9 had no falls within the last 6 months and had incontinence and decline in ability due to COVID-19 and was added to incontinent rounds and placed on 2-hour checks for assistance toileting. Review of the progress notes dated [DATE] at 7:02 AM by RN DD revealed Resident #9 returned from the hospital at 6:35 AM with Dermabond to the bridge of her nose laceration (cut), contusion (bruising) to forehead, and multiple nose fractures (broken nasal bones) with no deviations (deformity). Review of the Post-Fall Evaluation dated [DATE] at 1:04 PM by RN I revealed Resident #9 had a fall from the toilet and was instructed to use her call light for transfers. The root cause analysis indicated the resident was sleepy and did not use her call light and resident was educated on need for increased help while recovering from COVID-19. Review of the incident report dated [DATE] at 3:25 AM by LVN U revealed Resident #9 had an unwitnessed fall and was found face down on the floor in her bathroom and was not able to respond to verbal commands or conversation and was unable to describe what happened or to lift up her head. Resident #9 was placed on a swing so she would be lifted to the stretcher and the paramedics transported her to the hospital. LVN U stated that Resident #9 complained of pain to the top of her head. Review of Resident #9s hospital visit documentation, dated [DATE] revealed she had no fractures. Review of Resident #9's Physical Therapy evaluation and plan of treatment dated [DATE] revealed she was referred to physical therapy services due to having 2 falls in one week after having COVID-19. Resident #9's previous level of function with transfers was moderately independent and she currently required minimal assistance. The evaluation revealed Resident #9 had fallen 2 times in the past year, had an injury of bruising to face and toes, felt unsteady while standing, walking, and worried about falling. Review of Resident #9's Occupational Therapy Evaluation and Plan of Treatment dated [DATE] revealed she was referred to occupational therapy due to a new onset of COVID-19 with two recent falls that resulted in a significant number of contusions to her face and elsewhere on her body and a fracture of her nose with a recent fall. Resident #9 had a decrease in strength, functional mobility, transfer ability, reduced functional activity tolerance, reduced static and dynamic balance, decreased judgment, increased need for assistance from others, reduced ADL participation and pain. She required minimal assistance with toilet transfers. Observation and interview on [DATE] at 10:28 AM with Resident #9 revealed she was seated in her power wheelchair in her room and had dark purple, brown, and yellow, bruises around her eyes, nose, and cheeks and medical tape on the bridge of her nose. She stated she had a fall two weeks prior, she broke her nose when she fell out of bed when she attempted to transfer herself to her wheelchair. She stated she had another fall on [DATE] when she fell asleep on the toilet and fell and hit her head which resulted in a big bump on her head. She stated that she did not have a prior history of falls before and thought it was due to taking melatonin and had requested it be discontinued. She stated that she was able to transfer herself, did not need staff assistance, and staff were responsive to her when she asked for assistance. Interview on [DATE] at 11:42 AM with CNA K revealed she was familiar with Resident #9 and was not working the day she fell and broke her nose or when she hit her head. She stated that Resident #9 was independent and required verbal cueing during toileting but did not require any physical assistance during transfers. She stated that Resident #9 did not refuse care and they got along well. Interview on [DATE] at 1:11 PM with CNA X revealed she was familiar with Resident #9. She stated Resident #9 was independent and used her call light to ask for assistance. She stated that she worked the day before Resident #9 fell and broke her nose. CNA X stated that after Resident #9 returned from the hospital she was incontinent and was required to stay in bed for a short time. CNA X stated she was currently unsure what level of assistance Resident #9 required with transfers and would typically ask CNA K if she had questions. CNA X stated that Resident #9 only required standby assistance when toileting. Interview on [DATE] at 1:49 PM with RN I revealed Resident #9 was independent and she was not working when she had the fall where she hit her head or broke her nose. She stated that after Resident #9 returned from the fall where she broke her nose, she was a two person assist, and now only required standby assistance. Interview on [DATE] at 3:07 PM with the MDS Coordinator revealed she had worked at the facility for less than a month. She stated she was responsible for completing MDS assessments that included the annual and quarterly MDS, which reflected a resident's abilities and needs. She stated that there was a look back period of 7 days where the IDT submitted their assessments of the resident's abilities, and the most severe or limited rating was entered into the system. The MDS Coordinator was shown Resident #9's MDS, dated [DATE], and she stated she was not sure what the number 3- partial/moderate assistance level meant and reviewed the legend. She stated that it might mean that they needed some sort of assistance such as putting on their shirt or cueing with touch. She stated for bed transfers a partial/moderate assistance coding might mean that they required verbal cuing, or light touch cuing. Interview on [DATE] at 3:24 PM with the Rehabilitation Director revealed he was familiar with Resident #9 and she was started on physical therapy and occupational therapy services on [DATE]. He stated that she was previously on physical and occupational therapy services in [DATE], and she was discharged on [DATE] due to not participating consistently. He stated upon discharge from therapy services she was able to transfer independently. He stated that after she had a fall where she broke her nose, they did not discuss bringing her back onto therapy services because of her previous refusals and she required minimal assistance with transfers which meant one person with a gait belt. Interview on [DATE] at 3:57 PM with ADON A revealed Resident #9 was fairly independent and her goal was to move into the community, so they tried to encourage her to be independent. ADON A stated that she was not sure what the MDS partial/moderate assistance meant, and she looked at the Kardex to find a resident's transfer status and the nurses informed each other of changes of condition during morning meetings. Interview on [DATE] at 4:10 PM with LVN U revealed on [DATE] she responded to Resident #9's call light and she was sitting on the floor of the bathroom. She stated Resident #9 told her that she fell asleep on the toilet and hit her head and shoulder on the wall. She stated on [DATE] she was called to the Resident's room by the roommate and Resident #9 had fallen off of the toilet and had an injury to the top of her head and was not responsive, so she was sent to the hospital. LVN U stated she was not working on [DATE] when resident fell and broke her nose. She stated that the MDS was accurate and reflected she required partial/moderate assistance with transfers and Resident #9 used to be able to transfer herself safely. Interview on [DATE] at 6:00 PM with the DON revealed Resident #9's had a history of falls, and they were care planned. The DON stated Resident #9 had never had a fracture before and was noncompliant with medication and care. He stated he was responsible for care plans and Resident #9's noncompliance might not be documented under falls but was documented under other care areas and was also noted in the progress notes. The DON stated that Resident #9 was able to transfer independently, and they discontinued the melatonin medication. The DON stated that he did not remember if he did an in-service with staff because they did what they were supposed to do, and she was able to tell them what happened. The DON stated that Resident #9 was previously on physical and occupational therapy services and was discontinued due to noncompliance and started again recently. Interview on [DATE] at 6:09 PM with the Administrator revealed Resident #9 had more falls lately and they thought it was due to medications such as melatonin made her drowsier. The Administrator stated that Resident #9 had a high BIMS score and was able to tell them what happened and did not do an in-service regarding her fall. Record review of facility's policy titled, Transfers of Residents, dated reviewed [DATE] reflected .The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident, to prevent injuries to staff member assisting the resident, and to enable the resident to as independent during the transfer as possible . Record review of facility's policy titled, Comprehensive Care Plans, dated [DATE], reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . will be prepared by an interdisciplinary team .The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative . Record review of the facility's job description for a Hospitality Aide revised on [DATE] revealed: . Responsible for providing resident related (no-hands-on) care in accordance with quality standards under the direction of a licensed charge nurse. The position is applicable prior to successfully receiving certification as a nursing assistant. Performs host/hostess type duties in accordance with accepted standards of non-hands-on resident care. Uses daily task assignments. Assist residents that are independent and residents that require minimal or supervision support with activities of daily living, set up bed bath and rinse and soap wash cloth handing to patient. Lay out clothes, hold clothes in position patient can dress self, button clothes, pull up pants, changes unoccupied bed linens, answers call lights assist within skill level, passing and serving water. Assists with resident's recreation programs and transports residents in wheelchairs. Labels personal care items. Keeps resident rooms tidy. Maintains clothing inventory. Reports changes of resident condition to nurse in charge, reports accidents and incidents, and provides support functions as directed by supervisor. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 12:30 PM. The Administrator, DON, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on [DATE] at 12:30 PM. The Immediate Jeopardy plan of removal was accepted on [DATE] at 6:05 PM and the Regional Nurse Consultant was notified of the acceptance. Immediate Jeopardy Removal Plan: Issue Cited: The facility failed to develop and implement a comprehensive care plan for Resident # 24 to address the left femur fracture sustained on [DATE] The facility failed do develop a comprehensive care plan for resident # 9 to address the nasal bone fracture and failed to follow resident # 9 transfer status 1. Immediate Action Taken A. On [DATE] the MDS nurse/Designee completed a comprehensive care plan for resident # 24 to address left femur fracture, and falls care plan to reflect appropriate interventions. This was completed [DATE] B. On [DATE] the MDS nurse/Designee completed an acute care plan for resident # 9 to address the nasal bone fracture, update the fall care plan to reflect appropriate interventions and resident # 9 right to refuse care with education provided at each point of contact. This was completed [DATE] C. On [DATE] a review of resident # 9 and resident # 24 care plan and Kardex was reviewed by Regional Reimbursement Consultant and validated that the care plan was accurate. This was completed on [DATE] D. On [DATE] the Regional Nurse consultant provided education to the MDS nurse on completion of, correct and timely care plan interventions, and that appropriate intervention(s) is reflective on the Kardex to include Activities of Daily Living. This was completed on [DATE]. The Regional Reimbursement Nurses will provide oversight on this process weekly x 4 weeks. E. On [DATE] the Regional Nurse consultant provided 1:1 education to the center's DON on care plan policy which defines the responsibility of the DON to complete acute care plans within 48 hours and with appropriate interventions, and that if applicable, the intervention(s) are reflective on the C.N.A. Kardex. This was completed on [DATE] at 12:00 pm. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks F. On [DATE] the Regional Nurse consultant provided 1:1 education to the center's MDS nurse that reflects that the MDS nurse is responsible for weekly care plan reviews, and that completed MDS's (ADL section) is correct on the ADL care plan, and that the resident's ADL's flow over to C.N.A. Kardex. This was completed on [DATE]. The Regional Reimbursement nurse will provide oversight on this process weekly x 4 weeks. 2. Identification of Residents Affected or Likely to be Affected: A. On [DATE] the Regional Reimbursement Nurse and MDS nurse conducted 100% audit of all residents MDS regarding ADL's. MDS nurse and Regional Reimbursement Consultant then validated that the ADL's coded on the MDS was accurate on each resident's care plans that the ADL's from each resident's care plan flowed over to the C.N. A. Kardex. This was completed on [DATE] and the Regional Reimbursement Consultant will provide oversight on this process weekly x 4 weeks. 3.Actions to Prevent Occurrence/Recurrence: o MDS nurse or Designee will review all residents with changes of conditions, including transfers, falls, daily in the morning meeting and will review/revise care plans as needed. o The Weekend Supervisor or Designee will review all residents with changes of conditions, including transfers, falls, on weekends and will review/revise care plans as needed On [DATE] the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related Comprehensive Care Plans and reviewed plan to sustain compliance On [DATE] the facility conducted and Ad Hoc QAPI meeting to discuss Care Plans and on sustaining compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________[DATE] Monitoring for Plan of Removal: Record review of the MDS in-service, provided by Regional Nurse Consultant, dated [DATE], topic- MDS will be responsible for the completion of comprehensive, annual, and significant changes care plans in a timely manner to ensure the care et [and] services a resident will need signed by MDS Coordinator. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic-care plans, Kardex, and activities of daily living signed by the DON, ADON A and ADON B. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic- Transfer of Residents 1. Gait belt 2. Standby assist 3. Hoyer 4. Transfer residents according to Kardex with comes from the care plan signed by the DON, ADON A and ADON B. Record review of the in-service, provided by RN I, dated [DATE]- Topic Nursing Aides Kardex . direct all aides (CNA, NA, HA) to review Kardex for appropriate assistance needed per resident . aides are to review Q [every] shift prior to being of shift . aides are to provide care to resident according to Kardex signed by 6 Hospitality Aides (Hospitality Aide P, R, S, T, V), 1 CNA (CNA FF), and 2 LVN's (LVN O and Q). Observation and interview on [DATE] at 10:10 AM with Resident #9 revealed she was lying in bed watching television. She stated she self-transfers herself from the bed to the wheelchair and planned to get up in about an hour. She stated she would not need assistance and stated no one had spoken with her about transfers. Observation and interview on [DATE] at 10:25 AM of Resident #9's care plan with the DON revealed there was no updated care plan for resident assistance with transfers or refusing assistance. The DON stated he had not attempted to educate Resident #9 between [DATE] and [DATE] because he had educated her in the past multiple times. The DON stated that Resident #9's noncompliance with transfers had not been care planned and he was unable to find a recent progress note that showed she refused assistance with transfers. Interview on [DATE] at 10:55 AM with the Administrator and the DON revealed Resident #9 had been educated to ask for assistance during transfers and provided an updated care plan. Record review of Resident #9's updated care plan revealed she was non-compliant with transfers, date initiated [DATE] and interventions included education on allowing staff to assist with transfers and respect resident's wishes regarding transfers; had potential for injury due to use of electric wheelchair with interventions of physical therapy assessment, reassess as needed, report any incidents to therapy and doctor, date initiated [DATE]; had potential for complications related to fractured nose with interventions of follow orders for treatment and report any changes in condition regarding the fracture to the doctor, date initiated [DATE]; transfer status was to limited x 1, date initiated [DATE] and revised on [DATE]; use gait belt with transfers, date initiated [DATE]. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic-care plans, Kardex, and activities of daily living signed by the DON, ADON A and ADON B. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic- Transfer of Residents 1. Gait belt 2. Standby assist 3. Hoyer 4. Transfer residents according to Kardex with comes from the care plan signed by the DON, ADON A and ADON B. Record review of in-service, provided by RN I, dated [DATE]- Topic Nursing Aides Kardex . direct all aides (CNA, NA, HA) to review Kardex for appropriate assistance needed per resident . aides are to review Q [every] shift prior to being of shift . aides are to provide care to resident according to Kardex signed by 6 Hospitality Aides (Hospitality Aide P, R, S, T, V), 1 CNA (CNA FF), and 2 LVN's (LVN O and Q). Observation on [DATE] at 1:45 PM of transfer of Resident #9 revealed she was seated in her wheelchair facing the bed at a 45-degree angle. ADON A was standing off to the side of Resident #9 and did not place a gait belt or prompt resident with a count down. Resident #9 stood up, stepped down from her wheelchair to the floor. ADON A placed her hand under Resident #9's elbow and Resident #9 turned and sat down on the bed. Resident #9 stayed seated for a minute and then stood up, leaned forward, and grabbed the handle of her wheelchair with her left hand, paused then stepped up onto her electric wheelchair and turned and sat down. ADON A assisted resident with her oxygen. Interview on [DATE] at 2:00 PM with the Regional Nurse Consultant revealed she was informed of ADON A's inappropriate transfer of Resident #9 and was going to reeducate ADON A immediately. Interviews on [DATE] between 3:14 PM - 3:30 PM with 5 Hospitality Aides (P, T, V, S, and R) revealed they [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision/assistance to prevent accidents for one (Resident #24) of four residents reviewed for accidents. The facility failed to ensure Resident #24 was free of accident hazard when HA (non-certified) C transferred Resident #24, without any assistance, for toileting. On [DATE] HA C transferred and toileted Resident #24 without any assistance. When transferring the resident from the toilet to the wheelchair, HA C heard a loud pop sound and the resident was not able to stand. The HA C lowered the resident to the floor. As a result of the transfer, Resident #24 sustained a fracture of left femur. Resident #24 required a surgical intervention. Resident #24 was required to be non weight bearing and have brace to the left leg after the incident. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:30 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facility was still monitoring the effectiveness of the plan of removal. This failure could place residents at risk for accidents and harm. Findings included: Record review of Resident #24's Comprehensive MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (damage to the brain from interruption of its blood supply), dysphagia (A condition that affects the ability to produce and understand spoken language), and hemiplegia and hemiparesis (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Resident #24's BIMS was 15, which indicated her cognition was intact. The MDS assessment indicated Resident #24 required extensive assistance of one-person physical assistance with transfer, and personal hygiene. GG functional section reflected the resident required substantial /maximal assistance with toilet transfer. Record review of Resident #24 care plan dated [DATE] reflected: Focus: Fall - [Resident #24] has the potential for falls related to . Gait/balance. Goal: The resident will be free of falls through the next review date. Interventions: Transfers with assist of 2 staff. Review of the Provider Investigation report for Resident #24 dated [DATE] reflected, .Incident date [DATE] at 8:30 PM .description of incident .Resident was being transferred by a non-certified aide and sustained an injury.Nurse assessed resident and noticed evidence of fracture. Resident was transported to hospital by EMS . HA C was suspended. MD and RP notified. Safe survey completed. In-service regarding abuse and neglect and fall prevention .Skin assessment performed on all resident who are unable to be interviewed. Staff educated regarding transfers . Review of the Nurses Notes for Resident #24 completed by LVN D and dated [DATE] reflected, . I was called to her room and found her lying in the bathroom floor. HA C stated she was transferring her back to wheelchair when there was a loud pop and she wasn't able to stand, HA C then lowered her to floor and got me. Left leg and foot were turned inward. Action: I notified DON and Doctor . Resident was transferred to the hospital . Review of Resident #24's hospital records, dated [DATE], reflected the following: .Female who presented to the emergency department from nursing home after a fall which occurred at the skilled nursing facility. She stated that she was using the commode when her left leg gave way and she fell . She began to experience pain in the left leg. She had imaging studies done at the local emergency department which revealed a complex comminuted fracture of the distal femur with mild displacement. She was therefore sent here for further management. Pre operation diagnoses: Left extra-articular distal femur fracture. Procedure: Intramedullary nailing of left distal femur fracture. During the course of the patient's operation, surgical assistance was provided. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, elevated blood pressure, and osteoarthritis. Resident #56's BIMS score was 15, which indicated his cognition was intact. In an interview on [DATE] at 9:25 AM, Resident #56 (Resident #24's Family Member living with Resident #24 in the same room), stated on [DATE] HA C assisted Resident #24 to the toilet without help of another staff. He stated usually 2 staff helped Resident #24 with transfer. Resident #56 stated HA C went in to help Resident #24 get off the toilet. When she helped get her up and turned her to the wheelchair for the transfer, her knees gave out and there was a loud pop as she was lowered to the ground. Resident #56 stated he yelled for help and the nurse and other staff came in for help, somebody called the ambulance and Resident #24 was sent to the hospital. In an interview on [DATE] at 9:30 AM, Resident #24 stated HA C dropped her on the floor in the toilet. Resident #24 stated usually 2 people transferred her before and after the incident of [DATE]. In an interview on [DATE] at 2:42 PM, LVN D stated she was working the evening of the incident when she heard Resident #24's Family Member calling for help in the room. LVN D stated when she walked in, the resident's leg was turned outward and looked to be broken. LVN D stated she assessed the resident. Another staff called the 911. Resident #24 was transferred to the hospital. LVN D stated Resident #24 is 2 persons assist with transfer. LVN D stated hospitality aides were not allowed to transfer residents. In an interview on [DATE] at 3:17 PM, HA C stated on [DATE] at approximately 9 PM she reported to Resident #24's room, resident needed to go to the restroom. HA C stated she assisted Resident #24 to the toilet. When transferring the resident from toilet back to wheelchair, resident used grab bars to assist in standing up, HA C assisted resident with pulling up pants, in the middle of turning the resident's left knee buckled, HA C instructed the resident to try and stand up. Resident #24 reported she could not. HA C stated she heard a loud pop and assisted resident to the floor. Resident #56 called for assistance, the nurse and staff member reported to resident's room. HA C confirmed she was not a CNA (her certificate was expired since 2014), and stated she had to work with a certified nurse aide on the floor at all times. At the time of this interview HA C stated she had received an in-service on transfers of Resident #24 after the fall occurred on the evening of [DATE]. HA C stated she assisted Resident #24 to the toilet without assistance because the CNA was break. She stated she supposed to call the nurse because Resident #24 needed 2 persons for transfer. She stated she never transferred Resident #24 before, because as a HA she was not allowed to transfer Resident #24 or any other resident. In an interview with the DON on [DATE] at 3:30 PM, he stated hospitality aides were not allowed to provide any direct care to residents. He stated HA C should not transfer Resident #24. He stated if the CNA was not available the HA C should notify the nurse about Resident #24 needs. He stated hospitality aides were in-serviced on job description up on hire. The DON did not provide the in-service on job description for HA C to the surveyor. The DON stated Resident #24 was 2 persons assist with transfer. The DON stated the amount of assistance needed by a resident would be reflected in the Kardex system for nursing staff. The surveyor asked if the care plan populated the Kardex because the Kardex did not show before and after the incident that Resident #24 was a two-person assist for transfer. The DON stated he was, and the ADONs, responsible to oversee the care plans for updates and the Kardex to reflect the care plans. The DON stated charge nurses, ADONs himself did routine rounds to monitor to ensure transfers were being done appropriately. Record review of the facility's policy Transfers of Residents dated [DATE], reflected Transfers are defined as the act of moving a resident from one surface such as from the bed to the wheelchair or from the from the wheelchair to the toilet. The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident. Record review of the facility's policy titled Abuse, Neglect and Exploitation dated [DATE], reflected, .Neglect - means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of the facility's policy titled Comprehensive Care Plans, dated [DATE] reflected, .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Record review of the facility's job description for a Hospitality Aide revised on [DATE] revealed: . Responsible for providing resident related (no-hands-on) care in accordance with quality standards under the direction of a licensed charge nurse. The position is applicable prior to successfully receiving certification as a nursing assistant. Performs host/hostess type duties in accordance with accepted standards of non-hands-on resident care. Uses daily task assignments. Assist residents that are independent and residents that require minimal or supervision support with activities of daily living, set up bed bath and rinse and soap wash cloth handing to patient. Lay out clothes, hold clothes in position patient can dress self, button clothes, pull up pants, changes unoccupied bed linens, answers call lights assist within skill level, passing and serving water. Assists with resident's recreation programs and transports residents in wheelchairs. Labels personal care items. Keeps resident rooms tidy. Maintains clothing inventory. Reports changes of resident condition to nurse in charge, reports accidents and incidents, and provides support functions as directed by supervisor. The facility administrator was notified on [DATE] at 12:30 PM that an Immediate Jeopardy situation had been identified due to the above failures. IJ template provided at this time and a Plan of Removal was requested. The facility's plan of removal was accepted on [DATE] at 6:05 PM and included: 1.On [DATE] resident # 24 was immediately sent the emergency room . 2.On [DATE] the hospitality aide involved in this incident was suspended until further notice 3.On [DATE] the DON/Designee completed the investigation on incident involving resident # 24. 4. On [DATE] at 12:30 pm, the Regional Nurse Consultant provided in-service education with the DON on Job descriptions to include Hospitality Aides job duties, and Certified Aide job duties This was completed on [DATE]. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks. 5. On [DATE] at 1:00 pm, the DON/Designee began in-service education with all clinical staff on Job descriptions to include Hospitality Aides job duties, and Certified Aide job duties to validate that each Aide had clear understanding of what was in their scope and practice. This was completed on [DATE] and no clinical staff will be allowed to work until this education has been completed. 6. On [DATE] the DON/Designee began in-service education with individual hospitality aides on their specific job duties and had the individual sign a new job description. This was completed on [DATE] either directly or by phone. This education included that at any time, a hospitality aide is performing care that is not in their job description, the DON/Administrator will be notified immediately, and staff will be asked to leave facility. This was completed on [DATE]. 7. On [DATE] at 12:30 pm, the Regional Nurse Consultant provided in-service education with the DON/Designee on transfers which guides staff on how to properly and safely transfer residents according to their plan of care and type of device if needed. This was completed on [DATE] at 1:00 pm. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks. 8. On [DATE] at 2:00 pm the DON/Designee began in-service education with all clinical staff on transfers which guides staff on how to properly and safely transfer residents according to their plan of care and type of device if needed this included skills competency on Transfers (Hoyer and gait belts). This was completed on [DATE] and no staff will be allowed to work until this education has been completed. DON/Designee will complete weekly hoyer skills validations and gait belt skills validation on 5 C.N.A. weekly, rotation shifts x 90 days. The Regional Nurse consultant will provide oversight for this process and will review monthly. 9. On [DATE] at 12:30 pm, the Regional Nurse Consultant provided in-service education with the DON/Designee On use of PCC Kardex to determine type and amount care residents require, including reporting to Charge Nurse if ADLS are not present and or accurate on Kardex. This was completed at completed on [DATE]. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks. 10. On [DATE] at 1:00 pm the DON/Designee began in-service education with all clinical staff on use of PCC Kardex to determine type and amount care residents require, including reporting to Charge Nurse if ADLS are not present and or accurate on Kardex. This was completed on [DATE], and no clinical staff will be allowed to work until this education has been completed. 11. On [DATE] the Regional Nurse Consultant provided 1:1 education to the Center's DON and two ADONS on care plans that they are responsible to review all incident reports including falls, updating care plan with appropriate interventions for each fall and make sure interventions are appropriate, ensuring timely completion and that interventions are reflective on Kardex. This was completed on [DATE]. 12. On [DATE] the facility conducted and Ad Hoc QAPI meeting to discuss Incidents/Accidents and Hazards and on sustaining compliance. On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observation on [DATE] at 11:15 AM CNA G and CNA K transferred Resident #24 from bed to wheelchair, using the gait belt. Observation on [DATE] at 10:15 AM ADON A transferred Resident #9 from bed to wheelchair, using the gait belt. Record review of in-service reflected the Regional Nurse Consultant provided: - On [DATE] 1:1 education to the DON on the Incident/Accident Policy to include report and investigate all incident and accidents that occur in the facility in a timely manner, including appropriate interventions, updating care plans with appropriate interventions related to falls. - On [DATE] education with the DON on job descriptions to include Hospitality Aides job duties and Certified Aide job duties. - On [DATE] education with the ADONs and the DON on care plans that they are responsible to review all incident reports including falls, updating care plan with appropriate interventions for each fall and make sure interventions are appropriate, ensuring timely completion and that interventions are reflective on Kardex. Record review of in-service reflected DON or designee provided: - On [DATE] education with all clinical staff on job descriptions to include Hospitality Aides job duties and Certified Aide job duties. - On [DATE] education with individual hospitality aides on their specific job duties and had the individual sign a new job description. - On [DATE] education with all clinical staff on transfers which guides staff on how to properly and safely transfer residents according to their plan of care and type of device if needed. - On [DATE] education with all clinical staff on use of PCC Kardex to determine type and amount care residents require, including reporting to charge nurse if ADLS are not present and or accurate on Kardex. Interviews conducted on [DATE] from 11:03 AM to 3:30 PM with 4 nurses (LVN M, LVN O, LVN Q, and LVN U), 6 hospitality aides (HA N, HA P, HA R, HA S, HA T, HA V), and 6 CNAs (CNA CC, CNA FF, CNA HH, CNA EE, CNA GG, and CNA KK) which represented all shifts revealed they had been in-serviced on abuse and neglect, they would check the Kardex system or ask their nurse to determine what level of care a resident required. Review of in-service records revealed they had been in serviced on the use of the Kardex/Plan of Care system and on transfers. Interviews with nursing management staff on [DATE] between 5:16 PM and 5:26 PM included ADON A and ADON B, revealed they had been in-serviced on neglect, resident transfer types and where to locate a resident's transfer status in the Kardex, which came from the care plan. Interview on [DATE] at 5:35 PM with the MDS Coordinator revealed she had been in-serviced on her job responsibilities as MDS Coordinator which included the different types of MDS's including comprehensive, annual, quarterly, and significant change. She stated that the MDS's trigger the care plan and Kardex. She stated that any acute changes are care planned and addressed in morning meeting with the interdisciplinary team, Monday through Friday. Interview on [DATE] at 5:00 PM with Regional Nurse Consultant revealed there were only 9 residents that needed an updated Kardex. Record review on [DATE] at 5:53 PM of 10 residents (Resident #3, #24, #6, #16, #33, #34, #36, #42, #54, and #58) Kardex's reflected their transfer status matched their MDS. Interview on [DATE] at 6:02 PM with the DON revealed he had been in-serviced on care plans and updating acute and comprehensive care plans including falls, fractures, and transfer assistance level. Interview on [DATE] at 6:15 PM with the Administrator revealed during morning meetings they will care plan immediately any resident changes including falls, fractures, and transfers assistance changes. She stated the DON was responsible for acute and comprehensive care plans. She stated the MDS Coordinator was responsible for quarterly and change of condition care plans were completely. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:30 PM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for three of four dietary staff (Dietary Aide Y, Dietary Aide Z and Dietary Manager) and the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the low temperature dish machine was working properly on 08/20/24 to ensure appropriate chlorine sanitizer ppm levels. 2. The facility failed to ensure the Dietary Aide Y, Dietary Aide Z and the Dietary Manager wore an effective hair restraint during the lunch meal preparation on 08/20/24. 3. The facility failed to ensure Dietary Aide Y and Dietary Aide Z performed hand hygiene during the lunch meal preparation on 08/20/24 These failures could place residents at risk for food contamination and food-borne illness. Findings include: 1. Observation on 08/20/24 at 10:10 AM revealed the low temperature dish machine was 127 degrees Fahrenheit for wash and 135 degrees Fahrenheit for rinse. The Dietary Manager used chlorine test strips and the strip did not change color to test the ppm. The Dietary Manager ran the low temperature dish machine again two more times and unable to get the strip to change any color. Interview on 08/20/24 at 10:18 AM with the Dietary Manager revealed the chlorine test strips should be changing color to indicate the chlorine sanitizer level for the low temperature dish machine. She stated this morning it was working. She stated it should read 50 ppm to 100 ppm. She stated she would have to contact the Contract company to get a representative out to look at it. She stated she would have to stop using the low temperature dish machine until it could be looked at to ensure proper sanitization levels to clean and sanitize dishes. Observation on 08/20/24 at 10:22 AM of Low Temperature Dish Machine Temperature and Sanitizer Log on the wall of the dish room revealed no sanitizer or temperature documented for the low temperature dish machine for 08/20/24. The last documented was on 08/19/24 at 2:00 PM which reflected water temperature was 123 degrees Fahrenheit and concentration (sanitizer level) was 100 ppm. Interview on 08/20/24 at 10:23 AM with Dietary Aide BB revealed he had not checked the sanitizer and temperature for the dish machine this morning so it was not documented on the log today. Follow-up Interview on 08/20/24 at 12:27 PM, the Dietary Manager stated a representative from the contract company came out and looked at the dish machine. She stated the low temperature dish machine was not showing sanitizer due to the line being clogged but it now had been fixed by the contract company representative. She stated it now reads the proper ppm for sanitizer. 2. Observation on 08/20/24 at 11:51 AM revealed the Dietary Manager wore a hair restraint that did not cover about 2 inches below the hair restraint in the back and about 1 inch near both of her ears while she was getting food out of oven. Observation on 08/20/24 at 11:53 AM to 12:05 PM revealed Dietary Aide Z wore a hair restraint that did not cover 3/4 inch above both of her ears and 2 inches of hair in the back while she did the food temperatures for lunch prior to serving. Observations on 08/20/24 from 12:10 PM to 12:43 PM during the lunch meal revealed Dietary Aide Z was getting a clean plate, scooped food and placed food on resident lunch plates with hair restraint not effectively covering 3/4 inch above both of her ears and 2 inches of hair in the back her hair. At 12:35 PM, Dietary Aide Z touched her face with her left hand, did not wash her hands and continued plating the food. Dietary Aide Y had a hair restraint not covering about 1/2 inch of hair above both of her ears and about 1.5 inches in the back of her hair. Dietary Aide Y was scooping food and putting biscuits on resident lunch plates. At 12:39 PM, Dietary Aide Y touched her face with her gloved hand. She did not take the gloves off and wash her hands. Dietary Aide Y continued plating food and putting biscuits on resident lunch plates with her gloved hands. Observation on 08/20/24 at 12:30 PM revealed the Dietary Manager with a hair restraint not covering about 2 inches below the hair restraint in the back and about 1 inch near both of her ears while she was in the dish area running the low temperature dish machine. Interview on 08/20/24 at 12:45 PM with Dietary Aides Y and Z revealed they were not aware their hair restraints were not covering their hair above the ears and in the back. Dietary Aide Y and Z stated they should wash their hands if they touched their face. Interview on 08/20/24 at 12:47 PM with the Dietary Manager revealed she did realize her hair restraint was not covering her hair completely. She stated she should have ensured her hair restraint was covering her hair in the kitchen. Follow-up interview on 08/20/24 at 2:10 PM with the Dietary Manager revealed all dietary staff which included herself should ensure hair was effectively covered to prevent hair from getting in the food and cross contamination. She stated dietary staff should be washing their hands when touching their face and put new gloves on to prevent cross contamination. She stated it was important to ensure the dish machine was sanitizing the dishes properly. Review of facility's in-service dated 07/24/24 included hand hygiene reflected ADON B in serviced Dietary Aide Y, Dietary Aide Z and Dietary Manager. Interview on 08/25/24 at 6:33 PM with the Administrator revealed it was important for dietary staff to have effective hair restraints to keep hair out of food and keep food from contamination. She stated hand hygiene was important to ensure dietary staff did not place residents at risk for illness and cross-contamination. She stated the dish machine meeting the minimum sanitization level ensured dishes were clean and sanitized properly. Record review of the facility's policy Ware Washing dated 08/2005 and last reviewed on 05/2015 reflected under procedure for Machine ware washing, 3 .Dish Machine temperatures (wash and rinse) will be observed and recorded on the Dish Machine Temperature Log before starting the ware washing process after each meal. For low temperature machines the chemical sanitizer strength will be tested and recorded as well. 4. Improper temperatures and/or sanitizer strength will be reported to the person in charge immediately and manual ware washing and/or paper products will be implemented until the problem is corrected Low temperature Dish machines b. chemical: Chlorine sanitizer 50 ppm . Record review of the facility's policy Personal Hygiene dated 11/2006 and last revised 11/2017 reflected Dietary employees will maintain proper Food safety practices through proper personal hygiene. Proper hand washing techniques and exclusion of infectious individuals from handling food are critical for prevention of foodborne illness .The health and personal hygiene habits of food service workers when not handled properly may potentially cause food contamination .4 .Hands must be washed between each glove use .11. Dietary employees shall wear hair covering, beard restraint, and clothing that covers body hair. Any staff entering the kitchen must comply with hair restraints and hand washing . Record review of the facility's policy Food Safety and Sanitation Plan dated 09/2005 and last reviewed on 07/22/21, reflected .ensures safe food handling practices from food procurement through food service. While all steps in the handling of food are important, specific steps have been identified as 'critical' in preventing food borne illness .Nursing home resident risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling .13. Personal Hygiene Practices - Thorough hand washing is required (but not limited to) the following situations .D. after .touching hair or face Record review of the FDA US Food Code 2022 reflected the following: -under section 2-3 Personal Cleanliness 2-301.11 Clean Condition Food Employees shall keep their hands and exposed portions of their arms clean. -under section 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.

Based on interview and record review the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for two of two residents (Resident #123 and Resident #67) reviewed for dialysis. 1. The facility failed to ensure Residents #123 and #67's dialysis communication sheets were completed to coordinate care with the dialysis center. 2. The facility failed to ensure residents had physician orders for dialysis treatment and to inspect vascular access sites for Residents #123 and #67. These failures could place residents at risk of not receiving proper care and adequate coordination of care. Findings include: 1. Record review of Resident #123's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #123 had diagnoses which included Congestive Heart Failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), Hypertension, Seizures, Chronic Kidney Disease (disease your kidneys are damaged and can't filter blood the way they should) and Chronic Obstructive Pulmonary Disease (common lung disease causing restricted airflow and breathing problems). Record review of Resident #123's Admission MDS assessment, dated 08/13/24, reflected Resident #123 had a BIMS of 15, which indicated she was cognitively intact. Resident #123 was on hemodialysis while a resident at the facility. Record review of Resident #123's Comprehensive Care Plan, initiated on 08/12/24, reflected Dialysis: Resident received dialysis related to renal failure and was at risk for the potential complications of dialysis. Interventions included: Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure to the physician. AV (arteriovenous) shunt: Auscultate shunt site for bruit and palpate for thrill as ordered. Notify physician for absence of bruit/thrill. Monitor/document/report to physician any signs or symptoms of infection at the access site such as redness, swelling, warmth, pain, or purulent drainage. Record review of Resident #123's Current physician orders, dated 08/22/24, reflected no orders for dialysis treatment or dialysis access site. Record review of Resident #123's August 2024 MAR/TAR reflected no documentation for dialysis access site or dialysis treatment. Record review of Resident #123's nurse progress notes for August 2024 reflected the following about dialysis: -dated 08/09/24 at 6:45 PM by RN F reflected Resident returned from dialysis on no obvious distress, denies needs. Dressing to port . Call light in reach, monitoring. -dated 08/09/24 at 9:47 PM by RN F reflected .A dialysis catheter is present. The catheter is clamped. No changes are noted to the resident's bladder .or dialysis systems . Remains on skilled services, dialysis resident, able to make needs known. Becomes [short of breath] on exertion but denies this issue this shift, came back at [approximately] 1845 [6:45 PM] from dialysis in good spirits. dated 08/12/24 at 5:24 PM by RN F reflected Returned from dialysis in no obvious distress, calm and awaiting dinner. Vitals updated. Dressing .to [right] chest port. -dated 08/14/24 at 10:58 AM reflected Resident is skipping dialysis today due to a granddaughter's death and they will be having the viewing today and if she went to dialysis she would miss the whole thing. Warnings of the dangers of missing dialysis given to resident. Explained to patient that it was not a good idea for her to miss another session since she missed 1 last week while moving to Texas from Iowa. She says that she understands and this is just something that she has to do. Will continue to monitor. -dated 08/16/24 from RN F reflected Returned from dialysis in no obvious distress, just states she is tired and requested tylenol for fatigue and joint pain. Vitals have been updated. -dated 08/21/24 at 6:04 PM from RN F reflected Returned from dialysis in no obvious distress, vitals updated and port . Monitoring Observation and interview on 08/22/24 at 2:30 PM with Resident #123 revealed she had not received a dialysis communication before 08/21/24 and this was the first time it was provided to her so she could take it with her to dialysis. She stated when she was at another facility, she was given the dialysis communication sheets prior to dialysis, gave it to dialysis center and brought it back with her. She stated the nurse at the facility did her vitals prior to going to dialysis most of the time. Interview on 08/23/24 at 2:14 PM and 2:34 PM with the Treatment Nurse revealed when resident returned with the dialysis communication sheet from dialysis it was uploaded into the electronic record. She stated she could not find any dialysis communication sheets in Resident #123's electronic record. She stated she only worked as a floor nurse prn and she usually was the treatment nurse. She stated she completed a dialysis communication sheet for her today and did assess her which included vitals prior to Resident #123's transportation arrival to take her to dialysis. She stated she could not find the dialysis treatment order for Resident #123 and the order to assess the dialysis access site for Resident #123. She stated she did the assessment which included vitals this morning and used the weight which was in the system for the pre-treatment weight. She stated she could not recall any training about dialysis communication sheets and stated she filled it out best she could. She stated Resident #67 was provided the dialysis communication sheet today and was still gone to dialysis. Interview on 08/23/24 at 3:22 PM with RN F revealed she worked during the week on the evening shift and Resident #123 went to dialysis on Mondays, Wednesdays and Fridays. RN F stated Resident #123 returned on her shift usually in the evening. She stated she only received the dialysis communication sheet for 08/21/24 from Resident #123 until yesterday (08/22/24). She stated 08/21/24 was the first time she received a dialysis communication sheet for Resident #123. RN F stated she put vitals and assessed Resident #123's dialysis access site when she returned. She stated Resident #123 had been on dialysis since she admitted . She would write a progress note and input vitals into the electronic system on dialysis days when she returned. She stated the admitting nurse was responsible to ensure dialysis orders were in the electronic record. She stated there were no orders for monitoring Resident #123's dialysis access site. 2. Record review of Resident #67's, undated, face sheet reflected Resident #67 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #67 had diagnoses which included End Stage Renal Disease (Kidney Failure), Fluid Overload, Idiopathic Peripheral Autonomic Neuropathy (nerve damage outside your brain or spinal cord) and Hypertension secondary to Renal Disorders (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys). Record review of Resident #67's quarterly MDS assessment, dated 06/19/24, reflected Resident #67 had End Stage Renal Disease since admission. Resident #67 had a BIMS of 15, which indicated he was cognitively intact. Record review of Resident #67's Comprehensive Care Plan, initiated on 03/17/24, reflected Dialysis: Resident was at risk for the potential complications of dialysis related to renal failure. Interventions included: Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure to the physician. AV (arteriovenous) shunt: Auscultate shunt site for bruit and palpate for thrill as ordered. Notify physician for absence of bruit/thrill. Monitor/document/report to physician any signs or symptoms of infection at the access site such as redness, swelling, warmth, pain, or purulent drainage. Record review of Resident #67's Current Physician Orders, dated 08/23/24, reflected the following: - Order dated 04/13/24 dialysis to be performed [Dialysis Company] on Mon, Wed, and Fri It did not give any more information about dialysis treatment. There was no physician order for monitoring dialysis access site for Resident #67. Record review of Resident #67's Progress notes, about dialysis treatment for 07/22/24 to 08/23/24, reflected the following: -dated 07/22/24 at 5:50 PM by LVN E reflected Resident returned from dialysis in [wheelchair] via facility transportation. Resident was in pleasant mood and no s/s of distress noted. Resident fistula to left forearm clean, dry and intact. Resident's dialysis catheter clean, dry and intact. V/S 97.5-142/114-102-18. Will continue to monitor dated 07/29/24 at 5:58 PM by LVN E reflected Returned from dialysis in w/c via facility van. Resident in pleasant mood no complaints of pain or cramping. Fistula to left forearm dressing [clean/dry/intact]. V/S 97.2-88-97/58 will continue to monitor. -dated 07/31/24 at 11:31 PM by LVN E reflected Resident returned from dialysis at 1720 [5:20 PM] in wheelchair via facility van. Resident was in pleasant mood. Resident complained of pain to fistula site, which was dressed and [clean dry intact]. This nurse gave PRN Hydrocodone @1725. V/S 98.3-130/91-81 -dated 08/09/24 at 5:14 PM by LVN E reflected Resident returned from dialysis in w/c via facility van. Resident in pleasant mood and complaining of pain rated 5/10. Received PRN Hydrocodone at this time. V/S 98.4-82-131/77-18. Dressing to left forearm [clean/dry/intact] Resident states that his dry weight is 272.0 -dated 08/15/24 at 4:23 PM by RN J reflected Resident's shorts noted having blood saturation on the left leg when he returned from dialysis. The nurse asked him what had happened and he stated his shunt had leaked. RN assessed and found the shunt was no longer leaking. RN assisted the resident in changing his shorts and discovered his wallet had been saturated as well. Resident cleaned up and dressed with clean shorts. Soiled shorts and contaminated wallet along with contents were given to housekeeping manager who cleaned and sanitized the items. Wallet returned to resident. -dated 08/19/24 at 5:46 PM by LVN E reflected Resident returned from dialysis in w/c via Facility van. V/S 157/99-100-98.2 Resident in pleasant mood, c/o pain and requested pain medication and PRN norco given as ordered. Fistula dressing [clean/dry/intact]. Record review of Resident #67's July and August 2024 MAR/TAR reflected no documentation for dialysis access site or dialysis treatment. Record review of Resident #67's Dialysis Communication Record for July to August 2024 reflecting the following: -dated 08/12/24 reflected no documentation from facility nurse prior to after dialysis treatment. It reflected pre and post treatment completed by dialysis facility. There were no other dialysis communication sheets for July to August 2024. Interview on 08/23/24 at 3:38 PM with RN J revealed Resident #67 was on dialysis since admission. RN J stated she thought the dialysis communication forms originated from the dialysis center and did not know the facility nurse was supposed to initiate and complete the dialysis communication form. She stated she was not aware she was supposed to complete the dialysis communication sheet pre and post dialysis for Resident #67. She stated she had not received any in-service on dialysis communication forms. She stated she was aware needed to assess Resident #67's dialysis access site pre and post dialysis but there were no physician orders for Resident #67's dialysis treatment or to assess his access site. She stated she had no where specifically to document her assessing the access site on dialysis days or to put the vitals so she would write a progress note and put it in the vitals. Interview on 08/23/24 at 3:40 PM with LVN E revealed she was not receiving dialysis communication sheets on Resident #67 and was not in-serviced on dialysis communication sheets. She stated when Resident #67 returned from dialysis she would assess him post dialysis which included his vitals and dialysis access site in the electronic record. She stated she only received communication from the dialysis center once for a resident. Interview on 08/24/24 at 4:14 PM with the ADONs A and B revealed all dialysis residents should have a physician order for dialysis. She stated the admitting nurse was responsible to ensure physician orders for dialysis were inputted upon admission for residents. The ADONs stated they or the DON were to review the admitting physician orders and compare to the hospital orders. The ADONs stated the nurse should input vital signs in the communication sheets before dialysis and the dialysis center should input vital signs and weight after dialysis and send it back with the resident. The ADON stated the purpose of the dialysis communication sheets were to monitor the resident before and after dialysis to determine how effective the dialysis was. Both ADONs stated they or the DON were supposed to monitor that the dialysis communication sheet was completed by the nurses, the dialysis center completed and received it back from the dialysis center. Interview on 08/24/24 at 04:26 PM with the DON revealed the admission nurse should be putting in dialysis orders upon admission. The DON stated he should review the chart within 72 hours after admission to ensure orders were in the resident charts. He stated he expected the charge nurse to complete the dialysis communication sheet which included vitals and the dialysis access site. The DON stated the dialysis communication sheet should have vitals and weights on it. He stated the dialysis communication should return with the resident and after the dialysis nurse should check vitals, the access site and review the dialysis treatment. He stated it was important to complete the dialysis communication sheet to determine how effective dialysis was for the resident. He stated the ADONs and the DON should be checking to ensure dialysis communication sheets were completed once a week. He stated there was not an in-service done on dialysis communication sheets since he had been the DON. Record review of the facility's policy Management of Resident Receiving Hemodialysis dated 06/01/24 reflected The interdisciplinary team will be in direct communication with the dialysis team to ensure that the coordination of care continues over the health care continuum .1. Residents receiving hemodialysis will have an order obtained from Physician and must include the following -Name and phone number of the Dialysis center - Address of the Dialysis Center - Days of the week that dialysis is performed - Usual time for pick-up by transport - Name and phone number of the transport company if applicable .5. Residents that are able to independently be transferred to and from dialysis will be provided with education on the following: -The importance of leaving with their dialysis communication form and giving it to the dialysis nurse. -The importance of giving the Dialysis communication .to the Charge Nurse upon return .7. Residents receiving hemodialysis will have an order to inspect their vascular access(s) each shift .11. The nurse on the unit is responsible for completion of the Dialysis communication form and check the vascular access prior to leaving for dialysis .

Based on observation, interview and record review the facility failed to ensure residents had a safe, clean, comfortable and homelike environment which included but not limited to receiving treatment and supports for daily living safely for 2 of 4 residents (Resident #43 and #18) reviewed for a homelike environment. 1. The facility failed to ensure Resident #43's room didn't have food debris, hair and trash under his bed. 2. The facility failed to ensure Resident #43's room window blinds and ledges were dusted or clean. 3. The facility failed to ensure Resident #18's window ledge and blinds were dusted. These failures could place residents at risk for an unsanitary, unhomelike environment, and a diminished quality of life. Findings include: 1. Record review of Resident #43's face sheet, dated 08/25/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #43 had diagnoses which included type 2 diabetes (high blood sugar), hypertension (high blood pressure) and stroke. Record review of Resident #43's Quarterly MDS, dated [DATE], Section B- Hearing, Speech, and Vision, reflected he had highly impaired vision and a BIMS score of 15, which indicated cognitively intact cognition. Record review of Resident #43's care plan reflected he had impaired visual function, dated 05/22/2024, required assistance with activities of daily living, dated 05/20/2024, and had a surgical wound to his left food and was at risk of infection, dated 06/17/2024. Observation on 08/20/2024 at 11:23 AM revealed the floor had crumbs of food, black and brown debris, and hair on the floor. Under Resident #43's bed revealed there was an opened white paper bag, the size of a paper lunch bag, laid on its side, under the head of his bed. The paper bag had a dried, brown water mark along the side of the bag and there were crumbs of food, a small plastic cup, and hair under his bed. The window ledge next to Resident #43's bed had a layer of dust and food debris. Interview on 08/20/2024 at 11:24 AM with Resident #43 revealed he was seated in a wheelchair in his room with the television on, there was a fly around his head. Resident #43 stated he thought housekeeping did a good job and he did not see the food or debris on the floor or under his bed and he complained the television did not have color. Observation of the television revealed it was in color. Observation and interview on 08/21/2024 at 9:04 AM of Resident #43's room with Housekeeper W revealed the debris and paper bag were still under Resident #43's bed and the window ledge and on the floor. Housekeeper W stated he had worked at the facility for about 3 months and was trained on cleaning resident rooms daily and had not been fully trained on deep cleanings. Housekeeper W stated he did not mop resident floors if they looked shiny and did not use the broom to sweep before he mopped the floor. Housekeeper W stated he used the mop head to sweep debris. Housekeeper W looked under Resident #43's bed and stated he observed the bag, debris, and hair under the bed and he did not look under the bed the previous day. Housekeeper W stated he did not typically look under the resident's beds. Housekeeper W observed Resident #43's window ledge and stated he did not clean the window ledges and was not sure if they were supposed to be completed during the everyday cleaning routine or during deep cleans. Housekeeper W stated he was supposed to move resident items and bedside tables when he cleaned and did not because he was worried residents would be upset he touched their things. Housekeeper W stated he was going to clean Resident #43's room shortly. Observation on 08/21/2024 at 04:09 PM of Resident #43's room revealed under his bed was not cleaned, the bag under the bed was removed and there was still debris under the bed and dust and residue on the windowsill remained the same, there were 2 flies in the room. Interview and observation on 08/21/24 at 04:17 PM with the Housekeeping Supervisor revealed Resident #43's room had food debris on the floor and under his bed, and the window blinds and sill had not been dusted. The Housekeeping Supervisor stated housekeepers cleaned resident rooms daily and were expected to dust the blinds and window ledges and sweep and mop the floors which included under the beds. 2. Record review of Resident #18's face sheet, dated 08/24/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18 had diagnoses which included stroke, dementia (loss of cognition), and hypertension (high blood pressure) and paraplegia (paralysis of the legs and lower body). Record review of Resident #18's Comprehensive MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated intact cognition. Record review of Resident #18's care plan reflected she required assistance with activities of daily living due to paraplegia (paralysis of the legs and lower body), dated initiated 11/23/2021. Interview on 08/20/24 at 11:14 AM with Resident #18 revealed housekeeping did not clean her room well. She stated they did not sweep her room daily and sometimes would just come in and only take the trash out. Resident #18 stated having a clean room was important to her because it was not sanitary. Observation and interview on 08/21/24 at 04:58 PM with the Housekeeping Supervisor of Resident #18's room revealed the window blinds and ledges were not dusted and there were thick cobwebs between the blinds and the window. The Housekeeping Supervisor stated the window blinds and window ledge were not dusted and the window ledge had dust and cobwebs and were supposed to be dusted every day by the housekeeping staff. He stated Housekeeper W should have cleaned the window ledge and blinds. He stated that it was important to clean the window areas for sanitation reasons and to ensure residents resided in a clean environment. Interview on 08/21/24 at 5:00 PM with Resident #18 revealed sometimes it seemed like they did not clean the floor at all and never saw housekeeping sweep or dust the window blinds or ledge. Resident #18 stated she complained to the Housekeeping Supervisor about her concern because it bothered her and he told her that he would address her concern with the housekeeping staff. Interview on 08/24/24 at 3:09 PM with the Housekeeping Supervisor revealed all housekeeping staff received 3 days of training where they shadowed a housekeeper, were shown what tasks to perform, took turns completing the tasks, and then cleaned on their own. He stated housekeeping staff were assessed once a year and he performed random checks of resident rooms to ensure they were being cleaned properly. He stated Housekeeper W did not have a performance review because he was new and did not have any random checks documented for him. He stated he believed the rooms were not cleaned properly because Housekeeper W was a newer employee and required more training. He stated Residents #43 and #18's rooms had not been cleaned properly and it was important to clean resident rooms properly because it was the frontline of infection control and residents deserved to live in a clean room. Interview on 08/25/24 at 06:15 PM with the Administrator revealed she was aware there were some housekeeping complaints. She stated her expectation was the resident rooms and common areas were cleaned thoroughly and there was a monthly deep clean schedule for resident rooms. She stated it was important resident rooms were cleaned properly because they were the resident's home and for infection control. She stated housekeeping services were through a contract company and they did not have a policy for cleaning resident rooms. She provided the policy for resident rights. Record review of the facility's resident rights policy titled, Resident Rights, dated 02/23/2016, reflected .8. The resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Resident #18, Resident #4, Resident #36, and Resident#69) reviewed for infection control. 1. The facility failed to ensure RN I disinfected the blood pressure cuff in between blood pressure checks for Residents #18, #4 and #36. 2. The facility failed to ensure CNA G changed soiled bed linen after she performed incontinence care for Resident # 69. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings include: 1. Record review of Resident #18's Comprehensive MDS assessment, dated 07/16/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18 had diagnoses which included elevated blood pressure, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and cerebral infarction (damage to the brain from interruption of its blood supply). Resident #18 had a BIMS of 15, which indicated Resident #18's cognition was intact. Record review of Resident #4's Quarterly MDS assessment, dated 07/18/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) and elevated blood pressure. Resident #4 had a BIMS of 08, which indicated Resident #4's cognition was moderately impaired. Record review of Resident #36's Quarterly MDS assessment, dated 07/30/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included elevated blood pressure, type 2 diabetes mellitus and chronic kidney disease. Resident #36 had a BIMS of 14, which indicated Resident #36's cognition was intact. Observation on 08/21/24 at 7:40 AM revealed RN I performed morning medication pass, during which time she checked the blood pressure on Resident #18. RN I did not sanitize the blood pressure cuff before and after use on Resident #18 and continued to the next resident without sanitizing the blood pressure cuff. RN I then checked Resident #4's blood pressure. RN I did not sanitize the blood pressure cuff before using it on Resident #4. RN I continued to the next resident without sanitizing the blood pressure cuff. RN I then checked Resident #36's blood pressure. RN I did not sanitize the blood pressure cuff before using it on Resident #36 . Interview on 08/21/24 at 8:20 AM, RN I stated reusable blood pressure cuffs, should be sanitized before and after use on each resident. She stated the risk of not sanitizing the blood pressure cuff between use would be cross contamination and spread of infections. She stated she forgot to sanitize the blood pressure cuff between use on Residents #18, #4, and #36. Record review of the facility's policy titled, Care, Cleaning and Storage of Equipment reviewed 2/13/2020, reflected, . Resident equipment is to be cleaned with EPA approved disinfectant or similar agent between residents 2. Record review of Resident #69's Comprehensive MDS assessment, dated 08/01/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS of 11, which indicted Resident #69's cognition was moderately impaired. Resident #69 had diagnoses which included type 2 diabetes mellitus, pancreatic cancer, and muscle weakness. Resident #69 was dependent requiring 2 persons assist with toileting hygiene and transfers. Record review of Resident #69's care plan with an onset date of 07/30/24 reflected, Focus: Incontinence: [Resident #69] is incontinent of bowel/bladder related to muscle weakness. Goal: The resident will be clean and odor free . Interventions: Incontinent: Check frequently for wetness and soiling and change as needed. Observation on 08/20/24 at 10:40 AM revealed CNA G and CNA H entered Resident #69's room to provide incontinence care. Both staff washed their hands and donned gloves and gowns CNA G unfastened the brief and cleaned the front pubic area using incontinent wipes. The resident was assisted onto her side. CNA H held resident on the side and CNA G cleaned the resident's buttocks area using several wipes revealing a medium bowel movement. Some of the bowel movement fell on to the bed linen. CNA G removed the bowel movement from the bed linen using wipes. CNA G discarded the dirty gloves, sanitized hands and she donned clean gloves, she placed a clean brief under the resident. Both staff repositioned the resident back on her back, onto the dirty linen. Both CNAs removed their gloves and gowns, and washed their hands and left the room. In an interview on 08/20/24 at 10:56 AM, CNA G stated she was supposed to change the bed linen after it was soiled by the bowel movement. She stated it was not acceptable to lay down a resident on dirty linen. She stated she did not change the bed linen because she was focused on hand hygiene, and she forgot to change the linen. CNA G stated the risk would be spread of infection and contamination of the resident environment. In an interview with the DON on 08/24/24 at 4:26 PM, he stated all the staff were trained numerous times on the expectation of sanitizing blood pressure cuffs after each use. The DON stated the CNA was to change the bed linen after it was soiled with the bowel movement to prevent the spread of infection. The DON stated to ensure staff were knowledgeable in the infection control practices he and the ADONs made daily rounds and watched care. Record review of the facility's policy titled, Hospitality Services reviewed May 2003, reflected . Infection control is paramount in this area. and the prevention of spreading infection must always be taken into consideration. Cross-contamination should be a concern in any areas containing clean or soiled linen.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents in the facility's only kitchen, only dining room area, and two of two resident rooms reviewed for pest control. 1. The facility failed to ensure the kitchen was free of flies. 2. The facility failed to ensure resident rooms were free of flies. 3. The facility failed to ensure installed pest control measures in resident rooms and the dining area were operational and clean. These failures could place residents at risk for cross contamination, food borne illnesses, and the spread of infection and disease, and a reduced quality of life. Findings include: Observation on 08/20/24 at 10:05 AM revealed 6 flies in kitchen landed on the trash can lid and 2 of the flies landed on the counter of food preperation area. Observation on 08/20/24 at 11:45 AM revealed 7 flies in the kitchen which landed on the trash can side and lid. Observations on 08/20/24 at 12:11 PM and 12:24 PM revealed a fly flew over the steam table while food was not covered . Observation on 08/20/24 at 12:15 PM revealed one small flying insect on the 3rd rack where bread was stored. Observation on 08/20/24 at 12:42 PM revealed 1 fly landed on a Splenda packet and another fly landed on a sour cream packet. Interview on 08/20/24 at 2:10 PM with the Dietary Manager revealed they cleaned the kitchen trash can and lid. She stated the pest control treated the drains for drain flies. She stated the facility had flies for about the last couple of months. She was not aware of a small flying insect on the bread rack and would have to look at the bread to look to see if any other flies were on them. An interview and observation of Resident #57 on 08/20/2024 at 2:50 PM revealed her to be in her room. A fly was observed to land near the resident's mouth. The resident stated she had a fly swatter and so did her roommate. Two flies were observed on the inside window in the resident's room. Observation of Resident #47 on 08/20/2024 at 12:30 PM, in the dining room, reflected the resident holding a fly swatter. Resident #47 was observed swatting flies on the table multiple times. During a confidential group interview revealed the smoking area brought a lot of flies into the building. The smoking area was near the dining room. The flies were annoying and nasty especially when there were activities in the dining room like bingo Everyone was swatting flies or each other during activities in the dining room. An interview with the EVS Manager (Environment Services) on 08/20/24 at 03:30 PM, revealed he was unaware of the fly issue. The EVS Manager stated there was a bug/fly trap near every exit door near the dining room and at the end of halls 1, 2, 3 and 4. The EVS Manager stated pest control went out weekly to change them out. The EVS Manager stated no one complained to him about the flies inside the building nor in the kitchen. The EVS Manager stated maintenance would receive complaints regarding flies. An interview with the Maintenance Director on 08/20/24 at 3:48 PM revealed an Aerator was installed that pushed air out so flies couldn't fly in. The Maintenance Director stated there was an Aerator near the smoking exit, a high traffic area. The Maintenance Director stated 8 lights were installed which contained UV lights with a sticky trap inside of them. He stated there was a light located inside of the door for hall 2, 3 in the dietary area (near the smoking door, near the kitchen, outside of the dishwasher), top of hall 1, the bottom of hall 4, outside of therapy (hall 3), and the top and bottom of hall 1. He said the Aerator was approximately 6 feet high. He stated he checked to ensure doors throughout the facility were sealed top and bottom and checked windows. He stated Pest Control went out weekly. He stated he received complaints regarding the flies. He stated he was limited due to the types of chemicals that could be used. He stated he was asked to refrain from using sticky traps and could only use sticky tubes outside of the building, not inside. He said he couldn't use heavy, evasive chemicals. He stated warmth attracted the flies in the kitchen area. He stated new air conditioning (A/C) units were being installed. He stated there was a new A/C unit in the kitchen. Observation on 08/22/24 at 10:45 AM revealed the location of the UV lights with sticky traps on hall 1 (3 UV lights observed), hall 2 (2 UV lights observed), hall 3 (2 UV lights observed) and hall 4 (2 UV lights observed). One UV light was observed in the dining room and kitchen. An interview with the Service Supervisor at with the Pest Control company on 08/23/2024 at 11:43 AM revealed there were 14 fly lights placed throughout the facility which contained UV lights to attract flies. He stated the fly/bait treatment administered at the facility during weekly visits took time for effect. He stated the fly issue at the facility had been on/off. He stated the facility was in a dry area which attracted flies plus the hot temperature outside. He said the door of the facility near the courtyard had lots of traffic in/out which caused flies to enter. Record review of the facility's Pest Control reports from June 2024 to August 2024 reflected fly issues brought to the Tech's attention and fly treatment were addressed in every report within this time frame. Record review of the facility's Dietary Policy and Procedure Manual revised 03/2012 reflected: Policy: The Dietary Department will maintain effective pest control program. Fundamental Information: An integrated pest management program consists of 5 steps: Inspection, Identification, Sanitation, Application of two or more pest management procedures, Evaluation of effectiveness of pest control measures, thorough follow-up inspections.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and procedures to investigate any such allegations for one of six residents (Resident #24) reviewed for abuse and neglect. The facility failed to follow their policy for abuse and neglect by not reporting an allegation of neglect within 2 hours when HA (non-certified) C transferred Resident #24, without any assistance, for toileting. On [DATE] HA C transferred and toileted Resident #24 without any assistance. When transferring the resident from the toilet to the wheelchair, HA C heard a loud pop sound, and the resident was not able to stand. The HA C lowered the resident to the floor. As a result of the transfer, Resident #24 sustained a fracture of left femur. Resident #24 required a surgical intervention. Resident #24 was required to be non-weight bearing and have brace to the left leg after the incident This failure could place residents at risk for not having their allegations of abuse and neglect investigated. Findings include: Record review of the facility's policy titled, Abuse, Neglect and Exploitation, dated [DATE], reflected, .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility's Abuse Prevention Coordinator is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Record review of Resident #24's Comprehensive MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to the brain from interruption of its blood supply), dysphagia (difficulty swallowing ), and hemiplegia and hemiparesis (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Resident #24's BIMS was 15, which indicated her cognition was intact. The MDS assessment indicated Resident #24 required extensive assistance of one-person physical assistance with transfer, and personal hygiene. GG functional section reflected the resident required substantial /maximal assistance with toilet transfer. Record review of Resident #24 care plan dated [DATE] reflected: Focus: Fall - [Resident #24] has the potential for falls related to . Gait/balance. Goal: The resident will be free of falls through the next review date. Interventions: Transfers with assist of 2 staff. Record review of the Resident #24's Nurses Notes completed by LVN D and dated [DATE] reflected, . I was called to her room and found her lying in the bathroom floor. HA C stated she was transferring her back to wheelchair when there was a loud pop and she wasn't able to stand, HA C then lowered her to floor and got me. Left leg and foot were turned inward. Action: I notified DON and Doctor . Resident was transferred to the hospital . Review of Resident #24's hospital records, dated [DATE], reflected the following: .Female who presented to the emergency department from nursing home after a fall which occurred at the skilled nursing facility. She stated that she was using the commode when her left leg gave way and she fell . She began to experience pain in the left leg. She had imaging studies done at the local emergency department which revealed a complex comminuted fracture of the distal femur with mild displacement. She was therefore sent here for further management. Pre operation diagnoses: Left extra-articular distal femur fracture. Procedure: Intramedullary nailing of left distal femur fracture. During the course of the patient's operation, surgical assistance was provided. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, elevated blood pressure, and osteoarthritis. Resident #56's BIMS score was 15, which indicated his cognition was intact. In an interview on [DATE] at 9:25 AM, Resident #56 (Resident #24's Family Member living with Resident #24 in the same room), stated on [DATE] HA C assisted Resident #24 to the toilet without help of another staff. He stated usually 2 staff helped Resident #24 with transfer. Resident #56 stated HA C went in to help Resident #24 get off the toilet. When she helped get her up and turned her to the wheelchair for the transfer, her knees gave out and there was a loud pop as she was lowered to the ground. Resident #56 stated he yelled for help and the nurse and other staff came in for help, somebody called the ambulance and Resident #24 was sent to the hospital. In an interview on [DATE] at 9:30 AM, Resident #24 stated HA C dropped her on the floor in the toilet. Resident #24 stated usually 2 people transferred her before and after the incident of [DATE]. In an interview on [DATE] at 2:42 PM, LVN D stated she was working the evening of the incident when she heard Resident #24's Family Member calling for help in the room. LVN D stated when she walked in, the resident's leg was turned outward and looked to be broken. LVN D stated she assessed the resident. Another staff called the 911. Resident #24 was transferred to the hospital. LVN D stated Resident #24 is 2 persons assist with transfer. LVN D stated hospitality aides were not allowed to transfer residents. LVN D stated she called the DON to notify him about the incident. In an interview on [DATE] at 3:17 PM, HA C stated on [DATE] at approximately 9 PM she reported to Resident #24's room, resident needed to go to the restroom. HA C stated she assisted Resident #24 to the toilet. When transferring the resident from toilet back to wheelchair, resident used grab bars to assist in standing up, HA C assisted resident with pulling up pants, in the middle of turning the resident's left knee buckled, HA C instructed the resident to try and stand up. Resident #24 reported she could not. HA C stated she heard a loud pop and assisted resident to the floor. Resident #56 called for assistance, the nurse and staff member reported to resident's room. HA C confirmed she was not a CNA (her certificate was expired since 2014), and stated she had to work with a certified nurse aide on the floor at all times. At the time of this interview HA C stated she had received an in-service on transfers of Resident #24 after the fall occurred on the evening of [DATE]. HA C stated she assisted Resident #24 to the toilet without assistance because the CNA was break. She stated she supposed to call the nurse because Resident #24 needed 2 persons for transfer. She stated she never transferred Resident #24 before, because as a HA she was not allowed to transfer Resident #24 or any other resident. In an interview with the DON on [DATE] at 3:30 PM, he stated hospitality aides were not allowed to provide any direct care to residents. He stated HA C should not transfer Resident #24. He stated if the CNA was not available the HA C should notify the nurse about Resident #24 needs. He stated hospitality aides were in-serviced on job description up on hire. The DON did not provide the in-service on job description for HA C to the surveyor. The DON stated Resident #24 was 2 persons assist with transfer. The DON stated the amount of assistance needed by a resident would be reflected in the Kardex system for nursing staff. The surveyor asked if the care plan populated the Kardex because the Kardex did not show before and after the incident that Resident #24 was a two-person assist for transfer. The DON stated he was, and the ADONs, responsible to oversee the care plans for updates and the Kardex to reflect the care plans. The DON stated charge nurses, ADONs himself did routine rounds to monitor to ensure transfers were being done appropriately. The DON stated the incident was discussed with the Administrator and the corporation staff, and it was determined not to report. In an interview with the Administrator on [DATE] at 4:35 PM, she stated she was notified on [DATE] by the DON of the incident that had occurred on [DATE]. The Administrator stated the incident was discussed with the corporation staff and it was determined not to report because the fall was witnessed, and the origin of the injury was known. The surveyor reviewed the provider letter with the Administrator, the Administrator determined that the incident was supposed to be reported to the state agency and investigated as an allegation of neglect because of the serious injury. The Administrator stated she would report the incident to the state agency. Record review of the Provider Investigation report for resident #24 dated [DATE] reflected, .Incident date [DATE] at 8:30 PM .description of incident .Resident was being transferred by a non-certified aide and sustained an injury.Nurse assessed resident and noticed evidence of fracture. Resident was transported to hospital by EMS . HA C was suspended. MD and RP notified. Safe survey completed. In-service regarding abuse and neglect and fall prevention .Skin assessment performed on all resident who are unable to be interviewed. Staff educated regarding transfers . In a follow u interview with the Administrator on [DATE] at 6:15 PM revealed she had been in-serviced on abuse/neglect policy and reporting requirements. She was knowledgeable of the facility policy including abuse and neglect definitions and reporting requirements as the abuse coordinator. She stated the facility's investigation into the incident findings was neglect and the Hospitality Aide should not have been transferring the resident or providing any direct care to the resident. She stated the Hospitality Aide involved in the incident was suspended and had not returned back to work at the facility. She stated all the hospitality aides have now been signed up for a class in [DATE] so they can work towards getting their nurse aide certification. She stated as the abuse coordinator she should have reported the neglect allegation with major injury within 2 hours to the state from notification of resident sustaining a fracture, suspended the hospitality aide pending investigation, conduct an investigation of the incident and report the findings to the state. Record review of the facility's job description for a Hospitality Aide revised on [DATE] revealed: . Responsible for providing resident related (no-hands-on) care in accordance with quality standards under the direction of a licensed charge nurse. The position is applicable prior to successfully receiving certification as a nursing assistant. Performs host/hostess type duties in accordance with accepted standards of non-hands-on resident care. Uses daily task assignments. Assist residents that are independent and residents that require minimal or supervision support with activities of daily living, set up bed bath and rinse and soap wash cloth handing to patient. Lay out clothes, hold clothes in position patient can dress self, button clothes, pull up pants, changes unoccupied bed linens, answers call lights assist within skill level, passing and serving water. Assists with resident's recreation programs and transports residents in wheelchairs. Labels personal care items. Keeps resident rooms tidy. Maintains clothing inventory. Reports changes of resident condition to nurse in charge, reports accidents and incidents, and provides support functions as directed by supervisor.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 medication carts (Nurses cart hall 3) reviewed for pharmacy services. The facility failed to ensure RN J, responsible for Nurses Cart hall 3, removed medications in unsecure containers from the Nurses Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings include: Record review and observation on 08/20/24 at 11:38 AM of Nurses Cart Hall 3, with RN J revealed the blister pack for Resident #69's Acetamin-codeine 300-30 mg tablet (controlled medication used for pain) had 2 blister seals broken and the pills still inside the broken blisters. Interview on 08/20/24 at 11:54 AM, RN J stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blister during the count because she did not check the back of the blister pack. She stated when a broken seal was observed, she would report it to the DON and would discard the pill with another nurse . She stated the risk would be potential for drug diversion. Interview on 08/24/24 at 4:26 PM, the DON stated he expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened . The DON stated the risk would be potential for drug diversion and infection control issue. He stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADONs, and the DON were supposed to check the carts weekly. Record review of the facility's policy Storage of Medications revised August 2020, reflected the following: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists

Based on interview, and record review the facility failed to ensure the resident had the right to be free from abuse or neglect for 1 of 5 residents (Resident #2), reviewed for abuse. The facility failed to ensure Resident #2 was free from verbal abuse/neglect by CNA B. The failure could place residents at risk for abuse/neglect, humiliation, intimidation, fear, shame, agitation, and psychological damage. Findings included: Record review of Resident #2's face sheet dated 12/13/23 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses of neuroleptic induced parkinsonism (tremor and rigidity), Meniere's disease (ear disorder), anxiety disorder (intense and excessive worry), post-traumatic stress disorder (triggered intrusive events), muscle wasting and atrophy (decrease in muscle size). Record review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #2 was understood and had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. Record review of the care plan dated 09/12/23 indicated Resident #2 was frequently incontinent of bladder related to urinary urgency (bladder control problem) and occasionally of bowel. During an interview on 12/12/23 at 3:18p.m, Resident #2 stated CNA B has been making her feel very ashamed and depressed on multiple occasions. Resident #2 explained she has urinary urgency and cannot control her bladder. On one occasion CNA B told her; she was nasty and disgusting. She felt bad and told CNA B she cannot help herself. Resident #2 noted her roommate was present when CNA B said she was nasty and disgusting for peeing on her brief. She felt bad and did like being called names because of her illness. She said CNA B shouts at her when she wets her brief. Resident #2 stated she don't understand why CNA B is mean to her. She explained she asked CNA B for water. The aide told her to go get it herself. In an interview with Resident #3 on 12/12/23 at 3:30p.m, she said she has been in the facility for 7 months and roommate of Resident #2. Resident #3 was alert, oriented to name, place, time and situations. Review of her MDS revealed a BIMS score of 15 indicating she was not cognitively impaired. Resident #3 stated she was present when CNA B told Resident #2 that she was nasty and disgusting because she had wet her brief. She said she don't like the way CNA B treats Resident #2. The aide makes Resident #2 feel bad and depressed. She said she is tired of it. Resident explained the aide should come in and do his jobs instead all the talking and shouting. She feels it saves everybody the headache if he can come and do his job and leave without all the drama. Resident #3 explained the CNA B is very hard on Resident #2, calling her names, complaining about taking care of her. She wishes he will just shut up and do his job. When she heard CNA B call Resident #2 nasty and disgusting, she told CNA C but nothing was done about it. Resident #3 said she remembered one day Resident #2 asked CNA B for water. He told her to go get it herself. She is tired of listening to the aides complain about Resident #2. She said Resident #2 is incontinent and cannot help her bowel and bladder. Resident #3 explained she goes to dialysis three days a week and is not here to hear their complaints but seem like she hears it every day. During interview with CNA B on 12/12/23 at 4:19pm, he was asked what verbal abuse was. He explained verbal abuse was cussing at residents and calling them names. CNA B stated he was familiar and responsible for Resident #2 during the afternoon shifts. He denied calling Resident #2 nasty and disgusting. CNA B explained he said the word nasty and disgusting in presence of Resident #2 but was referring to her brief not the resident. CNA B was also asked why he refused to get water for Resident #2 when she requested it. CNA B explained he was told by the facility to let the resident do more for herself. He believed Resident #2 can get her own water. However, when resident asked for water, he told her he will get it after making up her bed. He stated he did get her the water. In an interview with HK E on 12/14/23 at 10:10a.m, she said she was a housekeeper for the facility. HK E stated he works on hall 4 where Resident #2 resides. She explained she has observed CNA B get mad at Resident #2 when she wets her brief. HK E stated CNA B yells and shouts at Resident #2 just because she cannot control her bladder. On one occasion, CNA B left Resident #2 wet in bed. She decided to help clean the resident and got her a dry new gowns. CNA B stated to her hearing she just a nasty person. HK E explained she can tell Resident #2 feels bad about the way CNA B treats her. HK E was asked if she reported this incident. She said CNA C reported the incident and nothing has been done about it. During an interview on 12/13/23 at 3:36 p.m. with CNA C, she said she was employed for 5 years but no longer works for the company. She explained she left the facility because the Administration was playing favorites and refused to investigate issues of resident abuse. CNA C stated Resident #3 informed her that CNA B called Resident #2 nasty and disgusting. She immediately reported to the ADM. CNA C explained the ADM said she didn't believe CNA B did that and refused to investigate. She was promoted to activity director but quit because the Administration was not paying attention to the resident's welfare. In an interview with ADM on 12/13/23 at 10:12p.m she was informed this surveyor was investigating verbal abuse of Resident #2 by CNA B. The ADM said she was not aware of report of abuse by CNA B. She explained CNA B is good with residents and didn't think he could abuse any resident. Further interview with ADM on 12/13/23 at 3:15p.m revealed she had talked to Resident #2 and Resident #3 and validated the incident. She explained she has reported the abuse to HHSC and have initiated abuse/neglect in-services. The ADM was asked if CNA C informed her of the abuse as reflected on her interviewed. She said CNA C did not report abuse to her. Record review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation. Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing, and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Verbal abuse: Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Policy Explanation and Compliance Guidelines: 1. The facility provides resident protection that include: a) Prevention/prohibit resident abuse, neglect, and exploitation and misappropriation of resident property. b) Investigation of all allegations listed above and c) Training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and d) QAPI program includes review and evaluation of all allegations resident abuse, neglect, and exploitation and misappropriation of resident property. 2. The facility's Abuse Prevention Coordinator is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility provides ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of two residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 12/13/23, revealed a 39- year- old female admitted to the facility on [DATE] with diagnoses including Constipation, contracture of muscle, hemiplegia (partial or total paralysis), and diabetes mellitus. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required total assistance with most activities of daily living (ADLs). Resident #1 was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 08/15/23 revealed he had bowel and bladder incontinence related to impaired mobility from cerebral infarction (brain lesion). Its goal stated Resident will remain free from skin breakdown due to incontinence. Observation of incontinence care for Resident #1 on 12/13/23 at 11:04 a.m. revealed CNA A washed her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. CNA A wiped the resident from front to back. CNA A changed gloves after repositioning Resident #1. She continued to clean the resident. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. She removed her gloves and picked up the trash. CNA A washed her hands before leaving Resident #1's room. In an interview on 12134/23 at 11:23 a.m. with CNA A, she revealed she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for 7 years and received infection control training about a week ago. She said the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. During an interview with the DON on 12/13/23 at 3:22 p.m., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. Review of the facility's incontinent care policy dated 04/17/14 reflected: Purpose: To outline a procedure for cleansing the perineum and buttocks after an incontinence episode. Procedure: 1. Assemble equipment 2. Knock on door and request entrance 3. Introduce self, explain procedure, and provide privacy. Note: it is important to describe, as feasible, each step to the patient prior to care provision in order to reduce fear and promote comfort and dignity. 4. Wash hands 5. Put on non-sterile, latex-free gloves 6. Place linen or under pad beneath hips 7. Position on side turned away from caregiver 8. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile, latex-free gloves 10. Position on back with knees flexed and feet flat on bed ( care may also be provided with patient. sitting on commode or shower chair or in a standing position) 11. Cleanse pen-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Turn patient side to side to cleanse entire affected area, as needed. Rinse with water, If needed or per incontinent product manufacturer's instructions. Page 1 of2 12. Dry pen-area and buttocks from front to back 13. Apply skin protectant products, if needed and, or as ordered, per manufacturer's instructions 14. Remove linen/under pad and discard 15. Remove and discard gloves 16. Wash hands 17. Apply clean linen/under pad, brief or other incontinent products, as needed 18. Reposition for comfort with call light in reach and provide additional care as needed as requested by patient 19. Return equipment to designated area and clean/dispose as indicated

Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 (Resident #1, Resident #3, and Resident #5) of 5 residents reviewed for a clean and comfortable environment. 1. The facility failed to repair the cove base trim at the base of the wall in Resident #1's bathroom that exposed black discoloration, damaged dry wall, and water-damaged wood. The facility failed to repair or replace the linoleum flooring in Resident #1's bathroom observed to be discolored, buckled, and water damaged. 2. The facility failed to repair the cove base trim at the base of the wall in Resident #3 and Resident #5's bathroom under the sink that exposed damaged dry wall and discolored paint. The facility failed to repair or replace the linoleum flooring under the sink and around the toilet that was discolored, and water damaged in Resident #3 and Resident #5's bathroom. These failures could place residents at risk of a decrease in quality of life and self-worth. Findings include: Record review of Resident #1's Face Sheet, dated 11/07/2023 , revealed a [AGE] year-old male who was admitted into the facility on [DATE]. Resident #1's diagnoses included Heart Failure, Unspecified (characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements), and Type II Diabetes Mellitus (too much sugar circulating in the blood). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS of 15, which indicated intact cognitive response. Record review of Resident #3's Face Sheet, dated 11/07/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included Unspecified Dementia (lose the ability to think, remember, learn, make decisions, and solve problems) with Unspecified Severity, Major Depressive Disorder (persistent feelings of sadness and loss of interest), and Generalized Anxiety Disorder (worrying constantly and cannot control the worrying). Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 99, which indicated Resident #3 was unable to complete the interview. Record review of Resident #3's AHS-BIMS 3.0, a facility assessment, dated 04/05/2023, signed and dated by Social Services Director, revealed a BIMS score of 04, which indicated severe cognitive impact. Record review of Resident #5's Face Sheet, dated 11/15/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included Respiratory Failure (serious condition that makes it difficult to breathe on your own), Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), and Acute Kidney Failure, Unspecified (kidneys suddenly become unable to filter waster products from your blood). Record review of Resident #5 Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. During an interview on 11/07/2023 at 3:41 p.m., Resident #1 said the floor and the wall by his toilet was wet and had black stuff on the wall. Resident #1 said the black stuff was on the wall by his toilet and there was little space in between the wall area and the toilet. Resident #1 said the rubber area at the bottom of the wall started coming off approximately four to six weeks prior and the black stuff had been on his wall for about a month. Resident #1 said he told the big boss because she came in and looked at his bathroom. Resident #1 said he could not remember the name of the big boss, but said she was a woman. Resident #1 said housekeeping came in and cleaned his room, but he was not sure how often. Resident #1 said he was told the wall would be fixed but he had not heard when. During an observation on 11/07/2023 at 3:11 p.m., observed the bathroom of Resident #1. Observed an area from the corner behind the toilet, which expanded outwards parallel with the toilet that approximately five feet of the vinyl cove base trim (the piece of trim installed around the baseboard of a room that created a transition between the floor and the wall) had become unattached from the wall and damaged drywall and water-damaged wood was exposed. The drywall was covered with a black chalk-like substance. Observed the linoleum floor color was darker than the other floor areas of the bathroom and had sections near the wall, approximately 12 inches in length that were buckled out and water damaged. During an interview on 11/07/2023 at 4:05 p.m., Maintenance Director A said he was aware of the black discoloration on the wall by the toilet in Resident #1's bathroom. Maintenance Director A said he was made aware of the issue approximately three to four days prior and had the repair on his list to complete the week of the on-site investigation. Maintenance Director A said he was not able to repair the cove base or linoleum because he had to attend a meeting and was away from the facility for several days. Maintenance Director A said a process to report needed repairs was in place. Maintenance Director A said a work order book was located at the nurses' station and if staff found an issue that needed to be repaired, they would document the issue in the work order book. Maintenance Director A said he would check the book when he came on duty in the morning, or he would check the book several times throughout the day. Maintenance Director A said he was told verbally of the of the damaged wall in Resident #1's room. Maintenance Director A said all staff knew to document needed repairs in the work order book and he was not sure if staff had been in-serviced or not on the process. During an interview on 11/15/2023 at 12:35 p.m., CNA C said she was aware of Resident #1's issue with his bathroom floor. CNA C said she thought the damage had occurred due to a water leak. CNA C said she was not sure if the issue had been reported to the maintenance supervisor or had been documented in the work order book. During an observation on 11/07/2023 at 4:40 p.m., observed in the bathroom of Resident #3 and #5, a section of the cove base trim, approximately 12 inches in length, under the sink had separated from the wall and exposed untreated drywall and discolored paint. Observed a circular area of linoleum approximately the size of basketball by the toilet and approximately two inches in width around the base of the toilet, a dark gray discoloration. Observed the linoleum to be chipped and black in color around the base of the toilet. Resident #3 was unable to be interviewed about the issue with the bathroom cove base and floor due to her cognitive function. During an interview on 11/07/2023 at 4:50 p.m., Resident #5 said the floor in the bathroom had been discolored for several months. Resident #5 said the toilet had leaked at for a couple of months and had dried. Resident #5 said the sink had leaked at the faucet and ran over onto the floor and the floor was wet. Resident #5 said she told the housekeeper, but she was not sure if anyone ever fixed the leak. During an interview on 11/15/2023 at 11:13 a.m., Housekeeper B said she had been at the facility for eight months. Housekeeper B said she had observed the black, wet area in Resident #1's bathroom and was aware of the issue for approximately one month. Housekeeper B said the water damage came from a water leak in the staff bathroom that was on the same wall as Resident #1's bathroom. Housekeeper B said she reported the issue to her supervisor. During an interview on 11/16/2023 at 10:30 a.m., the Administrator said she was not aware of the need for repair in Resident #1 and Resident #3 and #5's bathroom. After observations, the Administrator said the issues with Resident #1 and Resident #3 and #5's bathrooms did not meet her expectation. The Administrator said her expectation was for staff who assisted the residents with activities of daily living and were in the bathrooms daily, to report the need for repairs immediately and she expected to be made aware of issues as well. The Administrator said building maintenance should be monitored by the Maintenance Director A and herself. Record review of policy, Maintenance & Facilities, not dated, revealed the facility would establish an environmental plan to ensure a physical environment was safe, neat, and sanitary and met regulations to protect the health and safety of the residents. The procedure was to ensure the building was maintained in good order and kept clean and safe.

Based on observation, interview, and record review the facility failed to ensure parenteral fluids were administered with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 residents (Resident #60 and Resident #220) reviewed for IV therapy. 1. The facility failed to provide adequate maintenance of the PICC line for Resident #60 by not performing a dressing change from 05/12/23 until either 05/26/23 or 05/29/23 (actual dressing change date unclear due to conflicting evidence). 2. The facility failed to provide adequate maintenance by not flushing the IV line, not performing dressing changes, and did not document insertion or removal or IV lines for Resident #220. These deficient practices could result in residents not receiving needed care to maintain optimum health and placing them at risk for infection and/or deterioration in their condition. Findings include: 1. Record review of Resident #60's electronic face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #60 had diagnoses which included Methicillin Susceptible Staphylococcus Aureus Infection (infection in the blood stream) and Cellulitis (skin infection) of right and left lower limb. Record review of Resident #60's Admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated no cognition impairment. Further review revealed Section O 0100. Special Treatment, procedures, and program. H: IV medications while a resident was coded-yes. Record review of Resident #60's Comprehensive Care plan, initiated 05/17/23, revealed no evidence or the resident receiving IV antibiotic therapy or having a PICC line. During an observation and interview on 05/30/23 at 1:24 PM, Resident #60 stated he received IV antibiotic therapy for a blood infection. He stated the PICC line dressing had not been changed until 05/29/23. Observation of the PICC line revealed the dressing was dated 05/25/23. Record review of Resident #60's nurses note, dated 05/12/23 at 10:25 AM, signed by LVN D, revealed Chest X-ray to verify PICC placement. PICC line in place. Record review of Resident #60's physicians orders, from 05/11/23-05/30/23, revealed no evidence of and order for PICC line placement or dressing changes. Physician's orders revealed: Cefazolin (antibiotic) Intravenous Solution 2 GM/100ML every 8 hours with a start date 05/12/23 and end date 05/23/23 and Cefazolin Intravenous Solution 2 GM/100ML every 8 hours with a start date 05/23/23 and end date 06/08/23. Physician's orders revealed: Sodium Chloride (saline) flush each lumen (port) with 10 ml prior and post administration of IV cefazolin to keep line patent with a start date of 05/21/23. Record review of Resident #60's MAR and TAR, from 05/11/23-05/30/23, revealed no evidence of PICC line dressing change being performed. Record review of Resident #60's nurses notes, from 05/11/23-05/28/23, revealed no evidence of PICC line dressing change being performed. Record review of Resident #60's nurses note, dated 05/29/23 at 3:00 PM, signed by LVN E, revealed: .PICC dressing changed with sterile technique this shift. 2. Record review of Resident #220's electronic face sheet, accessed 05/30/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #220 had diagnoses which included chronic kidney disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) dependence on renal dialysis, and Diabetes Type 2. Record review of Resident #220's Admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated no cognition impairment. Further review revealed Section O 0100. Special Treatment, procedures, and program. H: IV medications was coded-yes. Record review of Resident #220's Baseline Care Plan, dated 05/23/23, revealed no evidence of an IV line or antibiotic therapy. Record review of Resident #220's Comprehensive Care plan, initiated 05/24/23, revealed no evidence of the resident receiving IV antibiotic therapy or having an IV line. Record review of Resident #220's Admit Evaluation, dated 05/22/23, signed by LVN A, revealed no evidence of an IV line. Record review of Resident #220's Admit note, dated 05/22/23 at 8:54 PM, signed by LVN A, revealed no evidence of an IV line. Record review of Resident #220's physicians orders, from 05/22/23-05/31/23, revealed no evidence of an order to initiate an IV line, to flush an IV line, or for dressing changes to IV line. Further review of physician's orders revealed: Ceftriaxone (antibiotic) intravenous solution 2 GM intravenously every 24 hours with a start date of 05/26/2024 and end date of 05/30/23. Record review of Resident #220's nurses notes, from 05/22/23-05/28/23, revealed no evidence of IV-line insertion, removal, flushing, or dressing change. Record review of Resident #220's nurses note, dated 05/29/23 at 23:29 PM, signed by LVN E, revealed: IV start per protocol with 22g/1in in style to right AC with 2 attempts During observation and interview on 05/30/23 at 11:30 AM, Resident #220 stated he received IV antibiotic therapy. He stated he had his IV line when he was admitted . Observation revealed IV line to right AC (bend of arm) with dressing dated 05/20/23. During an interview on 05/31/23 at 3:30 PM, LVN A stated she was aware Resident #220 received IV antibiotic therapy. She stated he had an IV line to his right AC. She stated she never inserted an IV line in for Resident #220 and she did not know when it was done. LVN A stated the only way she would know a resident had an IV line was from hand off report she received from the previous nurse. LVN A stated the nurse on duty was responsible for entering all orders for new admissions and any received after. She stated he did not have an IV order at the time of admission, and she did not know who received the IV order. LVN A stated she was the nurse on duty the day Resident #220 was admitted . She stated she did assess Resident #220 and he did not have an IV line. LVN A she had never performed a PICC line dressing change on Resident #60. During an interview on 05/31/23 at 3:46 PM, the DON stated she knew Resident #60's dressing change was within the last 7 days because she verified it yesterday. She stated she was unsure the date of the dressing change. The DON stated there should have been on order for dressing changes. She stated not performing routine dressing changes could lead to infection. The DON stated Resident #220 had multiple IV lines inserted because he kept pulling them out. She stated there was no way he had the same IV line since 05/20/23. Resident #220 did not have an IV line at this time because IV antibiotic therapy was completed on 05/30/23. The DON did not know why none of this was documented. The DON stated the nurse on duty was responsible for entering all orders upon a resident's admission and any new orders. She stated not having the orders did not affect the residents care because the facility nurses communicated well during hand off report. The DON stated the failure ultimately occurred because she had not reviewed charts and orders. The DON stated she was going to review charts on Monday, but the State Surveyors entered, and she was busy. The DON stated the facility did not have any central lines and did not provide a policy for central line catheters. An interview was attempted with LVN E by phone, on 05/31/23 at 4:30 PM, however, the LVN was unavailable for interview. Record Review of the facility policy tilted, Intravenous Therapy implemented 03/20/21, revealed: Policy: The facility will adhere to accepted standards of practice regarding infusion practices. Compliance Guidelines .8. IV sites are changed every 72 hours, unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibit signs and symptoms of phlebitis.9. In the event and IV is left in place longer than 72 hours, IV site care will be done every 24 hours .12. A doctor's order is obtained before starting IV therapy. 13. IV sites are checked every four hours and as needed. 14. IV documentation is recorded in the nurses notes and or medication administration record.

Based on observation, interview and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, for 1 of 1 meal reviewed. The facility failed to follow the recipe when preparing the mechanical soft hamburger patty. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings include: Observation on 05/29/2023 between 11:30 AM and 1:00 PM, of the kitchen revealed Cook F added an unmeasured scoop of mayonnaise to the hamburger patties while she had chopped the cooked hamburger patties. Once prepared, the patties mixed with mayonnaise were plated and carried out to the dining room to be served to residents. During an interview on 05/29/20223 at 12:00 pm, Cook F stated she worked in kitchen for [AGE] years and she was taught to put mayonnaise in the mechanical soft meat to help hold it together on the bun. Cook F stated she had never looked at the recipe. During an interview on 5/29/2023 at 1:10 PM, the DM stated staff should have used the recipes. The DM stated mayonnaise should not have been added because the recipe did not call for mayonnaise. The DM stated altering recipes could have caused residents' to not receive their nutritional needs. The DM stated she had only been the DM since last week and felt staff were not trained properly by previous DM. During an interview on 05/31/2023 at 4:45 PM, the ADMN stated her expectation was for the cooks to follow the recipes. The ADMN stated what led to failure was the kitchen staff were in the middle of leadership transition and there were some staff that where not happy with the transition. The ADMN stated the effect on residents was they did not receive their correct nutritional needs and their preferences may have not been honored. The ADMN stated the cooks and the DM were responsible to ensure recipes were followed and ultimately it fell on ADMN. Record review of the facility's menu titled Beef Patty 4/1 on Bun dated 2/16/2023 revealed 5 mech soft step 1: per standard portion, process one piece of meat to a ground consistency. 6 mech soft step 2: combine ground meat with 1 tb per portion of *appropriate thickened low sodium beef broth for moisture. *mech soft thickened broth: for each 4 fl oz liquid add 1 tbsp thickener (corn starch based) HACCP: hold food at 135 f (57 c) or higher. 7 mech soft step 3: standard portion: serve 4 fl oz (#8 dipper) of ground meat mixture in between a soft bun/rolubread slices per recipe. serve with additional condiments/sauces per menu at time of service. Record review of the facility's polity titled, Diets, Nutrition and Hydration dated 3/2016 revealed, The facility will provide each resident with three meals daily and a nourishing snack at bedtime. Each meal will be provided according to physician orders, Facility Diet Manual, and menu spread sheet.

Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 3 of 10 residents (Residents #1, #26 and #8) reviewed during the lunch meal. The facility failed to ensure Resident #1, Resident #26 and Resident #8 received a dessert or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Observation on 05/29/2023 between 11:30 AM and 1:00 PM, revealed Resident #1, Resident #26 and Resident #8 did not receive a dessert with their meal. Record review of Resident #1's face sheet, dated 05/31/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with original admitted [DATE] with following diagnosis abnormal weight loss, anorexia and dehydration. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed: Section C: Cognitive Patterns- BIMS 99, which indicated severe cognitive impairment. Record review of Resident #8's face sheet, dated 05/31/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE], with original admitted [DATE] with following diagnosis Dementia and Type 2 Diabetes Mellitus without Complications. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed in Section C: Cognitive Patterns- BIMS 13, which indicated the resident was Cognitively intact. Record review of Resident #26 face sheet, dated 05/31/2023, revealed a [AGE] year-old female admitted on [DATE], with original admitted [DATE] with following diagnosis Type 2 Diabetes Mellitus, Nutritional deficiency, and Unspecified Protein- Calorie Malnutrition. Record review of Resident #26's Quarterly MDS dated [DATE], revealed Section C: Cognitive Patterns- BIMS 13(Cognitively intact) During an interview and observation on 05/29/2023 between 12:45 PM and 1:00 PM Resident # 26 stated he would like to get his lunch like everyone else at his table. After Resident#26 received lunch, he stated he would like to have dessert like the other residents around him. During an interview on 05/29/23 at 12:55 PM Resident #8 stated he did not receive a dessert and would like to have his dessert. During an interview on 05/29/2023 at 1:10 PM, the DM stated she had started in this position last week and was working under corporate Dietary Managers. The DM stated the menu should have been followed and residents should have received their entire meal, including dessert. The DM stated not receiving their entire meal could have affected residents by not having their nutritional needs met. During an interview on 05/31/2023 at 11:45 AM, DS H stated she had forgotten to serve dessert to Resident #1, Resident #26, and Resident #8, but did not realize it until the next day when she was told by the DM. Cook H stated the nurses usually checked trays, but it was a crazy day and that led to failure of items being forgotten. During an interview on 05/31/2023 at 4:45 PM, the ADMN stated her expectation was residents received all the food that was listed on the menu, unless they had requested a change. The ADMN stated what led to failure was the kitchen was in the middle of transition and there were some staff that where not happy with the transition. The ADMN stated the effect on residents could have been residents would not have received the nutrition needed, and their preferences not being met. The ADMN stated the cook and the DM were responsible to ensure residents received their entire meal and ultimately it fell on the ADMN. Record review of posted menu on 05/29/2023 revealed hamburger or hot dog, tater tots and chocolate chip cookie. Record review of the facility policy titled, Menus and Nutritional Adequacy, dated 05/30/2021, revealed Menus are planned to meet the average resident's nutritional needs . All menu changes will be reviewed and approved by the facility's Dietitian or Consultant Dietitian. When making menu changes it is important to make sure all food groups are represented in adequate numbers, and that menu changes are extended for all therapeutic diets per the facility diet manual.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. 2. The facility failed to ensure all food was not past the expiration date. 3. The facility failed to ensure staff utilized proper personal hygiene practices. 4. The facility failed to ensure dietary staff cleaned kitchen counters between pureeing different foods. These failures could place residents at risk for food borne illnesses. Findings include: Observations on [DATE] between 10:20 AM and 10:50 AM of the kitchen revealed the following: Refrigerator #1 1. A container of raw chicken was dated ,d+[DATE]. 2. 3 tubes of hamburger meat had a date of ,d+[DATE]. 3. 1 plastic bag containing sliced yellow cheese was not sealed. 4. A box of frozen shakes that did not have an open date but had a manufacture label that stated may leave unfrozen for less than 14 days. Dry Storage 1. A container of thickener was not labeled with a date and item description. 2. A container of sugar was not sealed, and not labeled with a date and item description. 3. A container of flour was not labeled with a date and item description. 4. A plastic bag contained croissants were not labeled with a date and item description. 5. A plastic bag with a seal that contained a peanut butter and jelly sandwich was dated ,d+[DATE]. Observations on [DATE] between 11:30 AM and 1:00 PM of kitchen revealed the following: -Cook F failed to clean the counter in between purees of different foods. Cook F pureed meat, changed gloves, then pureed vegetables. Cook F left the food soiled disposable gloves on the counter and failed to discard them in trash the can, while pureeing food. -DS H, Cook F and Cook G entered and exited the kitchen numerous times without changing gloves or performing hand hygiene during meal service. They handled resident food trays and plated food items. -Staff did not put soiled disposable gloves in the trash can, soiled gloves were thrown on the floor next to trash can. During an interview on [DATE] at 10:30 AM, Cook G stated food items should have been dated when they arrived in the kitchen, when they were opened, and with a use by date. Cook G stated food items should have been discarded after 7 days. Cook G stated the big containers contained thickener, sugar and flour. Cook G stated there was a label on the containers the other day and didn't know why someone would have taken them off. Cook G stated she was the dietary manager but was now a cook. During an interview on [DATE] at 1:10 PM, the DM stated she started in the position last week and was working under the Corporate Dietary Managers. The DM stated food items should have been dated with a receive date, open date and a use by date. The DM stated items should have been thrown out after 7 days. The DM stated the counter should have been cleaned between different types of puree food and dirty gloves should not have been left on the counter. The DM stated soiled gloves should have been thrown in the trash cans. The DM stated residents could have been affected by becoming sick because of cross contamination or food born illness. The DM stated what led to failure was lack of education. During an interview on [DATE] at 11:44 AM, DS H stated she should have washed her hands every time she entered the kitchen and changed her gloves. DS H stated it was a crazy day and she just forgot to change her gloves and wash her hands. During an interview on [DATE] at 4:45 PM, the ADMN stated her expectation was that food items in kitchen should have been labeled correctly with an open date, use by date and item description. The ADMN stated items should have been discarded after the use by date. The ADMN stated what led to the failure was the kitchen was in the middle of transition and there were some staff that where not happy with the transition. The ADMN stated the effect on residents could have been residents did not receive appropriate nutrition and food borne illness. Record review of CMS form 672, dated [DATE], revealed 68 of 69 resident ate from the kitchen. Record review of the facility policy titled, Food and Safety and Sanitation Plan dated [DATE], revealed: Review of Ready-to-eat food will be clearly labeled using calendar date to indicate the date the product was prepared and the date the product must be used or discarded. Use the following to determine the use by date: Held at 41 F or below= 7 days. Certain Bulk ready-to-eat foods (i.e. bulk cottage cheese, gallon milk, bulk sour cream) may go by manufacturer's use by date and do not need an additional use by date once opened . Commercially prepared PHF/TCS food products are clearly labeled using calendar date to indicate the date the product was opened and the date by which product must be used or discarded. The use by' date must not exceed the use by'' date established by the manufacturer . Thorough hand washing is required (but not limited to) the following situations: A. starting the work shift, B. after using the rest room, C. after handling raw food products, D. after coughing, sneezing, or touching hair or face, E. after eating, drinking or smoking, F. after use of any chemicals or cleaners. Record review of the facility policy titled Dry Food and Supplies Storage, dated [DATE], revealed: 6. The practice of First In, First Out (FIFO) will be utilized. Products which do not have an imprinted use by or expiration date on the product, will be dated when received and rotated as new inventory is purchased (the oldest product will be moved to the front for use first). Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded. If product is delivered with and out of date expiration date the vendor will be called, the product will be removed from useable stock. 7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lids. Each container must be labeled with the common name of the food. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food . 9.All opened products must be resealed effectively and properly labeled, dated and rotated for use. This may require storage in an approved NSF container or food grade storage bag. 10. Use by, Best by and Sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately. Record review of the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed [DATE]), Food Employees shall clean their hands and exposed portions of their arms . immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use article sp and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; .(D) . after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking . (E) After handling soiled equipment or utensils . (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #11) of 16 residents reviewed for quality of care. 1. LVN A failed to take immediate action when she made a significant medication error occurred and she gave Resident #11 [MEDICATION NAME] 500 rather than his prescribed [MEDICATION NAME] 100. As a result of the error, Resident #11's blood sugar began to drop below the resident's normal range. 2. LVN A failed to transcribe and carry out the physician's orders [REDACTED].#11's physician of his drop in blood sugar level. 3. LVN B failed to obtain the physician's orders [REDACTED]. report. 4. LVN B and LVN C failed to carry out the physician's orders [REDACTED].#11, per physician's orders [REDACTED]. 5. LVN B and LVN C failed to notify Resident #11's physician when they were unable to stabilize his blood sugar, place an IV, and had to send the resident to the emergency room . 6. LVN A, LVN B and LVN C failed to notify the DON about the medication error and change of condition with Resident #11 until the resident could not be stabilized and needed to be sent to the emergency room . An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed the 26 residents who resided on Hall 2 where LVN A, B, and C worked at risk of having a serious medication error resulting in a serious injury and possibly death. Findings Included: 1. Review of Resident #11's face sheet dated [DATE] reflected Resident #11 was an [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] his BIMS score was 09 which indicated moderate cognitive impairment. Review of Resident #11's physician's orders [REDACTED]. [MEDICATION NAME] ,[DATE] Suspension 100 units/ml; Inject 15 units subcutaneously two times a day, which was ordered on [DATE]. If fasting blood sugar is less than 60 and resident is responsive, Give 6 Oz of med plus 2.0 and recheck blood glucose every 15 minutes until blood glucose is greater than 60. If glucose is still less than 60 after 30 minutes call MD (doctor) or send to ER (emergency room ), which was an active order since [DATE]. Review of the emergency department report dated [DATE] at 3:15 a.m. reflected the history of present illness as abnormal glucose due being given the wrong kind of insulin at the nursing home. Nursing home transferred him because they were unable to get IV access. At its maximum, the severity was described as moderate. Resident #11 was described as anxious and disoriented. Treatment included observation and management of blood glucose levels in the Intensive Care Unit from [DATE] to [DATE]. Interview with Resident #11 on [DATE] at 4:30 p.m. revealed the resident was oriented to person, place, and time. He remembered in the middle of last week, [DATE] through [DATE], LVN A had given him his usual insulin shot right before dinner. He stated he does not normally look at the insulin when they give it to him. He stated after she gave him the insulin, he started to feel dizzy and nauseous. He stated he felt like 'crap' for a couple of hours. He stated after a while, two nurses kept checking his blood sugar and giving him peanut butter crackers. He stated he started feeling worse and worse and stated going in and out of consciousness. He stated the night nurses tried to start an IV and could not get it in. He stated he was miserable and finally they sent him to the emergency room where he had to go to the ICU (Intensive Care Unit) to be monitored for a couple of days. He stated the nurses never told him what was going on, but he knew something was up. He stated the ER staff finally told him at the hospital that LVN A gave him the wrong type of insulin and that he got way more insulin than he was supposed to. He stated no one in the facility had yet to come and talk to him about the incident. Interview with LVN A on [DATE] at 3:12 p.m. revealed on [DATE] she gave Resident #11, 15 units of insulin around 4:30 p.m. She stated she was checking his blood sugar that night a few hours after dinner and noted it was low for Resident #11. She stated at that time, she realized she might have given the wrong insulin. She stated there are only two bottles of insulin on the medication cart. Resident #11 and another resident whose insulin is five times stronger than Resident #11's insulin. She stated she immediately called the physician around 9:00 p.m. who gave her an order to start an IV and monitor Resident #11's blood sugars. She stated she forgot to transcribe the order and did not start an IV or monitor Resident #11's blood sugar. She stated she did tell LVN B about the possible medication error and the physician's orders [REDACTED]. She stated she has plans to go back to work. Two attempts were made to contact LVN B via telephone on [DATE] and [DATE]. Review of LVN B's undated witness statement revealed the incident occurred on [DATE]. She stated LVN A was giving her report at the start of her shift and LVN A mentioned that she thought she gave a resident another resident's insulin. LVN A told her that she had called the doctor and the doctor had told her to give the resident something to eat, monitor the blood sugars every hour, and to start an IV if Resident #11's blood sugar continued to drop. Review of the physician's orders [REDACTED]. According to https://www.drugs.com/mtm/[MEDICATION NAME]-5-in-water-injection.html, obtained on [DATE], [MEDICATION NAME] 5% in water (D5W) in water is used to treat low blood sugar ([DIAGNOSES REDACTED]), insulin shock, or dehydration (fluid loss). [MEDICATION NAME] 5% in water is also given for nutritional support to patients who are unable to eat because of illness, injury, or other medical condition. Review of the DON's witness statement dated [DATE] reflected she received a call from LVN C at 2:30 a.m. asking if LVN A had called her about Resident #11's blood sugar issues. She told LVN C she had not been notified of any issues and LVN C told her that Resident #11 may have received concentrated insulin from another resident's vial and his blood sugar was still fluctuating and she and LVN B were unable to successfully get an IV started. The DON gave instructions at that time to send the resident to the emergency room to monitor more closely. Interview with Resident #11's physician on [DATE] at 1:32 p.m. revealed he received a phone call from LVN A on [DATE] around 8:00 p.m. He stated LVN A told him she might have given the wrong insulin to Resident #11, and might have given another resident's insulin (U500) which was five times stronger, at 4:30 p.m. that day. He stated he told LVN A to start giving him foods high in carbohydrates and to start an IV with D5W if his blood sugar continued to drop. He stated Resident #11's blood sugar is usually very stable (in the 100s) and it was out of character for his blood sugar to go below 100 and so he believed LVN A probably gave him the wrong insulin. He stated LVN A or any other staff never called him again about the issue, so he assumed they had followed his orders and Resident #11 was fine. He stated if Resident #11's blood sugar had gotten too low and they would have not sent him to the emergency room when they did, he could have gone into a diabetic coma and died . He also stated he has discussed with the facility numerous times about keeping the U500 insulin separate from regular insulin because of potential mix ups. Review of LVN B's nurse's note dated [DATE] revealed she took Resident #11's blood sugar at midnight and it was 67 mg/dL. LVN B retook his blood sugar at 1:00 a.m. and it was 53 mg/dL. LVN B remeasured Resident #11's blood sugar at 2:00 a.m. and it was 49 mg/dL. LVN B goes on to state Resident #11 was being fed peanut butter crackers, 3 cartons of Boost but sugar continued to fall. LVN B tried to start an IV but was unable to get in the vein. Call placed to DON and she stated to send resident out to hospital. LVN B requested an ambulance at 2:35 a.m. and they arrived at 2:40 a.m. EMT was able to start an IV and gave 50 ml of glucose. BS was 66 mg/dL when IV started and after administration of glucose it was 244 mg/dL as they put Resident #11 on stretcher to transport to hospital. Resident was alert but slower than usual upon discharge. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of the Nursing Home to Hospital Transfer form for Resident #11 dated [DATE] revealed Resident #11 was sent to the hospital on [DATE] at 2:40 a.m. Reasons for transfer stated, Patient given U500 insulin at 4:00 p.m. which is the wrong insulin. Interview with the DON on [DATE] at 3:30 p.m. revealed LVN B had called her around 2:30 a.m. on [DATE] to tell her LVN A might have given Resident #11 U500 insulin instead of regular insulin and that his blood sugar was continuing to drop. She told LVN B to send Resident #11 to the hospital. She stated she was not sure why the facility has not disciplined or terminated LVN A because she made a major medication error and did not inform her, the resident, did not follow the physician's orders [REDACTED].#11 when she realized she made a medication error. She stated LVN B and LVN C should have notified her when LVN A told them she might have made a medication error. She stated LVN B and LVN C should have followed the physician's orders [REDACTED]. She stated LVN B and LVN C had not been disciplined or had individual in-servicing after the medication error. She stated she was unable to help with most of the investigation because she was suspended depending on an investigation of another incident. Interview with the Administrator on [DATE] at 3:00 p.m. revealed he was made aware of the drug error on [DATE] at the standup meeting, but he was going to let the DON and other nurses handle the situation. He stated LVN A was currently suspended but he did not believe there was enough evidence to prove LVN A made the medication error since he could not measure each insulin bottle to see if LVN A gave the wrong insulin. He stated he was not a medical professional, so he was unsure what could have caused Resident #11's blood sugar to drop. He stated he had not told LVN A she was suspended because she came in on [DATE] to talk to another surveyor about another situation and was too upset afterwards and she left the building. He stated he had yet to tell her that she was suspended, because LVN A was involved in another incident during the same time of the medication error and she had left the facility after talking to an investigator and he was unable to catch her before she left the building. Review of the Medication Error Report signed by the administrator on [DATE] reflected on [DATE] at 4:30 p.m. LVN A was not sure if she gave Resident #11 U500 insulin by mistake. Outcome to resident was listed as resident sent to ER for evaluation. Measures taken to prevent the recurrence of similar errors included removing U500 insulin from the insulin drawer and requiring two nurses to administer the U500 insulin. Stated the physician was notified at 6:00 p.m. and the DON was notified on [DATE] at 2:30 a.m. Review of the Medication Monitoring and Management policy, dated [DATE], reflected the following: F. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: 1. Requiring medication discontinuation or dose modification. Requiring hospitalization or extending a hospitalization . 2. Resulting in disability. 3. Requiring treatment with a prescription medication. 4. Resulting in cognitive deterioration or impairment. 5. Life threatening. 6. Resulting in death. G. The attending physician is notified promptly of any significant error or adverse consequence. H. The physician's orders [REDACTED]. An immediate jeopardy was identified on [DATE] at 10:35 a.m. The Administrator and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. The facility's Plan of Removal, accepted on [DATE] at 12:50 p.m. reflected: LVN A was suspended on Thursday [DATE] at 2:30 pm and has since been terminated on [DATE]. The following in services was started on Thursday [DATE] by the DON and ADON D and completed on [DATE]. No licensed nurse will be allowed to return to work until this education has been completed. Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] both LVN B and LVN C will be given 1:1 education regarding: Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.). Medication Administration (Medication administration according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines ( used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] the following in-services was started by the DON was completed [DATE] and no license nurse will be allowed to work until they have received this education. 18 of 23 license nurses have completed this education All education will have a post test completed to validate knowledge of staff training. This post test started on Friday [DATE] and will be completed on [DATE] as no nurse will be allowed to work until they complete the post test prior to starting the shift. Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.) Medication Administration (Medication administered according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] by the Administrator to all license nurses. 18 of 23 license nurses have completed this education. The remaining 5 nurses will have this education completed prior to returning to work. Physician Monitoring orders (to include how telephone orders can be received, how to transcribe order, following through with Physician orders) This education was started today by the DON and ADON D and will be completed today [DATE] and no nurse will be allowed to work until they have received this education. Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] and completed on [DATE] by the Administrator to all other staff in the facility. All staff will have this education completed prior to returning to work. The DON/ADON/Designee using the QAPI tool: Diabetic Insulin management tool will monitor every shift for the next 7 days validating nurses following physician orders [REDACTED]. The DON/ADON or designee will use the QAPI Acute Change in Condition tool to review all resident(s) with an acute change of condition to validate that assessment complete, family/resident was notified, the Physician was notified, following up completed until resolved. To verify the implementation of the plan of removal was in place, the following interviews, observations, and record reviews were completed. Review of the termination notice of LVN A was dated [DATE] and noted she was no longer employed at the facility. Review of all of the in-services on [DATE] reflected all of the licensed nurses had been in-serviced on immediate notification, transcribing physician's orders [REDACTED]. All of the licensed nurses had completed and passed a post test which went over all of the information covered in the in-services. Individual in-services with LVN B and LVN C was reviewed and revealed they received individual in-servicing over the insulin management process, immediate notification, transcribing physician's orders [REDACTED]. Interviews with LVN E, LVN F, LVN G, LVN H, LVN I, MDS Nurse J, and LVN K which represented staff across multiple shifts on [DATE] between 9:30 a.m. and 11:00 a.m. revealed they were all in-serviced over immediate notification, transcribing physician's orders [REDACTED]. All interviewed staff answered questions appropriately and there were no concerns noted. Observation of the Hall 200 Medication Cart on [DATE] at 9:20 a.m. revealed there was only one bottle of regular insulin available and no U500 insulin was available on the medication cart. The IJ was removed on [DATE] at 11:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. Review of the facility census dated [DATE] reflected there were 26 residents who resided on Hall 2 where LVN A, LVN B, and LVN C worked.

Based on observation, interview and record review, the facility failed to ensure the resident was free from neglect for one (Resident #11) of 16 residents reviewed for neglect. 1. LVN A failed to take immediate action when she made a significant medication error occurred and she gave Resident #11 [MEDICATION NAME] 500 rather than his prescribed [MEDICATION NAME] 100. As a result of the error, Resident #11's blood sugar began to drop below the resident's normal range. 2. LVN A failed to transcribe and carry out the physician's orders [REDACTED].#11's physician of his drop in blood sugar level. 3. LVN B failed to obtain the physician's orders [REDACTED]. report. 4. LVN B and LVN C failed to carry out the physician's orders [REDACTED].#11, per physician's orders [REDACTED]. 5. LVN B and LVN C failed to notify Resident #11's physician when they were unable to stabilize his blood sugar, place an IV, and had to send the resident to the emergency room . 6. LVN A, LVN B and LVN C failed to notify the DON about the medication error and change of condition with Resident #11 until the resident could not be stabilized and needed to be sent to the emergency room . An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed the 26 residents who resided on Hall 2 where LVN A, B, and C worked at risk of having a serious medication error resulting in a serious injury and possibly death. Findings Included: 1. Review of Resident #11's face sheet dated [DATE] reflected Resident #11 was an [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] his BIMS score was 09 which indicated moderate cognitive impairment. Review of Resident #11's physician's orders [REDACTED]. [MEDICATION NAME] ,[DATE] Suspension 100 units/ml; Inject 15 units subcutaneously two times a day, which was ordered on [DATE]. If fasting blood sugar is less than 60 and resident is responsive, Give 6 Oz of med plus 2.0 and recheck blood glucose every 15 minutes until blood glucose is greater than 60. If glucose is still less than 60 after 30 minutes call MD (doctor) or send to ER (emergency room ), which was an active order since [DATE]. Review of the emergency department report dated [DATE] at 3:15 a.m. reflected the history of present illness as abnormal glucose due being given the wrong kind of insulin at the nursing home. Nursing home transferred him because they were unable to get IV access. At its maximum, the severity was described as moderate. Resident #11 was described as anxious and disoriented. Treatment included observation and management of blood glucose levels in the Intensive Care Unit from [DATE] to [DATE]. Interview with Resident #11 on [DATE] at 4:30 p.m. revealed the resident was oriented to person, place, and time. He remembered in the middle of last week, [DATE] through [DATE], LVN A had given him his usual insulin shot right before dinner. He stated he does not normally look at the insulin when they give it to him. He stated after she gave him the insulin, he started to feel dizzy and nauseous. He stated he felt like 'crap' for a couple of hours. He stated after a while, two nurses kept checking his blood sugar and giving him peanut butter crackers. He stated he started feeling worse and worse and stated going in and out of consciousness. He stated the night nurses tried to start an IV and could not get it in. He stated he was miserable and finally they sent him to the emergency room where he had to go to the ICU (Intensive Care Unit) to be monitored for a couple of days. He stated the nurses never told him what was going on, but he knew something was up. He stated the ER staff finally told him at the hospital that LVN A gave him the wrong type of insulin and that he got way more insulin than he was supposed to. He stated no one in the facility had yet to come and talk to him about the incident. Interview with LVN A on [DATE] at 3:12 p.m. revealed on [DATE] she gave Resident #11, 15 units of insulin around 4:30 p.m. She stated she was checking his blood sugar that night a few hours after dinner and noted it was low for Resident #11. She stated at that time, she realized she might have given the wrong insulin. She stated there are only two bottles of insulin on the medication cart. Resident #11 and another resident whose insulin is five times stronger than Resident #11's insulin. She stated she immediately called the physician around 9:00 p.m. who gave her an order to start an IV and monitor Resident #11's blood sugars. She stated she forgot to transcribe the order and did not start an IV or monitor Resident #11's blood sugar. She stated she did tell LVN B about the possible medication error and the physician's orders [REDACTED]. She stated she has plans to go back to work. Two attempts were made to contact LVN B via telephone on [DATE] and [DATE]. Review of LVN B's undated witness statement revealed the incident occurred on [DATE]. She stated LVN A was giving her report at the start of her shift and LVN A mentioned that she thought she gave a resident another resident's insulin. LVN A told her that she had called the doctor and the doctor had told her to give the resident something to eat, monitor the blood sugars every hour, and to start an IV if Resident #11's blood sugar continued to drop. Review of the physician's orders [REDACTED]. According to https://www.drugs.com/mtm/[MEDICATION NAME]-5-in-water-injection.html, obtained on [DATE], [MEDICATION NAME] 5% in water (D5W) in water is used to treat low blood sugar ([DIAGNOSES REDACTED]), insulin shock, or dehydration (fluid loss). [MEDICATION NAME] 5% in water is also given for nutritional support to patients who are unable to eat because of illness, injury, or other medical condition. Review of the DON's witness statement dated [DATE] reflected she received a call from LVN C at 2:30 a.m. asking if LVN A had called her about Resident #11's blood sugar issues. She told LVN C she had not been notified of any issues and LVN C told her that Resident #11 may have received concentrated insulin from another resident's vial and his blood sugar was still fluctuating and she and LVN B were unable to successfully get an IV started. The DON gave instructions at that time to send the resident to the emergency room to monitor more closely. Interview with Resident #11's physician on [DATE] at 1:32 p.m. revealed he received a phone call from LVN A on [DATE] around 8:00 p.m. He stated LVN A told him she might have given the wrong insulin to Resident #11, and might have given another resident's insulin (U500) which was five times stronger, at 4:30 p.m. that day. He stated he told LVN A to start giving him foods high in carbohydrates and to start an IV with D5W if his blood sugar continued to drop. He stated Resident #11's blood sugar is usually very stable (in the 100s) and it was out of character for his blood sugar to go below 100 and so he believed LVN A probably gave him the wrong insulin. He stated LVN A or any other staff never called him again about the issue, so he assumed they had followed his orders and Resident #11 was fine. He stated if Resident #11's blood sugar had gotten too low and they would have not sent him to the emergency room when they did, he could have gone into a diabetic coma and died . He also stated he has discussed with the facility numerous times about keeping the U500 insulin separate from regular insulin because of potential mix ups. Review of LVN B's nurse's note dated [DATE] revealed she took Resident #11's blood sugar at midnight and it was 67 mg/dL. LVN B retook his blood sugar at 1:00 a.m. and it was 53 mg/dL. LVN B remeasured Resident #11's blood sugar at 2:00 a.m. and it was 49 mg/dL. LVN B goes on to state Resident #11 was being fed peanut butter crackers, 3 cartons of Boost but sugar continued to fall. LVN B tried to start an IV but was unable to get in the vein. Call placed to DON and she stated to send resident out to hospital. LVN B requested an ambulance at 2:35 a.m. and they arrived at 2:40 a.m. EMT was able to start an IV and gave 50 ml of glucose. BS was 66 mg/dL when IV started and after administration of glucose it was 244 mg/dL as they put Resident #11 on stretcher to transport to hospital. Resident was alert but slower than usual upon discharge. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of the Nursing Home to Hospital Transfer form for Resident #11 dated [DATE] revealed Resident #11 was sent to the hospital on [DATE] at 2:40 a.m. Reasons for transfer stated, Patient given U500 insulin at 4:00 p.m. which is the wrong insulin. Interview with the DON on [DATE] at 3:30 p.m. revealed LVN B had called her around 2:30 a.m. on [DATE] to tell her LVN A might have given Resident #11 U500 insulin instead of regular insulin and that his blood sugar was continuing to drop. She told LVN B to send Resident #11 to the hospital. She stated she was not sure why the facility has not disciplined or terminated LVN A because she made a major medication error and did not inform her, the resident, did not follow the physician's orders [REDACTED].#11 when she realized she made a medication error. She stated LVN B and LVN C should have notified her when LVN A told them she might have made a medication error. She stated LVN B and LVN C should have followed the physician's orders [REDACTED]. She stated LVN B and LVN C had not been disciplined or had individual in-servicing after the medication error. She stated she was unable to help with most of the investigation because she was suspended depending on an investigation of another incident. Interview with the Administrator on [DATE] at 3:00 p.m. revealed he was made aware of the drug error on [DATE] at the standup meeting, but he was going to let the DON and other nurses handle the situation. He stated LVN A was currently suspended but he did not believe there was enough evidence to prove LVN A made the medication error since he could not measure each insulin bottle to see if LVN A gave the wrong insulin. He stated he was not a medical professional, so he was unsure what could have caused Resident #11's blood sugar to drop. He stated he had not told LVN A she was suspended because she came in on [DATE] to talk to another surveyor about another situation and was too upset afterwards and she left the building. He stated he had yet to tell her that she was suspended, because LVN A was involved in another incident during the same time of the medication error and she had left the facility after talking to an investigator and he was unable to catch her before she left the building. Review of the Medication Error Report signed by the administrator on [DATE] reflected on [DATE] at 4:30 p.m. LVN A was not sure if she gave Resident #11 U500 insulin by mistake. Outcome to resident was listed as resident sent to ER for evaluation. Measures taken to prevent the recurrence of similar errors included removing U500 insulin from the insulin drawer and requiring two nurses to administer the U500 insulin. Stated the physician was notified at 6:00 p.m. and the DON was notified on [DATE] at 2:30 a.m. Review of the Abuse and Neglect Prohibition policy revised on ,[DATE] reflected the following: Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. Review of the Medication Monitoring and Management policy, dated [DATE], reflected the following: F. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: 1. Requiring medication discontinuation or dose modification. Requiring hospitalization or extending a hospitalization . 2. Resulting in disability. 3. Requiring treatment with a prescription medication. 4. Resulting in cognitive deterioration or impairment. 5. Life threatening. 6. Resulting in death. G. The attending physician is notified promptly of any significant error or adverse consequence. H. The physician's orders [REDACTED]. An immediate jeopardy was identified on [DATE] at 10:35 a.m. The Administrator and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. The facility's Plan of Removal, accepted on [DATE] at 12:50 p.m. reflected: LVN A was suspended on Thursday [DATE] at 2:30 pm and has since been terminated on [DATE]. The following in services was started on Thursday [DATE] by the DON and ADON D and completed on [DATE]. No licensed nurse will be allowed to return to work until this education has been completed. Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] both LVN B and LVN C will be given 1:1 education regarding: Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.). Medication Administration (Medication administration according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines ( used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] the following in-services was started by the DON was completed [DATE] and no license nurse will be allowed to work until they have received this education. 18 of 23 license nurses have completed this education All education will have a post test completed to validate knowledge of staff training. This post test started on Friday [DATE] and will be completed on [DATE] as no nurse will be allowed to work until they complete the post test prior to starting the shift. Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.) Medication Administration (Medication administered according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] by the Administrator to all license nurses. 18 of 23 license nurses have completed this education. The remaining 5 nurses will have this education completed prior to returning to work. Physician Monitoring orders (to include how telephone orders can be received, how to transcribe order, following through with Physician orders) This education was started today by the DON and ADON D and will be completed today [DATE] and no nurse will be allowed to work until they have received this education. Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] and completed on [DATE] by the Administrator to all other staff in the facility. All staff will have this education completed prior to returning to work. The DON/ADON/Designee using the QAPI tool: Diabetic Insulin management tool will monitor every shift for the next 7 days validating nurses following physician orders [REDACTED]. The DON/ADON or designee will use the QAPI Acute Change in Condition tool to review all resident(s) with an acute change of condition to validate that assessment complete, family/resident was notified, the Physician was notified, following up completed until resolved. To verify the implementation of the plan of removal was in place, the following interviews, observations, and record reviews were completed. Review of the termination notice of LVN A was dated [DATE] and noted she was no longer employed at the facility. Review of all of the in-services on [DATE] reflected all of the licensed nurses had been in-serviced on immediate notification, transcribing physician's orders [REDACTED]. All of the licensed nurses had completed and passed a post test which went over all of the information covered in the in-services. Individual in-services with LVN B and LVN C was reviewed and revealed they received individual in-servicing over the insulin management process, immediate notification, transcribing physician's orders [REDACTED]. Interviews with LVN E, LVN F, LVN G, LVN H, LVN I, MDS Nurse J, and LVN K which represented staff across multiple shifts on [DATE] between 9:30 a.m. and 11:00 a.m. revealed they were all in-serviced over immediate notification, transcribing physician's orders [REDACTED]. All interviewed staff answered questions appropriately and there were no concerns noted. Observation of the Hall 200 Medication Cart on [DATE] at 9:20 a.m. revealed there was only one bottle of regular insulin available and no U500 insulin was available on the medication cart. The IJ was removed on [DATE] at 11:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. Review of the facility census dated [DATE] reflected there were 26 residents who resided on Hall 2 where LVN A, LVN B, and LVN C worked.

Based on interview and record review, the facility failed to develop and implement policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property for one (Resident #11) of 16 residents reviewed for neglect. 1. LVN A failed to take immediate action when she made a significant medication error occurred and she gave Resident #11 [MEDICATION NAME] 500 rather than his prescribed [MEDICATION NAME] 100. As a result of the error, Resident #11's blood sugar began to drop below the resident's normal range. 2. LVN A failed to transcribe and carry out the physician's orders [REDACTED].#11's physician of his drop in blood sugar level. 3. LVN B failed to obtain the physician's orders [REDACTED]. report. 4. LVN B and LVN C failed to carry out the physician's orders [REDACTED].#11, per physician's orders [REDACTED]. 5. LVN B and LVN C failed to notify Resident #11's physician when they were unable to stabilize his blood sugar, place an IV, and had to send the resident to the emergency room . 6. LVN A, LVN B and LVN C failed to notify the DON about the medication error and change of condition with Resident #11 until the resident could not be stabilized and needed to be sent to the emergency room . An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed the 26 residents who resided on Hall 2 where LVN A, B, and C worked at risk of having a serious medication error resulting in a serious injury and possibly death. Findings Included: Review of the Abuse and Neglect Prohibition policy revised on ,[DATE] reflected the following: Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. Review of the Medication Monitoring and Management policy, dated [DATE], reflected the following: F. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: 1. Requiring medication discontinuation or dose modification. Requiring hospitalization or extending a hospitalization . 2. Resulting in disability. 3. Requiring treatment with a prescription medication. 4. Resulting in cognitive deterioration or impairment. 5. Life threatening. 6. Resulting in death. G. The attending physician is notified promptly of any significant error or adverse consequence. H. The physician's orders [REDACTED]. 1. Review of Resident #11's face sheet dated [DATE] reflected Resident #11 was an [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] his BIMS score was 09 which indicated moderate cognitive impairment. Review of Resident #11's physician's orders [REDACTED]. [MEDICATION NAME] ,[DATE] Suspension 100 units/ml; Inject 15 units subcutaneously two times a day, which was ordered on [DATE]. If fasting blood sugar is less than 60 and resident is responsive, Give 6 Oz of med plus 2.0 and recheck blood glucose every 15 minutes until blood glucose is greater than 60. If glucose is still less than 60 after 30 minutes call MD (doctor) or send to ER (emergency room ), which was an active order since [DATE]. Review of the emergency department report dated [DATE] at 3:15 a.m. reflected the history of present illness as abnormal glucose due being given the wrong kind of insulin at the nursing home. Nursing home transferred him because they were unable to get IV access. At its maximum, the severity was described as moderate. Resident #11 was described as anxious and disoriented. Treatment included observation and management of blood glucose levels in the Intensive Care Unit from [DATE] to [DATE]. Interview with Resident #11 on [DATE] at 4:30 p.m. revealed the resident was oriented to person, place, and time. He remembered in the middle of last week, [DATE] through [DATE], LVN A had given him his usual insulin shot right before dinner. He stated he does not normally look at the insulin when they give it to him. He stated after she gave him the insulin, he started to feel dizzy and nauseous. He stated he felt like 'crap' for a couple of hours. He stated after a while, two nurses kept checking his blood sugar and giving him peanut butter crackers. He stated he started feeling worse and worse and stated going in and out of consciousness. He stated the night nurses tried to start an IV and could not get it in. He stated he was miserable and finally they sent him to the emergency room where he had to go to the ICU (Intensive Care Unit) to be monitored for a couple of days. He stated the nurses never told him what was going on, but he knew something was up. He stated the ER staff finally told him at the hospital that LVN A gave him the wrong type of insulin and that he got way more insulin than he was supposed to. He stated no one in the facility had yet to come and talk to him about the incident. Interview with LVN A on [DATE] at 3:12 p.m. revealed on [DATE] she gave Resident #11, 15 units of insulin around 4:30 p.m. She stated she was checking his blood sugar that night a few hours after dinner and noted it was low for Resident #11. She stated at that time, she realized she might have given the wrong insulin. She stated there are only two bottles of insulin on the medication cart. Resident #11 and another resident whose insulin is five times stronger than Resident #11's insulin. She stated she immediately called the physician around 9:00 p.m. who gave her an order to start an IV and monitor Resident #11's blood sugars. She stated she forgot to transcribe the order and did not start an IV or monitor Resident #11's blood sugar. She stated she did tell LVN B about the possible medication error and the physician's orders [REDACTED]. She stated she has plans to go back to work. Two attempts were made to contact LVN B via telephone on [DATE] and [DATE]. Review of LVN B's undated witness statement revealed the incident occurred on [DATE]. She stated LVN A was giving her report at the start of her shift and LVN A mentioned that she thought she gave a resident another resident's insulin. LVN A told her that she had called the doctor and the doctor had told her to give the resident something to eat, monitor the blood sugars every hour, and to start an IV if Resident #11's blood sugar continued to drop. Review of the physician's orders [REDACTED]. According to https://www.drugs.com/mtm/[MEDICATION NAME]-5-in-water-injection.html, obtained on [DATE], [MEDICATION NAME] 5% in water (D5W) in water is used to treat low blood sugar ([DIAGNOSES REDACTED]), insulin shock, or dehydration (fluid loss). [MEDICATION NAME] 5% in water is also given for nutritional support to patients who are unable to eat because of illness, injury, or other medical condition. Review of the DON's witness statement dated [DATE] reflected she received a call from LVN C at 2:30 a.m. asking if LVN A had called her about Resident #11's blood sugar issues. She told LVN C she had not been notified of any issues and LVN C told her that Resident #11 may have received concentrated insulin from another resident's vial and his blood sugar was still fluctuating and she and LVN B were unable to successfully get an IV started. The DON gave instructions at that time to send the resident to the emergency room to monitor more closely. Interview with Resident #11's physician on [DATE] at 1:32 p.m. revealed he received a phone call from LVN A on [DATE] around 8:00 p.m. He stated LVN A told him she might have given the wrong insulin to Resident #11, and might have given another resident's insulin (U500) which was five times stronger, at 4:30 p.m. that day. He stated he told LVN A to start giving him foods high in carbohydrates and to start an IV with D5W if his blood sugar continued to drop. He stated Resident #11's blood sugar is usually very stable (in the 100s) and it was out of character for his blood sugar to go below 100 and so he believed LVN A probably gave him the wrong insulin. He stated LVN A or any other staff never called him again about the issue, so he assumed they had followed his orders and Resident #11 was fine. He stated if Resident #11's blood sugar had gotten too low and they would have not sent him to the emergency room when they did, he could have gone into a diabetic coma and died . He also stated he has discussed with the facility numerous times about keeping the U500 insulin separate from regular insulin because of potential mix ups. Review of LVN B's nurse's note dated [DATE] revealed she took Resident #11's blood sugar at midnight and it was 67 mg/dL. LVN B retook his blood sugar at 1:00 a.m. and it was 53 mg/dL. LVN B remeasured Resident #11's blood sugar at 2:00 a.m. and it was 49 mg/dL. LVN B goes on to state Resident #11 was being fed peanut butter crackers, 3 cartons of Boost but sugar continued to fall. LVN B tried to start an IV but was unable to get in the vein. Call placed to DON and she stated to send resident out to hospital. LVN B requested an ambulance at 2:35 a.m. and they arrived at 2:40 a.m. EMT was able to start an IV and gave 50 ml of glucose. BS was 66 mg/dL when IV started and after administration of glucose it was 244 mg/dL as they put Resident #11 on stretcher to transport to hospital. Resident was alert but slower than usual upon discharge. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of the Nursing Home to Hospital Transfer form for Resident #11 dated [DATE] revealed Resident #11 was sent to the hospital on [DATE] at 2:40 a.m. Reasons for transfer stated, Patient given U500 insulin at 4:00 p.m. which is the wrong insulin. Interview with the DON on [DATE] at 3:30 p.m. revealed LVN B had called her around 2:30 a.m. on [DATE] to tell her LVN A might have given Resident #11 U500 insulin instead of regular insulin and that his blood sugar was continuing to drop. She told LVN B to send Resident #11 to the hospital. She stated she was not sure why the facility has not disciplined or terminated LVN A because she made a major medication error and did not inform her, the resident, did not follow the physician's orders [REDACTED].#11 when she realized she made a medication error. She stated LVN B and LVN C should have notified her when LVN A told them she might have made a medication error. She stated LVN B and LVN C should have followed the physician's orders [REDACTED]. She stated LVN B and LVN C had not been disciplined or had individual in-servicing after the medication error. She stated she was unable to help with most of the investigation because she was suspended depending on an investigation of another incident. Interview with the Administrator on [DATE] at 3:00 p.m. revealed he was made aware of the drug error on [DATE] at the standup meeting, but he was going to let the DON and other nurses handle the situation. He stated LVN A was currently suspended but he did not believe there was enough evidence to prove LVN A made the medication error since he could not measure each insulin bottle to see if LVN A gave the wrong insulin. He stated he was not a medical professional, so he was unsure what could have caused Resident #11's blood sugar to drop. He stated he had not told LVN A she was suspended because she came in on [DATE] to talk to another surveyor about another situation and was too upset afterwards and she left the building. He stated he had yet to tell her that she was suspended, because LVN A was involved in another incident during the same time of the medication error and she had left the facility after talking to an investigator and he was unable to catch her before she left the building. Review of the Medication Error Report signed by the administrator on [DATE] reflected on [DATE] at 4:30 p.m. LVN A was not sure if she gave Resident #11 U500 insulin by mistake. Outcome to resident was listed as resident sent to ER for evaluation. Measures taken to prevent the recurrence of similar errors included removing U500 insulin from the insulin drawer and requiring two nurses to administer the U500 insulin. Stated the physician was notified at 6:00 p.m. and the DON was notified on [DATE] at 2:30 a.m. An immediate jeopardy was identified on [DATE] at 10:35 a.m. The Administrator and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. The facility's Plan of Removal, accepted on [DATE] at 12:50 p.m. reflected: LVN A was suspended on Thursday [DATE] at 2:30 pm and has since been terminated on [DATE]. The following in services was started on Thursday [DATE] by the DON and ADON D and completed on [DATE]. No licensed nurse will be allowed to return to work until this education has been completed. Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] both LVN B and LVN C will be given 1:1 education regarding: Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.). Medication Administration (Medication administration according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines ( used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] the following in-services was started by the DON was completed [DATE] and no license nurse will be allowed to work until they have received this education. 18 of 23 license nurses have completed this education All education will have a post test completed to validate knowledge of staff training. This post test started on Friday [DATE] and will be completed on [DATE] as no nurse will be allowed to work until they complete the post test prior to starting the shift. Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.) Medication Administration (Medication administered according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] by the Administrator to all license nurses. 18 of 23 license nurses have completed this education. The remaining 5 nurses will have this education completed prior to returning to work. Physician Monitoring orders (to include how telephone orders can be received, how to transcribe order, following through with Physician orders) This education was started today by the DON and ADON D and will be completed today [DATE] and no nurse will be allowed to work until they have received this education. Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] and completed on [DATE] by the Administrator to all other staff in the facility. All staff will have this education completed prior to returning to work. The DON/ADON/Designee using the QAPI tool: Diabetic Insulin management tool will monitor every shift for the next 7 days validating nurses following physician orders [REDACTED]. The DON/ADON or designee will use the QAPI Acute Change in Condition tool to review all resident(s) with an acute change of condition to validate that assessment complete, family/resident was notified, the Physician was notified, following up completed until resolved. To verify the implementation of the plan of removal was in place, the following interviews, observations, and record reviews were completed. Review of the termination notice of LVN A was dated [DATE] and noted she was no longer employed at the facility. Review of all of the in-services on [DATE] reflected all of the licensed nurses had been in-serviced on immediate notification, transcribing physician's orders [REDACTED]. All of the licensed nurses had completed and passed a post test which went over all of the information covered in the in-services. Individual in-services with LVN B and LVN C was reviewed and revealed they received individual in-servicing over the insulin management process, immediate notification, transcribing physician's orders [REDACTED]. Interviews with LVN E, LVN F, LVN G, LVN H, LVN I, MDS Nurse J, and LVN K which represented staff across multiple shifts on [DATE] between 9:30 a.m. and 11:00 a.m. revealed they were all in-serviced over immediate notification, transcribing physician's orders [REDACTED]. All interviewed staff answered questions appropriately and there were no concerns noted. Observation of the Hall 200 Medication Cart on [DATE] at 9:20 a.m. revealed there was only one bottle of regular insulin available and no U500 insulin was available on the medication cart. The IJ was removed on [DATE] at 11:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. Review of the facility census dated [DATE] reflected there were 26 residents who resided on Hall 2 where LVN A, LVN B, and LVN C worked.

Based on interview and record review, the facility failed to ensure that residents were free of any significant medication errors for one (Resident #11) of 16 residents reviewed for medication errors. 1. LVN A failed to take immediate action when she made a significant medication error occurred and she gave Resident #11 [MEDICATION NAME] 500 rather than his prescribed [MEDICATION NAME] 100. As a result of the error, Resident #11's blood sugar began to drop below the resident's normal range. 2. LVN A, LVN B and LVN C failed to notify the DON about the medication error and change of condition with Resident #11 until the resident could not be stabilized and needed to be sent to the emergency room . An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. These failures placed the 26 residents who resided on Hall 2 where LVN A, B, and C worked at risk of having a serious medication error resulting in a serious injury and possibly death. Findings Included: 1. Review of Resident #11's face sheet dated [DATE] reflected Resident #11 was an [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] his BIMS score was 09 which indicated moderate cognitive impairment. Review of Resident #11's physician's orders [REDACTED]. [MEDICATION NAME] ,[DATE] Suspension 100 units/ml; Inject 15 units subcutaneously two times a day, which was ordered on [DATE]. If fasting blood sugar is less than 60 and resident is responsive, Give 6 Oz of med plus 2.0 and recheck blood glucose every 15 minutes until blood glucose is greater than 60. If glucose is still less than 60 after 30 minutes call MD (doctor) or send to ER (emergency room ), which was an active order since [DATE]. Review of the emergency department report dated [DATE] at 3:15 a.m. reflected the history of present illness as abnormal glucose due being given the wrong kind of insulin at the nursing home. Nursing home transferred him because they were unable to get IV access. At its maximum, the severity was described as moderate. Resident #11 was described as anxious and disoriented. Treatment included observation and management of blood glucose levels in the Intensive Care Unit from [DATE] to [DATE]. Interview with Resident #11 on [DATE] at 4:30 p.m. revealed the resident was oriented to person, place, and time. He remembered in the middle of last week, [DATE] through [DATE], LVN A had given him his usual insulin shot right before dinner. He stated he does not normally look at the insulin when they give it to him. He stated after she gave him the insulin, he started to feel dizzy and nauseous. He stated he felt like 'crap' for a couple of hours. He stated after a while, two nurses kept checking his blood sugar and giving him peanut butter crackers. He stated he started feeling worse and worse and stated going in and out of consciousness. He stated the night nurses tried to start an IV and could not get it in. He stated he was miserable and finally they sent him to the emergency room where he had to go to the ICU (Intensive Care Unit) to be monitored for a couple of days. He stated the nurses never told him what was going on, but he knew something was up. He stated the ER staff finally told him at the hospital that LVN A gave him the wrong type of insulin and that he got way more insulin than he was supposed to. He stated no one in the facility had yet to come and talk to him about the incident. Interview with LVN A on [DATE] at 3:12 p.m. revealed on [DATE] she gave Resident #11, 15 units of insulin around 4:30 p.m. She stated she was checking his blood sugar that night a few hours after dinner and noted it was low for Resident #11. She stated at that time, she realized she might have given the wrong insulin. She stated there are only two bottles of insulin on the medication cart. Resident #11 and another resident whose insulin is five times stronger than Resident #11's insulin. She stated she immediately called the physician around 9:00 p.m. who gave her an order to start an IV and monitor Resident #11's blood sugars. She stated she forgot to transcribe the order and did not start an IV or monitor Resident #11's blood sugar. She stated she did tell LVN B about the possible medication error and the physician's orders [REDACTED]. She stated she has plans to go back to work. Two attempts were made to contact LVN B via telephone on [DATE] and [DATE]. Review of LVN B's undated witness statement revealed the incident occurred on [DATE]. She stated LVN A was giving her report at the start of her shift and LVN A mentioned that she thought she gave a resident another resident's insulin. LVN A told her that she had called the doctor and the doctor had told her to give the resident something to eat, monitor the blood sugars every hour, and to start an IV if Resident #11's blood sugar continued to drop. Review of the physician's orders [REDACTED]. According to https://www.drugs.com/mtm/[MEDICATION NAME]-5-in-water-injection.html, obtained on [DATE], [MEDICATION NAME] 5% in water (D5W) in water is used to treat low blood sugar ([DIAGNOSES REDACTED]), insulin shock, or dehydration (fluid loss). [MEDICATION NAME] 5% in water is also given for nutritional support to patients who are unable to eat because of illness, injury, or other medical condition. Review of the DON's witness statement dated [DATE] reflected she received a call from LVN C at 2:30 a.m. asking if LVN A had called her about Resident #11's blood sugar issues. She told LVN C she had not been notified of any issues and LVN C told her that Resident #11 may have received concentrated insulin from another resident's vial and his blood sugar was still fluctuating and she and LVN B were unable to successfully get an IV started. The DON gave instructions at that time to send the resident to the emergency room to monitor more closely. Interview with Resident #11's physician on [DATE] at 1:32 p.m. revealed he received a phone call from LVN A on [DATE] around 8:00 p.m. He stated LVN A told him she might have given the wrong insulin to Resident #11, and might have given another resident's insulin (U500) which was five times stronger, at 4:30 p.m. that day. He stated he told LVN A to start giving him foods high in carbohydrates and to start an IV with D5W if his blood sugar continued to drop. He stated Resident #11's blood sugar is usually very stable (in the 100s) and it was out of character for his blood sugar to go below 100 and so he believed LVN A probably gave him the wrong insulin. He stated LVN A or any other staff never called him again about the issue, so he assumed they had followed his orders and Resident #11 was fine. He stated if Resident #11's blood sugar had gotten too low and they would have not sent him to the emergency room when they did, he could have gone into a diabetic coma and died . He also stated he has discussed with the facility numerous times about keeping the U500 insulin separate from regular insulin because of potential mix ups. Review of LVN B's nurse's note dated [DATE] revealed she took Resident #11's blood sugar at midnight and it was 67 mg/dL. LVN B retook his blood sugar at 1:00 a.m. and it was 53 mg/dL. LVN B remeasured Resident #11's blood sugar at 2:00 a.m. and it was 49 mg/dL. LVN B goes on to state Resident #11 was being fed peanut butter crackers, 3 cartons of Boost but sugar continued to fall. LVN B tried to start an IV but was unable to get in the vein. Call placed to DON and she stated to send resident out to hospital. LVN B requested an ambulance at 2:35 a.m. and they arrived at 2:40 a.m. EMT was able to start an IV and gave 50 ml of glucose. BS was 66 mg/dL when IV started and after administration of glucose it was 244 mg/dL as they put Resident #11 on stretcher to transport to hospital. Resident was alert but slower than usual upon discharge. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of the Nursing Home to Hospital Transfer form for Resident #11 dated [DATE] revealed Resident #11 was sent to the hospital on [DATE] at 2:40 a.m. Reasons for transfer stated, Patient given U500 insulin at 4:00 p.m. which is the wrong insulin. Interview with the DON on [DATE] at 3:30 p.m. revealed LVN B had called her around 2:30 a.m. on [DATE] to tell her LVN A might have given Resident #11 U500 insulin instead of regular insulin and that his blood sugar was continuing to drop. She told LVN B to send Resident #11 to the hospital. She stated she was not sure why the facility has not disciplined or terminated LVN A because she made a major medication error and did not inform her, the resident, did not follow the physician's orders [REDACTED].#11 when she realized she made a medication error. She stated LVN B and LVN C should have notified her when LVN A told them she might have made a medication error. She stated LVN B and LVN C should have followed the physician's orders [REDACTED]. She stated LVN B and LVN C had not been disciplined or had individual in-servicing after the medication error. She stated she was unable to help with most of the investigation because she was suspended depending on an investigation of another incident. Interview with the Administrator on [DATE] at 3:00 p.m. revealed he was made aware of the drug error on [DATE] at the standup meeting, but he was going to let the DON and other nurses handle the situation. He stated LVN A was currently suspended but he did not believe there was enough evidence to prove LVN A made the medication error since he could not measure each insulin bottle to see if LVN A gave the wrong insulin. He stated he was not a medical professional, so he was unsure what could have caused Resident #11's blood sugar to drop. He stated he had not told LVN A she was suspended because she came in on [DATE] to talk to another surveyor about another situation and was too upset afterwards and she left the building. He stated he had yet to tell her that she was suspended, because LVN A was involved in another incident during the same time of the medication error and she had left the facility after talking to an investigator and he was unable to catch her before she left the building. Review of the Medication Error Report signed by the administrator on [DATE] reflected on [DATE] at 4:30 p.m. LVN A was not sure if she gave Resident #11 U500 insulin by mistake. Outcome to resident was listed as resident sent to ER for evaluation. Measures taken to prevent the recurrence of similar errors included removing U500 insulin from the insulin drawer and requiring two nurses to administer the U500 insulin. Stated the physician was notified at 6:00 p.m. and the DON was notified on [DATE] at 2:30 a.m. Review of the Medication Monitoring and Management policy, dated [DATE], reflected the following: F. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: 1. Requiring medication discontinuation or dose modification. Requiring hospitalization or extending a hospitalization . 2. Resulting in disability. 3. Requiring treatment with a prescription medication. 4. Resulting in cognitive deterioration or impairment. 5. Life threatening. 6. Resulting in death. G. The attending physician is notified promptly of any significant error or adverse consequence. H. The physician's orders [REDACTED]. An immediate jeopardy was identified on [DATE] at 10:35 a.m. The Administrator and DON were informed of the immediate jeopardy at that time and a plan of removal was requested. The facility's Plan of Removal, accepted on [DATE] at 12:50 p.m. reflected: LVN A was suspended on Thursday [DATE] at 2:30 pm and has since been terminated on [DATE]. The following in services was started on Thursday [DATE] by the DON and ADON D and completed on [DATE]. No licensed nurse will be allowed to return to work until this education has been completed. Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] both LVN B and LVN C will be given 1:1 education regarding: Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.). Medication Administration (Medication administration according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines ( used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Immediate Notification (regarding notification of DON. This includes when the DON must be notified immediately) Recognizing Medication Errors (What to do if you suspect a medication error, the immediate action to be taken to keep the resident safe, notifying the physician, family or resident if applicable, completing medication error report, monitoring of the resident for 72 hours) Transcribing or noting or discontinuing orders ( Guideline for when a physician's orders [REDACTED]. On [DATE] the following in-services was started by the DON was completed [DATE] and no license nurse will be allowed to work until they have received this education. 18 of 23 license nurses have completed this education All education will have a post test completed to validate knowledge of staff training. This post test started on Friday [DATE] and will be completed on [DATE] as no nurse will be allowed to work until they complete the post test prior to starting the shift. Insulin Management Process (following Physician's individual Insulin orders for each resident, monitoring for S/S of hyper [DIAGNOSES REDACTED], notifying Physician if BS outside of parameters, how to response for BS too high or too low based on parameters.) Medication Administration (Medication administered according to guidelines and physician orders, verifying accuracy by checking the medication with the MAR indicated [REDACTED]., circling medications not administered and documenting why, notify physician if medication not available, review MAR for completion of Administration prior to end of shift, complete a Medication Error Report if discrepancies, shift report) Notification in change of condition (Interact IV system is use when a change in a resident's condition is recognized, the assessment of the resident is completed by the nurse based upon the change, the S Bar is used as a way to communicate change to the Physician. The Change in condition/Interact IV is used as a guide on when to communicate acute changes in status to MD, NP, and / responsible party based on the S/S resident is displaying using immediate, and non immediate notification. Resident monitored for at least 72 hours. Clinical documentation guidelines used as a guide on how to document the resident health status and treatment, using legible clear concise entries, factual, objective information that pertains to the care, correct date, time, signature by narrator, how to document late entries, clarifying entries, omissions, error corrections, adding an addendum entry.) Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] by the Administrator to all license nurses. 18 of 23 license nurses have completed this education. The remaining 5 nurses will have this education completed prior to returning to work. Physician Monitoring orders (to include how telephone orders can be received, how to transcribe order, following through with Physician orders) This education was started today by the DON and ADON D and will be completed today [DATE] and no nurse will be allowed to work until they have received this education. Education on Abuse/Neglect/Misappropriation including post test to validate knowledge, was started on [DATE] and completed on [DATE] by the Administrator to all other staff in the facility. All staff will have this education completed prior to returning to work. The DON/ADON/Designee using the QAPI tool: Diabetic Insulin management tool will monitor every shift for the next 7 days validating nurses following physician orders [REDACTED]. The DON/ADON or designee will use the QAPI Acute Change in Condition tool to review all resident(s) with an acute change of condition to validate that assessment complete, family/resident was notified, the Physician was notified, following up completed until resolved. To verify the implementation of the plan of removal was in place, the following interviews, observations, and record reviews were completed. Review of the termination notice of LVN A was dated [DATE] and noted she was no longer employed at the facility. Review of all of the in-services on [DATE] reflected all of the licensed nurses had been in-serviced on immediate notification, transcribing physician's orders [REDACTED]. All of the licensed nurses had completed and passed a post test which went over all of the information covered in the in-services. Individual in-services with LVN B and LVN C was reviewed and revealed they received individual in-servicing over the insulin management process, immediate notification, transcribing physician's orders [REDACTED]. Interviews with LVN E, LVN F, LVN G, LVN H, LVN I, MDS Nurse J, and LVN K which represented staff across multiple shifts on [DATE] between 9:30 a.m. and 11:00 a.m. revealed they were all in-serviced over immediate notification, transcribing physician's orders [REDACTED]. All interviewed staff answered questions appropriately and there were no concerns noted. Observation of the Hall 200 Medication Cart on [DATE] at 9:20 a.m. revealed there was only one bottle of regular insulin available and no U500 insulin was available on the medication cart. The IJ was removed on [DATE] at 11:00 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. Review of the facility census dated [DATE] reflected there were 26 residents who resided on Hall 2 where LVN A, LVN B, and LVN C worked.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for seven (Residents #2, #3, #4, #5, one unidentified resident, #7 and #10) of seven residents reviewed for abuse/neglect. 1. On [DATE] Resident #1 ran his hands up Resident #2's, a totally dependent resident, clothing. His care plan was updated, and he was started on [MEDICATION NAME] (antidepressant). The facility failed to monitor the resident's location and redirect the resident based on his behaviors, per the plan of care. Another incident occurred in the Assisted Dining Room with Resident #2. Resident #1 had his hand under her pant leg and his hand was up to the resident's crotch and the resident was hollering. CNA K reported the incident and provided a written statement regarding the incident to the facility. The facility failed to investigate the incident, failed to complete an Incident Report, failed to report the incident to the Administrator, and Resident #1's care plan was not updated. On [DATE] Resident #1 rubbed Resident #3's back and put his hands on her buttocks without her consent. Staff were informed, including the SW, and completed an Incident report, but failed to conduct an investigation. Resident #1's care plan was updated to provide diversional activities, evaluate and monitor the effectiveness of the [MEDICATION NAME]. The facility failed to provide Resident #1 with appropriate diversional activities. On [DATE] Resident #1 attempted to fondle an unidentified female resident in the front lobby, which was reported to LVN I by the NP. LVN I removed Resident #1 from the situation and took him to smoke. LVN I failed to complete an Incident Report and no investigation was conducted. Resident #1's care plan was not updated. On [DATE], Resident #1 entered Resident #4's room without consent and cornered the resident in her bathroom, which startled her. She reported the incident, but the incident was not documented, not investigated, no Incident report completed and no care plan update was made. Resident #1's medication was adjusted, but the facility failed to adequately monitor his behavior. On [DATE] Resident #1 got into bed with a totally dependent resident, Resident #5, opened her brief , exposed her, spread her legs and buried his hand between her legs. The facility transferred Resident #1. These failures resulted in Residents #2 and #5 being sexually assaulted by Resident #1 and Residents #3 and #4 being fearful of being assaulted by Resident #1. 2. Facility staff failed to implement interventions to protect Resident #10, who went out on pass every weekend with a family member and returned with suspicious bruising and who alleged the bruising was from her family member "hitting" her. 3. Facility staff failed to implement interventions, such as diversional activities, for Resident #7, who had known wandering behaviors including wandering in other resident's rooms, to keep her from entering Residents #6's, #8's, #9's, and #12's rooms and to protect her from potential abuse by other residents. Residents #6, #8, #9 and #12 all requested the staff keep Resident #7 out of their rooms. These failures resulted in Resident #6 shooting Resident #7 in the face with water from a water gun and Resident #8 threatening to break Resident #7's fingers if staff did not keep Resident #7 away from her (Resident #8's) dining table. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the facility's 91 residents, including Residents #3, #4, #5, #7, and #10, by placing them at risk for sexual abuse, physical abuse, and verbal abuse resulting in Depression, Anxiety, Anger, feelings of insecurity and physical injuries. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. 1. Resident #1's Admission Record, dated [DATE], reflected the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male, and included [DIAGNOSES REDACTED]. The resident was assessed as having short and long-term memory problems and being severely impaired in his ability for daily decision making with disorganized thinking patterns. He was assessed as having verbal behavioral symptoms directed at others occurring one to three days each week which would significantly intrude on the privacy or activity of others. Resident #1's MDS assessment reflected he had wandering behaviors which occurred four to six times weekly, but less than daily and the wandering significantly intruded on the privacy or activities of others. Resident #1's Care Plan dated [DATE] reflected no problem was identified with resident behaviors. The resident was care planned for Depression and included: " ...2) Encourage resident to be involved in activities of choice and preference ... 4) Give meds per order - monitor labs - report abn.s (abnormals) to M.D. Dr. ___ to monitor. " a) Review of Resident #2's closed record revealed she died on [DATE]. Review of Resident #2's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's MDS assessment dated [DATE] reflected she was [AGE] years-old and admitted to the facility on [DATE]. The resident had severe cognitive impairment and was totally dependent on staff for ADLs. On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. She stated Resident #1 was in a wheelchair, he did not walk but was mobile in his wheelchair without assistance. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications, she revealed he was reported to be more compliant on the 3:00 PM to 11:00 PM shift with his medications. She stated, "The night nurse can get him to take his meds. So he is not missing all of them." When asked about Resident #1's inappropriate behavior, LVN I revealed she was aware of an incident when Resident #1 tried to run his hands up Resident #2's dress. When queried further, LVN I explained Resident #2 was in the lobby in a Geri chair. She stated someone stopped him and moved him away from the other resident. She also revealed Resident #1 used vulgar language and would curse at the caregivers. She stated he was "easily directed out of trouble." Review of the Incident and Accident Reports for [DATE] revealed an incident where Resident #1 "was caught" running his hand up the leg and dress of Resident #2. Resident #1's care plan dated [DATE] (the day after the incident) reflected inappropriate sexual behavior was identified on [DATE] and the goal was for the resident to show no inappropriate behaviors over the next 90 days. The approaches were: " 1) psych services as needed Receiving psych serv/ Dr. ___notified by SSD 2) adm (administer) medications as ordered & eval (evaluate) effectiveness 3) monitor resident location/activities 4) redirect when behavior occurs 5) [MEDICATION NAME] per orders - Monitor for side effects/monitor effectiveness of med (medication) 6) Q (every) 15 min (minutes) a Q 30 min checks re: location and activity." Review of Resident #1's SS Notes dated [DATE] (the day after the incident) revealed "was informed that resident exhibited some inappropriate behaviors towards a female resident that was in Geri-recliner yesterday ...Resident (was) counseled to keep hands to himself whether it was a resident or a staff member. Resident denies doing anything wrong or remembering incident...Resident will be monitored to his whereabouts and his surroundings. Resident could not remember any inappropriate behaviors." Interview with the SW on [DATE] at 3:48 PM about Resident #1's SS Notes dated [DATE] revealed she could not recall the nature of the "inappropriate touching" of the resident in the Geri-recliner. She revealed she talked with the nurses and informed the nurses to watch him and called the psychiatrist. She did not recall if she had talked to other residents to see if it was happening to them. Review of Resident #1's Psychiatric Follow-up by NP dated [DATE] revealed she identified Resident #1's [DIAGNOSES REDACTED]. Staff reports 'he is very touchy/feely where he shouldn't. Tried to put his hand down another resident (brief). Staff stopped him before he could." She revealed "Pt (patient) does not remember any inappropriate sexual behavior. We discussed boundaries." NP assessed Resident #1 as being alert with impaired cognition and memory. Review of Resident #1's SS notes dated [DATE] revealed, "(MD V)'s assistant here to see resident for follow up and noted that resident exhibits inappropriate sexual behaviors, had his hands on several other resident/staff." MD V's response to the behaviors was to start the resident on [MEDICATION NAME]. Interview with the SW on [DATE] at 3:48 PM revealed she was unable to identify the "other residents" who were referred to in the [DATE] SS Note. When asked if she called the doctor after reading the psychiatrist note to see if they had additional information or could identify the residents, she stated, "I doubt it. I don't usually see the psych notes for a while." Review of the DADS computer reporting database revealed the [DATE] incident between Resident #1 and Resident #2 was reported to DADS and investigated. b) During an interview on [DATE] at 3:30 PM, CNA K revealed she had worked with Resident #1. She stated he was very mobile and could "get around." She stated because of his behaviors "we had to watch him all the time to keep him away from the women." She stated she stepped out of the assisted dining room "for a moment and when I came back, he had his hand up her (Resident #2's) pant leg all the way to her crotch and she was hollering out the best she could but she could not stop him." She was unable to give the date of the incident. In an effort to clarify the incident, CNA K stated this was a separate incident from the time Resident #1 did the same thing to Resident #2 in the lobby. She stated she reported the incident and wrote a statement about the incident. Consequently, Resident #1 was banned from the dining room for a period of time. When asked if she thought Resident #1 knew what he was doing, she stated, "Yes! He would laugh and make comments when we told him not to do that." CNA K revealed other residents were afraid of Resident #1 because he would go into their rooms and put his hands on their legs. The other residents would holler and throw things at him when he went into their rooms. CNA K was asked if the residents were in danger because of Resident #1. She replied, "Yes, I believe they were ...I would call it sexual assault." During an interview on [DATE] at 9:25 AM, Resident #14 revealed she knew Resident #1 and described him as "scary." She stated she was told to "watch out" for him from the time she came into the facility. She stated she was not afraid of him because she would "knock the hell out of him" if he touched her. She stated the resident "did not have any God-damn sense ...He shouldn't have been here." Review of the facility's Incident and Accident Reports from August until current revealed no Incident Reports about Resident #1 sexually abusing a resident in the assisted dining room. No investigation was conducted for the incident. Review of the NN, the SW notes dated [DATE] - [DATE] for Resident #1 revealed no documentation of an incident of Resident #1 sexually assaulting a female resident in a Geri Chair in he Assisted Dining room. Interview with DON on [DATE] at 10:45 AM about incident with Resident #1 in the Assisted Dining room revealed she was not aware of the incident occurring. She had not seen an incident report or was aware Resident #1 had run his hand up the leg of a female resident into her crotch during dinner. Interview with ADM on [DATE] at 10:30 AM revealed she was unaware of the Incident with Resident #1 running his hand up the pant leg of a female resident in the Assisted dining room. She was informed a report was made by CNA K but no Incident Report was located. She revealed she would go check. No documentation of the incident was provided to the investigator. Review of Resident #1's care plan revealed no review or update. Resident #1's behavior continued as follows: Review of Resident #1's SS Notes dated [DATE] revealed, "resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care ... Resident is assisted into his wheelchair daily and he wanders about the facility ...." Interview with the SW on [DATE] at 3:48 PM regarding her Note dated [DATE] revealed the "inappropriate behaviors" were sexual in nature. When asked why it was not addressed as sexual, the SW stated, "I guess I should have put that in." Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "nurse reports resident doing well on current medications. No inappropriate behavior reported. Self propels about (the) facility. We increased [MEDICATION NAME] at last visit with good effect." Resident #1 was assessed as being alert with impaired cognition and memory with a [DIAGNOSES REDACTED]." c) Review of Resident #3's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's SS Note "late entry [DATE]" revealed, "informed that resident went into (Resident #3's) room and was touching her and was asked to leave and reported to charge nurse. SSD talked with resident and he denies inappropriate behaviors. SSD spoke with (Resident #3) and she stated he came into her room and they were talking and then he started rubbing her back. She asked him to stop. At first he didn't and she asked him again to stop or she was going to hit him and he did stop. Her roommate stated she was going to call for the nurse and he left the room... stated shortly afterwards, they could hear someone down the hall say for him to get out of their room." Interview with the SW on [DATE] at 1:35 PM regarding her Note dated [DATE] for Resident #1 and Resident #3 revealed she reported the incident to the ADON. She revealed Resident #1 was someone you could set boundaries with "to a point." She stated they would have to keep reminding him of those boundaries. The SW stated, "You just could not say it once." Review of Resident #1's Nurse's Notes dated [DATE] revealed an "incident" with an unidentified resident at 1:15 PM. The Notes reflected Resident #1's location should be checked and documented every 15 minutes. The Notes reflected the monitoring started on [DATE] through [DATE] when it was discontinued. The Nurse's Notes reflected an inservice was held for staff on [DATE] regarding Abuse and recorded the names of the staff attending the inservice. No specifics of the incident with Resident #1 were documented in his Nurse's Notes. Review of Resident #1's Care Plan revealed "inappropriate behaviors involving other residents" was identified on [DATE]. Approaches included: "1. Frequently remind resident to not touch other residents. 2. Provide diversional activities for resident. 3. Redirect as indicated. 4. Continue psych services. 5. Administer [MEDICATION NAME] as ordered and evaluate effectiveness monitor for side effects with meds and notify physician if present. 6. Give positive reinforcement for appropriate behaviors. 7. Location/activity surveillance as indicated." On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications she revealed, LVN I reported the resident was more compliant on the 3:00 PM to 11:00 PM shift with his medications. " The night nurse can get him to take his meds. So he is not missing all of them. " Review of the [DATE] CHR Behavior Detail Report (the CNA Kiosk care tracker) revealed Resident #1 was documented as being socially inappropriate twice, verbally abusive twice, physically abusive once, and with wandering behaviors one day, for a total of six days. Resident #1's behavior was documented as " socially inappropriate " on [DATE]. No other behaviors were documented in [DATE]. Review of Resident #1's Psychiatric follow-up dated [DATE] by MD V revealed "the resident continues to have inappropriate behavior with staff (sexually). Pt (patient) does not believe he had any behavioral issues. Doesn't recall anything." MD V listed Resident #1's abnormal involuntary movements as "Acts like going to grab me - somewhat inappropriate." The [DIAGNOSES REDACTED]." Review of an Incident report dated [DATE] reflected Resident #1 "entered another residents room & put his hands on her back and buttocks. Witnessed by room-mate." The staff interviewed the roommate, but no additional investigation was conducted. d) Review of Resident #1's Nurse's Notes dated [DATE] by LVN I revealed the NP "came into the facility and told this nurse that resident was up in lobby trying to fondle another res (resident). (She) went to the lobby to remove res from situation both res arguing back and forth, When this nurse got to res other res stated, you better get him out of here before I hurt him. Took res to patio for smoke break at this time." Interview with LVN I on [DATE] at 10:57 AM revealed she made the Nurse's Notes entry dated [DATE], and she recalled the incident. She revealed she did not witness the incident; it was reported to her by the NP. She also revealed she could not recall the female resident Resident #1 was assaulting. She stated the incident occurred in the front lobby of the facility and Resident #1 was attempting to fondle the female resident. She revealed she did not complete an Incident Report about it, because she was not a witness. When asked if she was knowledgeable about the prior incident on [DATE] in the front lobby with Resident #1 and Resident #2, she revealed she was. She stated she was also aware of the incident with Resident # 1 and Resident #3. She stated, "I did not really think about it. If I thought about it I would have reported it." She stated, "Sometimes you get to the point where you have been here too long that some behaviors become so normal that you don't really notice. It is like you cannot see the trees for the forest. But I am going to work on that a little bit better." Review of the Care Plans for Resident #1 revealed no updates following the [DATE] incident in the front lobby. No Incident Report was located for the [DATE] incident in the front lobby and no investigation was located. Resident #1's behaviors continued as demonstrated by Resident #1's Psychiatric follow-up note dated [DATE] by the NP. The NP revealed, "In common area today arguing with another resident. Increased anxiety and anger. Redirected with resistance.... Increase in sexually inappropriate behaviors, verbal/grabbing aids. 'Are you gonna get in bed with me?'" Resident #1's [DIAGNOSES REDACTED]." Review of Resident #1's SW's Quarterly Assessment notes, dated [DATE] revealed, "was informed that resident exhibits increasing behaviors such as almost got into a fight in the dining room, was observed picking up food with hands and then throwing it on his tray. Also several employees have reported resident exhibiting inappropriate sexual behaviors around him the last couple of days ... Noted that resident was in common living area today, arguing with another resident, increased anxiety and anger ....Increased sexually inappropriate behaviors, verbal/grabbing aides." The physician increased the resident's [MEDICATION NAME]. Interview with the SW on [DATE] at 1:38 PM regarding her Note dated [DATE] revealed they were trying to protect the residents from Resident #1 by keeping him in public, common areas to watch him, having "psych" to talk with him and adjusting his medications. Interview on 07/ ,[DATE] at 11:45 AM with Activity Director revealed she had worked in the facility the last three years and she knew Resident #1. She revealed Resident #1 liked to work a bead puzzle and liked to go outside. She stated she had never been asked to create a list of diversion activities for staff to use on Resident #1. She stated she had never been asked to talk with the CNAs or give them any instructions on diversional activities for Resident #1. Interview on [DATE] at 10:57 with LVN L revealed she has not been given a list of diversional activities to try with Resident #1. She had instructed the CNAs working with Resident #1 to bring him to the front lobby by the nursing station when he was a problem. Interview on [DATE] at 4:15 PM with CNA N revealed when she had problems with Resident #1 she would tell the charge nurse. When asked if was given any help from nursing when she reported he behavior she revealed " A couple of times but generally they just said to chart it. " CNA N was asked if behaviors ocurred, when they always documented on the kiosk. She responded, "No." She explained that Resident #1's behaviors were mostly all the time; they just were not always documented. When asked if she had been given any diversional activities to try with Resident she revealed " No. I just generally brought him up to the front lobby. " Her only instructions were to " take him to get coffee, put him in the front lobby by the TV and just try to occupy him. " Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate three days, verbally abusive one day, physically abusive one day, wandering behaviors three days, and resisting care one day for a total of nine days. No behavior was documented for [DATE], the date of the incident in the front lobby with Resident #1 trying to fondle an unknown resident. Review of the clinical record, NN and the SW notes did not reveal any monitoring of Resident #1 had occurred after the [DATE] incident in the front lobby. e) Resident #1 ' s behaviors continued as follows: Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "tried to run over a nurse with w/c (wheelchair). Resident is now wandering into other rooms. Nurse is very concerned about residents change in behavior. The resident [DIAGNOSES REDACTED]." Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate six days, verbally abusive two days, physically abusive three days, wandering behaviors two days, and resisting care one day for a total of 14 documented behaviors. No behaviors were noted for [DATE], the date Resident #1 tried to run over a nurse with a wheelchair. Review of Resident #1's current Care Plan per the DON revealed, "Inappropriate sexual behaviors" dated [DATE]. The Approaches included: "1. Psych services as needed. 2. Adm (administer) medications as need. 3. Monitor where abouts of res (resident). 4. Redirect when behavior happens and document. 5. Provide diversional activities." The Care Plan reflected it was reviewed on [DATE], [DATE], and [DATE] and that the problem was " ongoing. " The Care Plan did not identify any " diversional activities " for the staff to use with Resident #1. The Care Plan reflected the notation "(MD V) to see on round." dated [DATE]. The Care Plan did not reflect any other notations. Review of the Incident Reports revealed no incident report or investigation had been conducted following the [DATE] incident with Resident #1 trying to run over a nurse with his wheel chair. Review of Resident #1's SW's Quarterly assessment dated [DATE] revealed, "Resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care." Interview with the SW on [DATE] at 1:38 PM regarding her SS Note dated [DATE] for Resident #1 revealed they had updated the care plan for the Resident #1 in January. She stated, "What more could we have done?" She revealed the care plan was updated for inappropriate behavior, they were monitoring the resident for his location and MD V was involved in his care. She revealed she had not witnessed these incidents. The SW stated she had seen him reach out and touch an arm or a leg in the "knee area." She stated, "If my mother was here and he had been targeting my mother and they couldn't keep him away from her, I would move her." When asked if she saw his behavior as escalating in frequency, she revealed it would vary with medication adjustment. She stated she was not aware Resident #1 was refusing his medications and stated, "I don't think I recall being told that." Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate six days, physically abusive two days, wandering behaviors one day, and resisting care four days, for a total of 13 days. There was no other documentation of the Resident #1 ' s behaviors. Review of the February 2012 CHR Behavior Detail Report revealed Resident #1 had documented behaviors as socially inappropriate one time, verbally abusive three times for a total of four days. There was no other documentation of the Resident #1 ' s behaviors. Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was socially inappropriate one day, verbally abusive one day, physical abusive one day, resisting care two days, for a total of four days. . There was no other documentation of the Resident #1 ' s behaviors. Review of Resident #1's SS notes dated [DATE] revealed the resident had been combative, cursing and hitting at CNAs. The SS notes indicated the physician ordered [MEDICATION NAME] (antianxiety). f) Review of Resident #1's SS Notes dated [DATE] revealed, "Resident threw a cup of coffee on aide this morning. Resident also seen going into other resident's room and was redirected out of their room. Resident is invasive to other residents privacy and staff reports that the startles others when he comes up behind then and tried to touch/grab at them. Resident had been counseled several times for inappropriate behavior but he mumbles and asks if it is smoke time." Review of Resident #4's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on [DATE] at 3:45 p.m. with the DON revealed on or around [DATE] Resident #1 had gone into Resident #4's room when the resident was in her room and closed the door. Review of Resident #1's SS Notes dated [DATE] revealed, "that resident went into another resident's room and startled her, she was in (the) bathroom and she could not get out and had to pull (the) call light to get him out of her room." The note indicated the physician changed Resident #1's antipsychotic medication to [MEDICATION NAME]. Review of Resident #1's Nurse's Notes dated [DATE] at 3:00 PM revealed, "resident placed on one hour surveillance monitoring due to wandering into other residents rooms as well as making inappropriate sexual comments and gestures toward other residents and staff. Nursing staff notified." Resident #1's Nurse's Note dated [DATE] at 3:20 PM reflected "resident overheard telling another male resident that he was going to 'stir up some[***]' Residents were separated." Interview with CNA F on [DATE] at 11:30 PM revealed he had worked at the facility for two years and knew Resident #1. He revealed Resident #1 was verbally, sexually suggestive, but he did not know of the resident being aggressive. He stated Resident #1 did wander into other residents' rooms and close the door, due to his confusion. During an interview on [DATE] at 1:25 PM, NA D described Resident #1's behaviors as "nasty." She stated Resident #1 had grabbed her breast. She stated at another time he had asked her to lay (sic) with him. Another time, he put his hands on her buttocks. When asked if she reported these behaviors to anyone, she revealed she could not remember. She stated she knew she should have, but "I am not sure if I did or not." She stated redirecting Resident #1 was difficult; the resident had to be told several times before he would respond. She also revealed Resident #1 would "always go into other residents' rooms. He would lay (sic) down in their bed." She stated documentation of all residents' behaviors was done on the CNA Care Tracker kiosk. At that time Resident #1's [DATE] Behavior Detailed Report was reviewed with NA D and revealed NA D had not documented any behaviors for Resident #1. NA D confirmed she had failed to document Resident #1's behaviors. On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She stated Resident #1 was in a wheelchair; he did not walk but was mobile in his wheelchair without assistance. LVN I stated he wandered the building, in and out of rooms. She stated when Resident #1 went into other residents' rooms, sometimes the staff would have to go and get him. She stated, "You had to watch him constantly" because of his wandering. LVN I stated the other residents did not want him in their rooms and sometimes would threaten to hurt him to get him to leave. During an interview with CNA J on [DATE] at 11:35 AM, CNA J was queried about Resident #1's behavior with other residents. CNA J revealed, "There were a couple of residents who already knew who he was and knew to stay away from him." CNA J stated other residents were afraid of him because of the "touching" and wandering into their rooms. She stated on several occasions, Resident #1 wandered into residents' rooms and startled them by waking them up. When asked if Resident #1 knew what he was doing when he exhibited the inappropriate behavior, CNA J stated, "Some of the time, yes. Some of the time, I don't know." When asked if Resident #1 knew what he was doing was wrong, she stated, "Yes." No diversional activities were noted to be offered to Resident #1 in the SW notes, or the NN or the CHR Behavioral Detail Report even though behaviors were noted on [DATE], [DATE] and [DATE]. Review of Resident #1's Nurse's Note dated [DATE] at 3:00 PM revealed Resident #1 was found in Hall Three (Resident's room was located on Hall one), and was redirected to Hall One. The Notes reflected, "very disruptive and doesn't follow commands or direction well due to

Based on observation, interview and record review, the facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and pscyhosocial well-being of for eight (Residents #1, #2, #3, #4, #5, one unidentified resident, #7 and #10) of eight residents reviewed for abuse and neglect. 1) The ADM failed to implement and follow the facility's Abuse and Neglect P/P. Staff failed to report Resident #1's sexual assault of Resident #2 to the facility Administrator. Staff failed to report Resident #1's sexual assault of an unidentified resident to the facility Administrator. Staff failed to report Resident #1's inappropriate behavior with Residents #3 and #4. The Administrator failed to thoroughly investigate Resident #1's sexual assault of Resident #5. On [DATE] Resident #1 he ran his hands up Resident #2's, a totally dependent resident, clothing. His care plan was updated, and he was started on [MEDICATION NAME] (antidepressant). The facility failed to monitor the resident's location and redirect the resident based on his behaviors, per the plan of care. Another incident occurred in the Assisted Dining Room with Resident #2. Resident #1 had his hand under her pant leg and his hand was up to the resident's crotch and the resident was hollering. CNA K reported the incident and provided a written statement regarding the incident to the facility. The facility failed to investigate the incident, failed to complete an Incident Report, failed to report the incident to the Administrator, and Resident #1's care plan was not updated. On [DATE] Resident #1 rubbed Resident #3's back and put his hands on her buttocks without her consent. Staff were informed, including the SW, and completed an Incident report, but failed to conduct an investigation. Resident #1's care plan was updated to provide diversional activities, evaluate and monitor the effectiveness of the [MEDICATION NAME]. The facility failed to provide Resident #1 with appropriate diversional activities. On [DATE] Resident #1 attempted to fondle an unidentified female resident in the front lobby, which was reported to LVN I by the NP. LVN I removed Resident #1 from the situation and took him to smoke. LVN I failed to complete an Incident Report and no investigation was conducted. Resident #1's care plan was not updated. On [DATE], Resident #1 entered Resident #4's room without consent and cornered the resident in her bathroom, which startled her. She reported the incident, but the incident was not documented, not investigated, no Incident report completed and no care plan update was made. Resident #1's medication was adjusted, but the facility failed to adequately monitor his behavior. On [DATE] Resident #1 got into bed with a totally dependent resident, Resident #5, opened her brief , exposed her, spread her legs and buried his hand between her legs. The facility transferred Resident #1. These failures resulted in Residents #2 and #5 being sexually assaulted by Resident #1 and Residents #3 and #4 being fearful of being assaulted by Resident #1. 2) The DON failed to supervise the nurses to ensure they were conducting skin assessments on Resident #10 prior to and after her visits out on pass with her family to check for bruising of unknown origin. She failed to train nursing staff regarding caring for residents with behaviors. These failures resulted in Resident #10 continuing to suffer bruising of unknown origin. 3. Staff failed to report Resident #6 shooting Resident #7 with a water gun to the Administrator. Staff also failed to report Resident #8's threat to break Resident #7's finger. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the facility's 91 residents by placing them at risk for abuse, neglect, mistreatment, fear, anxiety, Depression, physical injuries, and a decreased quality of life. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. 1. Resident #1's Admission Record, dated [DATE], reflected the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male, and included [DIAGNOSES REDACTED]. The resident was assessed as having short and long-term memory problems and being severely impaired in his ability for daily decision making with disorganized thinking patterns. He was assessed as having verbal behavioral symptoms directed at others occurring one to three days each week which would significantly intrude on the privacy or activity of others. Resident #1's MDS assessment reflected he had wandering behaviors which occurred four to six times weekly, but less than daily and the wandering significantly intruded on the privacy or activities of others. Resident #1's Care Plan dated [DATE] reflected no problem was identified with resident behaviors. The resident was care planned for Depression and included: " ...2) Encourage resident to be involved in activities of choice and preference ... 4) Give meds per order - monitor labs - report abn.s (abnormals) to M.D. Dr. ___ to monitor. " a) Review of Resident #2's closed record revealed she died on [DATE]. Review of Resident #2's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's MDS assessment dated [DATE] reflected she was [AGE] years-old and admitted to the facility on [DATE]. The resident had severe cognitive impairment and was totally dependent on staff for ADLs. On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. She stated Resident #1 was in a wheelchair, he did not walk but was mobile in his wheelchair without assistance. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications, she revealed he was reported to be more compliant on the 3:00 PM to 11:00 PM shift with his medications. She stated, "The night nurse can get him to take his meds. So he is not missing all of them." When asked about Resident #1's inappropriate behavior, LVN I revealed she was aware of an incident when Resident #1 tried to run his hands up Resident #2's dress. When queried further, LVN I explained Resident #2 was in the lobby in a Geri chair. She stated someone stopped him and moved him away from the other resident. She also revealed Resident #1 used vulgar language and would curse at the caregivers. She stated he was "easily directed out of trouble." Resident #1's care plan dated [DATE] (the day after the incident) reflected inappropriate sexual behavior was identified on [DATE] and the goal was for the resident to show no inappropriate behaviors over the next 90 days. The approaches were: " 1) psych services as needed Receiving psych serv/ Dr. ___notified by SSD 2) adm (administer) medications as ordered & eval (evaluate) effectiveness 3) monitor resident location/activities 4) redirect when behavior occurs 5) [MEDICATION NAME] per orders - Monitor for side effects/monitor effectiveness of med (medication) 6) Q (every) 15 min (minutes) a Q 30 min checks re: location and activity." b) During an interview on [DATE] at 3:30 PM, CNA K revealed she had worked with Resident #1. She stated he was very mobile and could "get around." She stated because of his behaviors "we had to watch him all the time to keep him away from the women." She stated she stepped out of the assisted dining room "for a moment and when I came back, he had his hand up her (Resident #2's) pant leg all the way to her crotch and she was hollering out the best she could but she could not stop him." She was unable to give the date of the incident. In an effort to clarify the incident, CNA K stated this was a separate incident from the time Resident #1 did the same thing to Resident #2 in the lobby. She stated she reported the incident and wrote a statement about the incident. Consequently, Resident #1 was banned from the dining room for a period of time. When asked if she thought Resident #1 knew what he was doing, she stated, "Yes! He would laugh and make comments when we told him not to do that." CNA K revealed other residents were afraid of Resident #1 because he would go into their rooms and put his hands on their legs. The other residents would holler and throw things at him when he went into their rooms. CNA K was asked if the residents were in danger because of Resident #1. She replied, "Yes, I believe they were ...I would call it sexual assault." During an interview on [DATE] at 9:25 AM, Resident #14 revealed she knew Resident #1 and described him as "scary." She stated she was told to "watch out" for him from the time she came into the facility. She stated she was not afraid of him because she would "knock the hell out of him" if he touched her. She stated the resident "did not have any God-damn sense ...He shouldn't have been here." Review of the facility's Incident and Accident Reports from August until current revealed no Incident Reports about Resident #1 sexually abusing a resident in the assisted dining room. No investigation was conducted for the incident. Review of the NN, the SW notes dated [DATE] - [DATE] for Resident #1 revealed no documentation of an incident of Resident #1 sexually assaulting a female resident in a Geri Chair in he Assisted Dining room. Interview with DON on [DATE] at 10:45 AM about incident with Resident #1 in the Assisted Dining room revealed she was not aware of the incident occurring. She had not seen an incident report or was aware Resident #1 had run his hand up the leg of a female resident into her crotch during dinner. Interview with ADM on [DATE] at 10:30 AM revealed she was unaware of the Incident with Resident #1 running his hand up the pant leg of a female resident in the Assisted dining room. She was informed a report was made by CNA K but no Incident Report was located. She revealed she would go check. No documentation of the incident was provided to the investigator. Review of Resident #1's care plan revealed no review or update. Resident #1's behavior continued as follows: Review of Resident #1's SS Notes dated [DATE] revealed, "resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care ... Resident is assisted into his wheelchair daily and he wanders about the facility ...." Interview with the SW on [DATE] at 3:48 PM regarding her Note dated [DATE] revealed the "inappropriate behaviors" were sexual in nature. When asked why it was not addressed as sexual, the SW stated, "I guess I should have put that in." Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "nurse reports resident doing well on current medications. No inappropriate behavior reported. Self propels about (the) facility. We increased [MEDICATION NAME] at last visit with good effect." Resident #1 was assessed as being alert with impaired cognition and memory with a [DIAGNOSES REDACTED]." c) Review of Resident #3's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's SS Note "late entry [DATE]" revealed, "informed that resident went into (Resident #3's) room and was touching her and was asked to leave and reported to charge nurse. SSD talked with resident and he denies inappropriate behaviors. SSD spoke with (Resident #3) and she stated he came into her room and they were talking and then he started rubbing her back. She asked him to stop. At first he didn't and she asked him again to stop or she was going to hit him and he did stop. Her roommate stated she was going to call for the nurse and he left the room... stated shortly afterwards, they could hear someone down the hall say for him to get out of their room." Interview with the SW on [DATE] at 1:35 PM regarding her Note dated [DATE] for Resident #1 and Resident #3 revealed she reported the incident to the ADON. She revealed Resident #1 was someone you could set boundaries with "to a point." She stated they would have to keep reminding him of those boundaries. The SW stated, "You just could not say it once." Review of Resident #1's Nurse's Notes dated [DATE] revealed an "incident" with an unidentified resident at 1:15 PM. The Notes reflected Resident #1's location should be checked and documented every 15 minutes. The Notes reflected the monitoring started on [DATE] through [DATE] when it was discontinued. The Nurse's Notes reflected an inservice was held for staff on [DATE] regarding Abuse and recorded the names of the staff attending the inservice. No specifics of the incident with Resident #1 were documented in his Nurse's Notes. Review of Resident #1's Care Plan revealed "inappropriate behaviors involving other residents" was identified on [DATE]. Approaches included: "1. Frequently remind resident to not touch other residents. 2. Provide diversional activities for resident. 3. Redirect as indicated. 4. Continue psych services. 5. Administer [MEDICATION NAME] as ordered and evaluate effectiveness monitor for side effects with meds and notify physician if present. 6. Give positive reinforcement for appropriate behaviors. 7. Location/activity surveillance as indicated." On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications she revealed, LVN I reported the resident was more compliant on the 3:00 PM to 11:00 PM shift with his medications. " The night nurse can get him to take his meds. So he is not missing all of them. " Review of Resident #1's Psychiatric follow-up dated [DATE] by MD V revealed "the resident continues to have inappropriate behavior with staff (sexually). Pt (patient) does not believe he had any behavioral issues. Doesn't recall anything." MD V listed Resident #1's abnormal involuntary movements as "Acts like going to grab me - somewhat inappropriate." The [DIAGNOSES REDACTED]." Review of an Incident report dated [DATE] reflected Resident #1 "entered another residents room & put his hands on her back and buttocks. Witnessed by room-mate." The staff interviewed the roommate, but no additional investigation was conducted. d) Review of Resident #1's Nurse's Notes dated [DATE] by LVN I revealed the NP "came into the facility and told this nurse that resident was up in lobby trying to fondle another res (resident). (She) went to the lobby to remove res from situation both res arguing back and forth, When this nurse got to res other res stated, you better get him out of here before I hurt him. Took res to patio for smoke break at this time." Interview with LVN I on [DATE] at 10:57 AM revealed she made the Nurse's Notes entry dated [DATE], and she recalled the incident. She revealed she did not witness the incident; it was reported to her by the NP. She also revealed she could not recall the female resident Resident #1 was assaulting. She stated the incident occurred in the front lobby of the facility and Resident #1 was attempting to fondle the female resident. She revealed she did not complete an Incident Report about it, because she was not a witness. When asked if she was knowledgeable about the prior incident on [DATE] in the front lobby with Resident #1 and Resident #2, she revealed she was. She stated she was also aware of the incident with Resident # 1 and Resident #3. She stated, "I did not really think about it. If I thought about it I would have reported it." She stated, "Sometimes you get to the point where you have been here too long that some behaviors become so normal that you don't really notice. It is like you cannot see the trees for the forest. But I am going to work on that a little bit better." Review of the Care Plans for Resident #1 revealed no updates following the [DATE] incident in the front lobby. No Incident Report was located for the [DATE] incident in the front lobby and no investigation was located. Resident #1's behaviors continued as demonstrated by Resident #1's Psychiatric follow-up note dated [DATE] by the NP. The NP revealed, "In common area today arguing with another resident. Increased anxiety and anger. Redirected with resistance.... Increase in sexually inappropriate behaviors, verbal/grabbing aids. 'Are you gonna get in bed with me?'" Resident #1's [DIAGNOSES REDACTED]." Review of Resident #1's SW's Quarterly Assessment notes, dated [DATE] revealed, "was informed that resident exhibits increasing behaviors such as almost got into a fight in the dining room, was observed picking up food with hands and then throwing it on his tray. Also several employees have reported resident exhibiting inappropriate sexual behaviors around him the last couple of days ... Noted that resident was in common living area today, arguing with another resident, increased anxiety and anger ....Increased sexually inappropriate behaviors, verbal/grabbing aides." The physician increased the resident's [MEDICATION NAME]. Interview with the SW on [DATE] at 1:38 PM regarding her Note dated [DATE] revealed they were trying to protect the residents from Resident #1 by keeping him in public, common areas to watch him, having "psych" to talk with him and adjusting his medications. Interview on 07/ ,[DATE] at 11:45 AM with Activity Director revealed she had worked in the facility the last three years and she knew Resident #1. She revealed Resident #1 liked to work a bead puzzle and liked to go outside. She stated she had never been asked to create a list of diversion activities for staff to use on Resident #1. She stated she had never been asked to talk with the CNAs or give them any instructions on diversional activities for Resident #1. Interview on [DATE] at 10:57 with LVN L revealed she has not been given a list of diversional activities to try with Resident #1. She had instructed the CNAs working with Resident #1 to bring him to the front lobby by the nursing station when he was a problem. Interview on [DATE] at 4:15 PM with CNA N revealed when she had problems with Resident #1 she would tell the charge nurse. When asked if was given any help from nursing when she reported he behavior she revealed " A couple of times but generally they just said to chart it. " CNA N was asked if behaviors ocurred, when they always documented on the kiosk. She responded, "No." She explained that Resident #1's behaviors were mostly all the time; they just were not always documented. When asked if she had been given any diversional activities to try with Resident she revealed " No. I just generally brought him up to the front lobby. " Her only instructions were to " take him to get coffee, put him in the front lobby by the TV and just try to occupy him. " Review of the clinical record, NN and the SW notes did not reveal any monitoring of Resident #1 had occurred after the [DATE] incident in the front lobby. e) Resident #1 ' s behaviors continued as follows: Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "tried to run over a nurse with w/c (wheelchair). Resident is now wandering into other rooms. Nurse is very concerned about residents change in behavior. The resident [DIAGNOSES REDACTED]." Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate six days, verbally abusive two days, physically abusive three days, wandering behaviors two days, and resisting care one day for a total of 14 documented behaviors. No behaviors were noted for [DATE], the date Resident #1 tried to run over a nurse with a wheelchair. Review of Resident #1's current Care Plan per the DON revealed, "Inappropriate sexual behaviors" dated [DATE]. The Approaches included: "1. Psych services as needed. 2. Adm (administer) medications as need. 3. Monitor where abouts of res (resident). 4. Redirect when behavior happens and document. 5. Provide diversional activities." The Care Plan reflected it was reviewed on [DATE], [DATE], and [DATE] and that the problem was " ongoing. " The Care Plan did not identify any " diversional activities " for the staff to use with Resident #1. The Care Plan reflected the notation "(MD V) to see on round." dated [DATE]. The Care Plan did not reflect any other notations. Review of the Incident Reports revealed no incident report or investigation had been conducted following the [DATE] incident with Resident #1 trying to run over a nurse with his wheel chair. Interview with the SW on [DATE] at 1:38 PM regarding her SS Note dated [DATE] for Resident #1 revealed they had updated the care plan for the Resident #1 in January. She stated, "What more could we have done?" She revealed the care plan was updated for inappropriate behavior, they were monitoring the resident for his location and MD V was involved in his care. She revealed she had not witnessed these incidents. The SW stated she had seen him reach out and touch an arm or a leg in the "knee area." She stated, "If my mother was here and he had been targeting my mother and they couldn't keep him away from her, I would move her." When asked if she saw his behavior as escalating in frequency, she revealed it would vary with medication adjustment. She stated she was not aware Resident #1 was refusing his medications and stated, "I don't think I recall being told that." Review of Resident #1's SS notes dated [DATE] revealed the resident had been combative, cursing and hitting at CNAs. The SS notes indicated the physician ordered [MEDICATION NAME] (antianxiety). f) Review of Resident #1's SS Notes dated [DATE] revealed, "Resident threw a cup of coffee on aide this morning. Resident also seen going into other resident's room and was redirected out of their room. Resident is invasive to other residents privacy and staff reports that the startles others when he comes up behind then and tried to touch/grab at them. Resident had been counseled several times for inappropriate behavior but he mumbles and asks if it is smoke time." Review of Resident #4's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on [DATE] at 3:45 p.m. with the DON revealed on or around [DATE] Resident #1 had gone into Resident #4's room when the resident was in her room and closed the door. Review of Resident #1's SS Notes dated [DATE] revealed, "that resident went into another resident's room and startled her, she was in (the) bathroom and she could not get out and had to pull (the) call light to get him out of her room." The note indicated the physician changed Resident #1's antipsychotic medication to [MEDICATION NAME]. Review of Resident #1's Nurse's Notes dated [DATE] at 3:00 PM revealed, "resident placed on one hour surveillance monitoring due to wandering into other residents rooms as well as making inappropriate sexual comments and gestures toward other residents and staff. Nursing staff notified." Resident #1's Nurse's Note dated [DATE] at 3:20 PM reflected "resident overheard telling another male resident that he was going to 'stir up some[***]' Residents were separated." Interview with CNA F on [DATE] at 11:30 PM revealed he had worked at the facility for two years and knew Resident #1. He revealed Resident #1 was verbally, sexually suggestive, but he did not know of the resident being aggressive. He stated Resident #1 did wander into other residents' rooms and close the door, due to his confusion. During an interview on [DATE] at 1:25 PM, NA D described Resident #1's behaviors as "nasty." She stated Resident #1 had grabbed her breast. She stated at another time he had asked her to lay (sic) with him. Another time, he put his hands on her buttocks. When asked if she reported these behaviors to anyone, she revealed she could not remember. She stated she knew she should have, but "I am not sure if I did or not." She stated redirecting Resident #1 was difficult; the resident had to be told several times before he would respond. She also revealed Resident #1 would "always go into other residents' rooms. He would lay (sic) down in their bed." She stated documentation of all residents' behaviors was done on the CNA Care Tracker kiosk. At that time Resident #1's [DATE] Behavior Detailed Report was reviewed with NA D and revealed NA D had not documented any behaviors for Resident #1. NA D confirmed she had failed to document Resident #1's behaviors. On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She stated Resident #1 was in a wheelchair; he did not walk but was mobile in his wheelchair without assistance. LVN I stated he wandered the building, in and out of rooms. She stated when Resident #1 went into other residents' rooms, sometimes the staff would have to go and get him. She stated, "You had to watch him constantly" because of his wandering. LVN I stated the other residents did not want him in their rooms and sometimes would threaten to hurt him to get him to leave. During an interview with CNA J on [DATE] at 11:35 AM, CNA J was queried about Resident #1's behavior with other residents. CNA J revealed, "There were a couple of residents who already knew who he was and knew to stay away from him." CNA J stated other residents were afraid of him because of the "touching" and wandering into their rooms. She stated on several occasions, Resident #1 wandered into residents' rooms and startled them by waking them up. When asked if Resident #1 knew what he was doing when he exhibited the inappropriate behavior, CNA J stated, "Some of the time, yes. Some of the time, I don't know." When asked if Resident #1 knew what he was doing was wrong, she stated, "Yes." No diversional activities were noted to be offered to Resident #1 in the SW notes, or the NN or the CHR Behavioral Detail Report even though behaviors were noted on [DATE], [DATE] and [DATE]. Review of Resident #1's Nurse's Note dated [DATE] at 3:00 PM revealed Resident #1 was found in Hall Three (Resident's room was located on Hall one), and was redirected to Hall One. The Notes reflected, "very disruptive and doesn't follow commands or direction well due to decreased cognitive status." Review of the facility's Incident and Accident Reports from [DATE] until current revealed no Incident Reports involving Resident #1. Review of the Residents Care Plan revealed no additions to the Care Plan were noted after the [DATE] incident with Resident #4. Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was verbally abusive two days, wandering four days, socially inappropriate two days, for a total of eight days of the month. No wandering behaviors were noted on [DATE] (the date of the incident with Resident #4). Review of the most recent Care Plan for Resident #1 revealed no additions to the care plan after the [DATE] incident of cornering Resident #4 in her bathroom and continued wandering behaviors. No diversional activities were listed on the care plan for the staff to use with Resident #1. Resident #1's Nurse's Note dated [DATE] at 2:00 AM reflected, "Occ (occasional) sexual advances toward staff." Resident #1's Nurse's Note dated [DATE] at 1:55 AM reflected, "Very occ sexual advances toward staff at times." Resident #1's Nurse's Note dated [DATE] at 12:35 AM reflected, " ...calls staff 'baby cakes' occasionally." Review of Resident #1's closed clinical record revealed a 15 Minute Surveillance Log dated [DATE] with documentation of every 15 minutes checks conducted beginning at 3:00 PM that day and they were discontinued on [DATE] at 10:00 PM. Review of the facility's Incident and Accident Reports from [DATE] until current revealed no Incident Reports involving Resident #1. Resident #1's Nurse's Notes dated [DATE] did not reflect the reason the Surveillance Log was initiated. Interview on [DATE] at 3:15 PM with LVN I revealed she remembered the Surveillance Log was completed for Resident #1 for [DATE] through [DATE], but she did not recall the events that triggered the Surveillance Log. g) Review of Resident #5's MDS assessment dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was unable to participate in the cognitive assessment and was assessed as being rarely/never being able to make herself understood and being severely impaired in cognitive skills for daily decision making. Resident #5's MDS assessment reflected she required extensive assistance in transfers and required extensive assistance in bed mobility, dressing, eating and personal hygiene. Observation of Resident #5 on [DATE] at 9:22 AM revealed an elderly female lying in bed, non-responsive to verbal stimulation. Her eyes were closed and she was scratching continuously at her right cheek with her right hand. The facility's Provider Investigation Report dated [DATE] provided by the ADM reflected an allegation of abuse was investigated involving Resident #1 and Resident #5. The report reflected Resident #1 was found by CNA G "sitting on the side of (Resident #5's) bed with his hand down her brief." Resident #1 was immediately removed and placed on one-to-one monitoring. The Provider Investigation Report reflected Resident #5 was assessed, did not have any injuries, and was transferred to a psychiatric facility. Included with the Provider's Investigation Report was a handwritten report of seven residents' responses to the question, "Are you bothered by wandering residents and have you noticed any inappropriate behaviors?" All responded no, except for two residents who identified one wandering resident, but not Resident #1. Also with the Investigation Report was a typed summary of the incident signed by the ADM. The summary reflected an inservice was provided on [DATE] and all staff members who did not attend that inservice, one would be provided. Review of the Provider Investigation Report and attached documents revealed no witness statements or employee statements. Interview with CNA F on [DATE] at 11:30 PM revealed he had worked at the facility for two years and knew Resident #1. He revealed Resident #1

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for seven (Resident #2, #3, #4, #5, one unidentified resident, #7 and #10) of seven residents reviewed for abuse/neglect and six (Admissions Coordinator, CNA A, CNA B, LVN C, NA D, CNA E) of seven employees reviewed for mistreatment, neglect,and abuse prevention. The facility failed to ensure: 1. Staff failed to report Resident #1's sexual assault of Resident #2 to the facility Administrator. Staff failed to report Resident #1's sexual assault of an unidentified resident to the facility Administrator. Staff failed to report Resident #1's inappropriate behavior with Residents #3 and #4. The Administrator failed to thoroughly investigate Resident #1's sexual assault of Resident #5. These failures resulted in Residents #3 and #4 being afraid of Resident #1. 2. The Administrator and DON failed to thoroughly investigate Resident #10's bruising of unknown source and to investigate the resident's allegation that she was being hit by a family member. These failures resulted in Resident #10 continuing to suffer bruising of unknown origin. 3. Staff failed to report Resident #6 shooting Resident #7 with a water gun to the Administrator. Staff also failed to report Resident #8's threat to break Resident #7's finger. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. 4. The facility failed to check the EMR for LVN C prior to hiring her for 26 days. 5. The facility failed to conduct criminal background checks prior to employment for: the Admissions Coordinator, CNA A, CNA B, NA D and CNA E. These failures could affect the facility's 91 residents by placing them at risk for abuse, neglect, mistreatment, fear, anxiety, Depression, physical injuries, and a decreased quality of life. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. 1. The facility's Abuse Prohibition Policy and Procedure, reviewed and revised February 2012 and provided as current reflected: "Residents have the right to be free from abuse...The following procedures will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents ...family members or legal guardians, friends, or other individuals. The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services (if appropriate) will be notified in accordance with federal and state law... Abuse* - Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly thorugh words or physical action which causes or could cause mental or physical injury or harm or death to a resident..."Sexual Abuse"* - Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault... Neglect* - A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident... Injuries of Unknown Source - an injury is classified as an "unknown source" when the source of the injury was not witnessed or cannot be explained by any other person or the resident involved and the injury itself is suspicious in nature due to its extent or location, or a number of injuries are noted at a particular point in time or the incidence of injuries over time is noted...Prevention of Abuse ... A committee...meet, as needed, to: Identify, correct and intervene in situations in which abuse, neglect...is more likely to occur. This includes an analysis of ...The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring resident while giving care...The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff...The facilities (sic) interdisciplinary team in conjunction with the facilities (sic) administrative team will: Identify residents whose personal histories render them at risk for abusing other residents. Will (sic) develop intervention strategies to prevent occurrences. Will (sic) monitor these residents for changes that would trigger abusive behavior. And will re-assess interventions at a minimum during quarterly care planning conference and/or as needed; based on the individuals response to interventions...Identification: The facility will be proactive in identifying events and occurrences that may contribute to abuse or neglect: A. Through Resident Council, Care Plan Conferences, Family Conferences and/or Staff Meetings, residents families and staff will be educated and encouraged to report concerns, incidents and grievances without fear of retaliation. B. Review Incident Reports and complete an Investigation Report to determine if such things as suspicious bruising of residents have occurred or if there are patterns or trends of incidents or occurrences that may constitute abuse. Determine if the direction of the investigation is appropriate...Investigation: A. The facility must have evidence that all violations, including allegations, are thoroughly investigated...B. The results of the investigation must be reported to the Administrator and to other officials in accordance with state law (including the State survey and certification agency) within 5 working days of the incident...Reporting and Response to Alleged Incidents...All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall re reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON... The nurse must document all incidents of alleged abuse/neglect on the Incident Report and on the 24-hour report...G. The Administrator or designated representative will immediately begin an investigation and follow the State Guidelines for reporting incidents and accidents...." 2. Resident #1's Admission Record, dated [DATE], reflected the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male, and included [DIAGNOSES REDACTED]. The resident was assessed as having short and long-term memory problems and being severely impaired in his ability for daily decision making with disorganized thinking patterns. He was assessed as having verbal behavioral symptoms directed at others occurring one to three days each week which would significantly intrude on the privacy or activity of others. Resident #1's MDS assessment reflected he had wandering behaviors which occurred four to six times weekly, but less than daily and the wandering significantly intruded on the privacy or activities of others. Resident #1's Care Plan dated [DATE] reflected no problem was identified with resident behaviors. The resident was care planned for Depression and included: " ...2) Encourage resident to be involved in activities of choice and preference ... 4) Give meds per order - monitor labs - report abn.s (abnormals) to M.D. Dr. ___ to monitor. " a) Review of Resident #2's closed record revealed she died on [DATE]. Review of Resident #2's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's MDS assessment dated [DATE] reflected she was [AGE] years-old and admitted to the facility on [DATE]. The resident had severe cognitive impairment and was totally dependent on staff for ADLs. On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. She stated Resident #1 was in a wheelchair, he did not walk but was mobile in his wheelchair without assistance. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications, she revealed he was reported to be more compliant on the 3:00 PM to 11:00 PM shift with his medications. She stated, "The night nurse can get him to take his meds. So he is not missing all of them." When asked about Resident #1's inappropriate behavior, LVN I revealed she was aware of an incident when Resident #1 tried to run his hands up Resident #2's dress. When queried further, LVN I explained Resident #2 was in the lobby in a Geri chair. She stated someone stopped him and moved him away from the other resident. She also revealed Resident #1 used vulgar language and would curse at the caregivers. She stated he was "easily directed out of trouble." Review of the Incident and Accident Reports for [DATE] revealed an incident where Resident #1 "was caught" running his hand up the leg and dress of Resident #2. Resident #1's care plan dated [DATE] (the day after the incident) reflected inappropriate sexual behavior was identified on [DATE] and the goal was for the resident to show no inappropriate behaviors over the next 90 days. The approaches were: " 1) psych services as needed Receiving psych serv/ Dr. ___notified by SSD 2) adm (administer) medications as ordered & eval (evaluate) effectiveness 3) monitor resident location/activities 4) redirect when behavior occurs 5) [MEDICATION NAME] per orders - Monitor for side effects/monitor effectiveness of med (medication) 6) Q (every) 15 min (minutes) a Q 30 min checks re: location and activity." Review of Resident #1's SS Notes dated [DATE] (the day after the incident) revealed "was informed that resident exhibited some inappropriate behaviors towards a female resident that was in Geri-recliner yesterday ...Resident (was) counseled to keep hands to himself whether it was a resident or a staff member. Resident denies doing anything wrong or remembering incident...Resident will be monitored to his whereabouts and his surroundings. Resident could not remember any inappropriate behaviors." Interview with the SW on [DATE] at 3:48 PM about Resident #1's SS Notes dated [DATE] revealed she could not recall the nature of the "inappropriate touching" of the resident in the Geri-recliner. She revealed she talked with the nurses and informed the nurses to watch him and called the psychiatrist. She did not recall if she had talked to other residents to see if it was happening to them. Review of Resident #1's Psychiatric Follow-up by NP dated [DATE] revealed she identified Resident #1's [DIAGNOSES REDACTED]. Staff reports 'he is very touchy/feely where he shouldn't. Tried to put his hand down another resident (brief). Staff stopped him before he could." She revealed "Pt (patient) does not remember any inappropriate sexual behavior. We discussed boundaries." NP assessed Resident #1 as being alert with impaired cognition and memory. Review of Resident #1's SS notes dated [DATE] revealed, "(MD V)'s assistant here to see resident for follow up and noted that resident exhibits inappropriate sexual behaviors, had his hands on several other resident/staff." MD V's response to the behaviors was to start the resident on [MEDICATION NAME]. Interview with the SW on [DATE] at 3:48 PM revealed she was unable to identify the "other residents" who were referred to in the [DATE] SS Note. When asked if she called the doctor after reading the psychiatrist note to see if they had additional information or could identify the residents, she stated, "I doubt it. I don't usually see the psych notes for a while." Review of the DADS computer reporting database revealed the [DATE] incident between Resident #1 and Resident #2 was reported to DADS and investigated. b) During an interview on [DATE] at 3:30 PM, CNA K revealed she had worked with Resident #1. She stated he was very mobile and could "get around." She stated because of his behaviors "we had to watch him all the time to keep him away from the women." She stated she stepped out of the assisted dining room "for a moment and when I came back, he had his hand up her (Resident #2's) pant leg all the way to her crotch and she was hollering out the best she could but she could not stop him." She was unable to give the date of the incident. In an effort to clarify the incident, CNA K stated this was a separate incident from the time Resident #1 did the same thing to Resident #2 in the lobby. She stated she reported the incident and wrote a statement about the incident. Consequently, Resident #1 was banned from the dining room for a period of time. When asked if she thought Resident #1 knew what he was doing, she stated, "Yes! He would laugh and make comments when we told him not to do that." CNA K revealed other residents were afraid of Resident #1 because he would go into their rooms and put his hands on their legs. The other residents would holler and throw things at him when he went into their rooms. CNA K was asked if the residents were in danger because of Resident #1. She replied, "Yes, I believe they were ...I would call it sexual assault." During an interview on [DATE] at 9:25 AM, Resident #14 revealed she knew Resident #1 and described him as "scary." She stated she was told to "watch out" for him from the time she came into the facility. She stated she was not afraid of him because she would "knock the hell out of him" if he touched her. She stated the resident "did not have any God-damn sense ...He shouldn't have been here." Review of the facility's Incident and Accident Reports from August until current revealed no Incident Reports about Resident #1 sexually abusing a resident in the assisted dining room. No investigation was conducted for the incident. Review of the NN, the SW notes dated [DATE] - [DATE] for Resident #1 revealed no documentation of an incident of Resident #1 sexually assaulting a female resident in a Geri Chair in he Assisted Dining room. Interview with DON on [DATE] at 10:45 AM about incident with Resident #1 in the Assisted Dining room revealed she was not aware of the incident occurring. She had not seen an incident report or was aware Resident #1 had run his hand up the leg of a female resident into her crotch during dinner. Interview with ADM on [DATE] at 10:30 AM revealed she was unaware of the Incident with Resident #1 running his hand up the pant leg of a female resident in the Assisted dining room. She was informed a report was made by CNA K but no Incident Report was located. She revealed she would go check. No documentation of the incident was provided to the investigator. Review of Resident #1's care plan revealed no review or update. Resident #1's behavior continued as follows: Review of Resident #1's SS Notes dated [DATE] revealed, "resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care ... Resident is assisted into his wheelchair daily and he wanders about the facility ...." Interview with the SW on [DATE] at 3:48 PM regarding her Note dated [DATE] revealed the "inappropriate behaviors" were sexual in nature. When asked why it was not addressed as sexual, the SW stated, "I guess I should have put that in." Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "nurse reports resident doing well on current medications. No inappropriate behavior reported. Self propels about (the) facility. We increased [MEDICATION NAME] at last visit with good effect." Resident #1 was assessed as being alert with impaired cognition and memory with a [DIAGNOSES REDACTED]." c) Review of Resident #3's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's SS Note "late entry [DATE]" revealed, "informed that resident went into (Resident #3's) room and was touching her and was asked to leave and reported to charge nurse. SSD talked with resident and he denies inappropriate behaviors. SSD spoke with (Resident #3) and she stated he came into her room and they were talking and then he started rubbing her back. She asked him to stop. At first he didn't and she asked him again to stop or she was going to hit him and he did stop. Her roommate stated she was going to call for the nurse and he left the room... stated shortly afterwards, they could hear someone down the hall say for him to get out of their room." Interview with the SW on [DATE] at 1:35 PM regarding her Note dated [DATE] for Resident #1 and Resident #3 revealed she reported the incident to the ADON. She revealed Resident #1 was someone you could set boundaries with "to a point." She stated they would have to keep reminding him of those boundaries. The SW stated, "You just could not say it once." Review of Resident #1's Nurse's Notes dated [DATE] revealed an "incident" with an unidentified resident at 1:15 PM. The Notes reflected Resident #1's location should be checked and documented every 15 minutes. The Notes reflected the monitoring started on [DATE] through [DATE] when it was discontinued. The Nurse's Notes reflected an inservice was held for staff on [DATE] regarding Abuse and recorded the names of the staff attending the inservice. No specifics of the incident with Resident #1 were documented in his Nurse's Notes. Review of Resident #1's Care Plan revealed "inappropriate behaviors involving other residents" was identified on [DATE]. Approaches included: "1. Frequently remind resident to not touch other residents. 2. Provide diversional activities for resident. 3. Redirect as indicated. 4. Continue psych services. 5. Administer [MEDICATION NAME] as ordered and evaluate effectiveness monitor for side effects with meds and notify physician if present. 6. Give positive reinforcement for appropriate behaviors. 7. Location/activity surveillance as indicated." On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications she revealed, LVN I reported the resident was more compliant on the 3:00 PM to 11:00 PM shift with his medications. " The night nurse can get him to take his meds. So he is not missing all of them. " Review of the [DATE] CHR Behavior Detail Report (the CNA Kiosk care tracker) revealed Resident #1 was documented as being socially inappropriate twice, verbally abusive twice, physically abusive once, and with wandering behaviors one day, for a total of six days. Resident #1's behavior was documented as " socially inappropriate " on [DATE]. No other behaviors were documented in [DATE]. Review of Resident #1's Psychiatric follow-up dated [DATE] by MD V revealed "the resident continues to have inappropriate behavior with staff (sexually). Pt (patient) does not believe he had any behavioral issues. Doesn't recall anything." MD V listed Resident #1's abnormal involuntary movements as "Acts like going to grab me - somewhat inappropriate." The [DIAGNOSES REDACTED]." Review of an Incident report dated [DATE] reflected Resident #1 "entered another residents room & put his hands on her back and buttocks. Witnessed by room-mate." The staff interviewed the roommate, but no additional investigation was conducted. d) Review of Resident #1's Nurse's Notes dated [DATE] by LVN I revealed the NP "came into the facility and told this nurse that resident was up in lobby trying to fondle another res (resident). (She) went to the lobby to remove res from situation both res arguing back and forth, When this nurse got to res other res stated, you better get him out of here before I hurt him. Took res to patio for smoke break at this time." Interview with LVN I on [DATE] at 10:57 AM revealed she made the Nurse's Notes entry dated [DATE], and she recalled the incident. She revealed she did not witness the incident; it was reported to her by the NP. She also revealed she could not recall the female resident Resident #1 was assaulting. She stated the incident occurred in the front lobby of the facility and Resident #1 was attempting to fondle the female resident. She revealed she did not complete an Incident Report about it, because she was not a witness. When asked if she was knowledgeable about the prior incident on [DATE] in the front lobby with Resident #1 and Resident #2, she revealed she was. She stated she was also aware of the incident with Resident # 1 and Resident #3. She stated, "I did not really think about it. If I thought about it I would have reported it." She stated, "Sometimes you get to the point where you have been here too long that some behaviors become so normal that you don't really notice. It is like you cannot see the trees for the forest. But I am going to work on that a little bit better." Review of the Care Plans for Resident #1 revealed no updates following the [DATE] incident in the front lobby. No Incident Report was located for the [DATE] incident in the front lobby and no investigation was located. Resident #1's behaviors continued as demonstrated by Resident #1's Psychiatric follow-up note dated [DATE] by the NP. The NP revealed, "In common area today arguing with another resident. Increased anxiety and anger. Redirected with resistance.... Increase in sexually inappropriate behaviors, verbal/grabbing aids. 'Are you gonna get in bed with me?'" Resident #1's [DIAGNOSES REDACTED]." Review of Resident #1's SW's Quarterly Assessment notes, dated [DATE] revealed, "was informed that resident exhibits increasing behaviors such as almost got into a fight in the dining room, was observed picking up food with hands and then throwing it on his tray. Also several employees have reported resident exhibiting inappropriate sexual behaviors around him the last couple of days ... Noted that resident was in common living area today, arguing with another resident, increased anxiety and anger ....Increased sexually inappropriate behaviors, verbal/grabbing aides." The physician increased the resident's [MEDICATION NAME]. Interview with the SW on [DATE] at 1:38 PM regarding her Note dated [DATE] revealed they were trying to protect the residents from Resident #1 by keeping him in public, common areas to watch him, having "psych" to talk with him and adjusting his medications. Interview on 07/ ,[DATE] at 11:45 AM with Activity Director revealed she had worked in the facility the last three years and she knew Resident #1. She revealed Resident #1 liked to work a bead puzzle and liked to go outside. She stated she had never been asked to create a list of diversion activities for staff to use on Resident #1. She stated she had never been asked to talk with the CNAs or give them any instructions on diversional activities for Resident #1. Interview on [DATE] at 10:57 with LVN L revealed she has not been given a list of diversional activities to try with Resident #1. She had instructed the CNAs working with Resident #1 to bring him to the front lobby by the nursing station when he was a problem. Interview on [DATE] at 4:15 PM with CNA N revealed when she had problems with Resident #1 she would tell the charge nurse. When asked if was given any help from nursing when she reported he behavior she revealed " A couple of times but generally they just said to chart it. " CNA N was asked if behaviors ocurred, when they always documented on the kiosk. She responded, "No." She explained that Resident #1's behaviors were mostly all the time; they just were not always documented. When asked if she had been given any diversional activities to try with Resident she revealed " No. I just generally brought him up to the front lobby. " Her only instructions were to " take him to get coffee, put him in the front lobby by the TV and just try to occupy him. " Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate three days, verbally abusive one day, physically abusive one day, wandering behaviors three days, and resisting care one day for a total of nine days. No behavior was documented for [DATE], the date of the incident in the front lobby with Resident #1 trying to fondle an unknown resident. Review of the clinical record, NN and the SW notes did not reveal any monitoring of Resident #1 had occurred after the [DATE] incident in the front lobby. e) Resident #1 ' s behaviors continued as follows: Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "tried to run over a nurse with w/c (wheelchair). Resident is now wandering into other rooms. Nurse is very concerned about residents change in behavior. The resident [DIAGNOSES REDACTED]." Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate six days, verbally abusive two days, physically abusive three days, wandering behaviors two days, and resisting care one day for a total of 14 documented behaviors. No behaviors were noted for [DATE], the date Resident #1 tried to run over a nurse with a wheelchair. Review of Resident #1's current Care Plan per the DON revealed, "Inappropriate sexual behaviors" dated [DATE]. The Approaches included: "1. Psych services as needed. 2. Adm (administer) medications as need. 3. Monitor where abouts of res (resident). 4. Redirect when behavior happens and document. 5. Provide diversional activities." The Care Plan reflected it was reviewed on [DATE], [DATE], and [DATE] and that the problem was " ongoing. " The Care Plan did not identify any " diversional activities " for the staff to use with Resident #1. The Care Plan reflected the notation "(MD V) to see on round." dated [DATE]. The Care Plan did not reflect any other notations. Review of the Incident Reports revealed no incident report or investigation had been conducted following the [DATE] incident with Resident #1 trying to run over a nurse with his wheel chair. Review of Resident #1's SW's Quarterly assessment dated [DATE] revealed, "Resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care." Interview with the SW on [DATE] at 1:38 PM regarding her SS Note dated [DATE] for Resident #1 revealed they had updated the care plan for the Resident #1 in January. She stated, "What more could we have done?" She revealed the care plan was updated for inappropriate behavior, they were monitoring the resident for his location and MD V was involved in his care. She revealed she had not witnessed these incidents. The SW stated she had seen him reach out and touch an arm or a leg in the "knee area." She stated, "If my mother was here and he had been targeting my mother and they couldn't keep him away from her, I would move her." When asked if she saw his behavior as escalating in frequency, she revealed it would vary with medication adjustment. She stated she was not aware Resident #1 was refusing his medications and stated, "I don't think I recall being told that." Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate six days, physically abusive two days, wandering behaviors one day, and resisting care four days, for a total of 13 days. There was no other documentation of the Resident #1 ' s behaviors. Review of the February 2012 CHR Behavior Detail Report revealed Resident #1 had documented behaviors as socially inappropriate one time, verbally abusive three times for a total of four days. There was no other documentation of the Resident #1 ' s behaviors. Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was socially inappropriate one day, verbally abusive one day, physical abusive one day, resisting care two days, for a total of four days. . There was no other documentation of the Resident #1 ' s behaviors. Review of Resident #1's SS notes dated [DATE] revealed the resident had been combative, cursing and hitting at CNAs. The SS notes indicated the physician ordered [MEDICATION NAME] (antianxiety). f) Review of Resident #1's SS Notes dated [DATE] revealed, "Resident threw a cup of coffee on aide this morning. Resident also seen going into other resident's room and was redirected out of their room. Resident is invasive to other residents privacy and staff reports that the startles others when he comes up behind then and tried to touch/grab at them. Resident had been counseled several times for inappropriate behavior but he mumbles and asks if it is smoke time." Review of Resident #4's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on [DATE] at 3:45 p.m. with the DON revealed on or around [DATE] Resident #1 had gone into Resident #4's room when the resident was in her room and closed the door. Review of Resident #1's SS Notes dated [DATE] revealed, "that resident went into another resident's room and startled her, she was in (the) bathroom and she could not get out and had to pull (the) call light to get him out of her room." The note indicated the physician changed Resident #1's antipsychotic medication to [MEDICATION NAME]. Review of Resident #1's Nurse's Notes dated [DATE] at 3:00 PM revealed, "resident placed on one hour surveillance monitoring due to wandering into other residents rooms as well as making inappropriate sexual comments and gestures toward other residents and staff. Nursing staff notified." Resident #1's Nurse's Note dated [DATE] at 3:20 PM reflected "resident overheard telling another male resident that he was going to 'stir up some[***]' Residents were separated." Interview with CNA F on [DATE] at 11:30 PM revealed he had worked at the facility for two years and knew Resident #1. He revealed Resident #1 was verbally,

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source were immediately reported the Administrator of the facility and to the State survey and certification agency, to have evidence all alleged violations were thoroughly investigated, and to prevent further potential abuse while the investigation was in progress for seven (Resident #2, #3, #4, #5, one unidentified resident, #7 and #10) of seven residents reviewed for abuse/neglect. 1. Staff failed to report Resident #1's sexual assault of Resident #2 to the facility Administrator. Staff failed to report Resident #1's sexual assault of an unidentified resident to the facility Administrator. Staff failed to report Resident #1's inappropriate behavior with Residents #3 and #4. The Administrator failed to thoroughly investigate Resident #1's sexual assault of Resident #5. These failures resulted in Residents #3 and #4 being afraid of Resident #1. 2. The Administrator and DON failed to thoroughly investigate Resident #10's bruising of unknown source and to investigate the resident's allegation that she was being hit by a family member. These failures resulted in Resident #10 continuing to suffer bruising of unknown origin. 3. Staff failed to report Resident #6 shooting Resident #7 with a water gun to the Administrator. Staff also failed to report Resident #8's threat to break Resident #7's finger. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the facility's 91 residents by placing them at risk for abuse, neglect, mistreatment, fear, anxiety, Depression, physical injuries, and a decreased quality of life. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. 1. Resident #1's Admission Record, dated [DATE], reflected the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male, and included [DIAGNOSES REDACTED]. The resident was assessed as having short and long-term memory problems and being severely impaired in his ability for daily decision making with disorganized thinking patterns. He was assessed as having verbal behavioral symptoms directed at others occurring one to three days each week which would significantly intrude on the privacy or activity of others. Resident #1's MDS assessment reflected he had wandering behaviors which occurred four to six times weekly, but less than daily and the wandering significantly intruded on the privacy or activities of others. Resident #1's Care Plan dated [DATE] reflected no problem was identified with resident behaviors. The resident was care planned for Depression and included: " ...2) Encourage resident to be involved in activities of choice and preference ... 4) Give meds per order - monitor labs - report abn.s (abnormals) to M.D. Dr. ___ to monitor. " a) Review of Resident #2's closed record revealed she died on [DATE]. Review of Resident #2's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's MDS assessment dated [DATE] reflected she was [AGE] years-old and admitted to the facility on [DATE]. The resident had severe cognitive impairment and was totally dependent on staff for ADLs. On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. She stated Resident #1 was in a wheelchair, he did not walk but was mobile in his wheelchair without assistance. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications, she revealed he was reported to be more compliant on the 3:00 PM to 11:00 PM shift with his medications. She stated, "The night nurse can get him to take his meds. So he is not missing all of them." When asked about Resident #1's inappropriate behavior, LVN I revealed she was aware of an incident when Resident #1 tried to run his hands up Resident #2's dress. When queried further, LVN I explained Resident #2 was in the lobby in a Geri chair. She stated someone stopped him and moved him away from the other resident. She also revealed Resident #1 used vulgar language and would curse at the caregivers. She stated he was "easily directed out of trouble." Review of the Incident and Accident Reports for [DATE] revealed an incident where Resident #1 "was caught" running his hand up the leg and dress of Resident #2. Resident #1's care plan dated [DATE] (the day after the incident) reflected inappropriate sexual behavior was identified on [DATE] and the goal was for the resident to show no inappropriate behaviors over the next 90 days. The approaches were: " 1) psych services as needed Receiving psych serv/ Dr. ___notified by SSD 2) adm (administer) medications as ordered & eval (evaluate) effectiveness 3) monitor resident location/activities 4) redirect when behavior occurs 5) [MEDICATION NAME] per orders - Monitor for side effects/monitor effectiveness of med (medication) 6) Q (every) 15 min (minutes) a Q 30 min checks re: location and activity." Review of Resident #1's SS Notes dated [DATE] (the day after the incident) revealed "was informed that resident exhibited some inappropriate behaviors towards a female resident that was in Geri-recliner yesterday ...Resident (was) counseled to keep hands to himself whether it was a resident or a staff member. Resident denies doing anything wrong or remembering incident...Resident will be monitored to his whereabouts and his surroundings. Resident could not remember any inappropriate behaviors." Interview with the SW on [DATE] at 3:48 PM about Resident #1's SS Notes dated [DATE] revealed she could not recall the nature of the "inappropriate touching" of the resident in the Geri-recliner. She revealed she talked with the nurses and informed the nurses to watch him and called the psychiatrist. She did not recall if she had talked to other residents to see if it was happening to them. Review of Resident #1's Psychiatric Follow-up by NP dated [DATE] revealed she identified Resident #1's [DIAGNOSES REDACTED]. Staff reports 'he is very touchy/feely where he shouldn't. Tried to put his hand down another resident (brief). Staff stopped him before he could." She revealed "Pt (patient) does not remember any inappropriate sexual behavior. We discussed boundaries." NP assessed Resident #1 as being alert with impaired cognition and memory. Review of Resident #1's SS notes dated [DATE] revealed, "(MD V)'s assistant here to see resident for follow up and noted that resident exhibits inappropriate sexual behaviors, had his hands on several other resident/staff." MD V's response to the behaviors was to start the resident on [MEDICATION NAME]. Interview with the SW on [DATE] at 3:48 PM revealed she was unable to identify the "other residents" who were referred to in the [DATE] SS Note. When asked if she called the doctor after reading the psychiatrist note to see if they had additional information or could identify the residents, she stated, "I doubt it. I don't usually see the psych notes for a while." Review of the DADS computer reporting database revealed the [DATE] incident between Resident #1 and Resident #2 was reported to DADS and investigated. b) During an interview on [DATE] at 3:30 PM, CNA K revealed she had worked with Resident #1. She stated he was very mobile and could "get around." She stated because of his behaviors "we had to watch him all the time to keep him away from the women." She stated she stepped out of the assisted dining room "for a moment and when I came back, he had his hand up her (Resident #2's) pant leg all the way to her crotch and she was hollering out the best she could but she could not stop him." She was unable to give the date of the incident. In an effort to clarify the incident, CNA K stated this was a separate incident from the time Resident #1 did the same thing to Resident #2 in the lobby. She stated she reported the incident and wrote a statement about the incident. Consequently, Resident #1 was banned from the dining room for a period of time. When asked if she thought Resident #1 knew what he was doing, she stated, "Yes! He would laugh and make comments when we told him not to do that." CNA K revealed other residents were afraid of Resident #1 because he would go into their rooms and put his hands on their legs. The other residents would holler and throw things at him when he went into their rooms. CNA K was asked if the residents were in danger because of Resident #1. She replied, "Yes, I believe they were ...I would call it sexual assault." During an interview on [DATE] at 9:25 AM, Resident #14 revealed she knew Resident #1 and described him as "scary." She stated she was told to "watch out" for him from the time she came into the facility. She stated she was not afraid of him because she would "knock the hell out of him" if he touched her. She stated the resident "did not have any God-damn sense ...He shouldn't have been here." Review of the facility's Incident and Accident Reports from August until current revealed no Incident Reports about Resident #1 sexually abusing a resident in the assisted dining room. No investigation was conducted for the incident. Review of the NN, the SW notes dated [DATE] - [DATE] for Resident #1 revealed no documentation of an incident of Resident #1 sexually assaulting a female resident in a Geri Chair in he Assisted Dining room. Interview with DON on [DATE] at 10:45 AM about incident with Resident #1 in the Assisted Dining room revealed she was not aware of the incident occurring. She had not seen an incident report or was aware Resident #1 had run his hand up the leg of a female resident into her crotch during dinner. Interview with ADM on [DATE] at 10:30 AM revealed she was unaware of the Incident with Resident #1 running his hand up the pant leg of a female resident in the Assisted dining room. She was informed a report was made by CNA K but no Incident Report was located. She revealed she would go check. No documentation of the incident was provided to the investigator. Review of Resident #1's care plan revealed no review or update. Resident #1's behavior continued as follows: Review of Resident #1's SS Notes dated [DATE] revealed, "resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care ... Resident is assisted into his wheelchair daily and he wanders about the facility ...." Interview with the SW on [DATE] at 3:48 PM regarding her Note dated [DATE] revealed the "inappropriate behaviors" were sexual in nature. When asked why it was not addressed as sexual, the SW stated, "I guess I should have put that in." Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "nurse reports resident doing well on current medications. No inappropriate behavior reported. Self propels about (the) facility. We increased [MEDICATION NAME] at last visit with good effect." Resident #1 was assessed as being alert with impaired cognition and memory with a [DIAGNOSES REDACTED]." c) Review of Resident #3's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's SS Note "late entry [DATE]" revealed, "informed that resident went into (Resident #3's) room and was touching her and was asked to leave and reported to charge nurse. SSD talked with resident and he denies inappropriate behaviors. SSD spoke with (Resident #3) and she stated he came into her room and they were talking and then he started rubbing her back. She asked him to stop. At first he didn't and she asked him again to stop or she was going to hit him and he did stop. Her roommate stated she was going to call for the nurse and he left the room... stated shortly afterwards, they could hear someone down the hall say for him to get out of their room." Interview with the SW on [DATE] at 1:35 PM regarding her Note dated [DATE] for Resident #1 and Resident #3 revealed she reported the incident to the ADON. She revealed Resident #1 was someone you could set boundaries with "to a point." She stated they would have to keep reminding him of those boundaries. The SW stated, "You just could not say it once." Review of Resident #1's Nurse's Notes dated [DATE] revealed an "incident" with an unidentified resident at 1:15 PM. The Notes reflected Resident #1's location should be checked and documented every 15 minutes. The Notes reflected the monitoring started on [DATE] through [DATE] when it was discontinued. The Nurse's Notes reflected an inservice was held for staff on [DATE] regarding Abuse and recorded the names of the staff attending the inservice. No specifics of the incident with Resident #1 were documented in his Nurse's Notes. Review of Resident #1's Care Plan revealed "inappropriate behaviors involving other residents" was identified on [DATE]. Approaches included: "1. Frequently remind resident to not touch other residents. 2. Provide diversional activities for resident. 3. Redirect as indicated. 4. Continue psych services. 5. Administer [MEDICATION NAME] as ordered and evaluate effectiveness monitor for side effects with meds and notify physician if present. 6. Give positive reinforcement for appropriate behaviors. 7. Location/activity surveillance as indicated." On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She revealed she normally worked Hall One, and worked with Resident #1. LVN I revealed Resident #1 was non-compliant with his medications and diet. She explained he would sometimes refuse to take his medication. She stated the DON and ADM were aware of his non-compliance. When asked what they did about him not taking his medications she revealed, LVN I reported the resident was more compliant on the 3:00 PM to 11:00 PM shift with his medications. " The night nurse can get him to take his meds. So he is not missing all of them. " Review of the [DATE] CHR Behavior Detail Report (the CNA Kiosk care tracker) revealed Resident #1 was documented as being socially inappropriate twice, verbally abusive twice, physically abusive once, and with wandering behaviors one day, for a total of six days. Resident #1's behavior was documented as " socially inappropriate " on [DATE]. No other behaviors were documented in [DATE]. Review of Resident #1's Psychiatric follow-up dated [DATE] by MD V revealed "the resident continues to have inappropriate behavior with staff (sexually). Pt (patient) does not believe he had any behavioral issues. Doesn't recall anything." MD V listed Resident #1's abnormal involuntary movements as "Acts like going to grab me - somewhat inappropriate." The [DIAGNOSES REDACTED]." Review of an Incident report dated [DATE] reflected Resident #1 "entered another residents room & put his hands on her back and buttocks. Witnessed by room-mate." The staff interviewed the roommate, but no additional investigation was conducted. d) Review of Resident #1's Nurse's Notes dated [DATE] by LVN I revealed the NP "came into the facility and told this nurse that resident was up in lobby trying to fondle another res (resident). (She) went to the lobby to remove res from situation both res arguing back and forth, When this nurse got to res other res stated, you better get him out of here before I hurt him. Took res to patio for smoke break at this time." Interview with LVN I on [DATE] at 10:57 AM revealed she made the Nurse's Notes entry dated [DATE], and she recalled the incident. She revealed she did not witness the incident; it was reported to her by the NP. She also revealed she could not recall the female resident Resident #1 was assaulting. She stated the incident occurred in the front lobby of the facility and Resident #1 was attempting to fondle the female resident. She revealed she did not complete an Incident Report about it, because she was not a witness. When asked if she was knowledgeable about the prior incident on [DATE] in the front lobby with Resident #1 and Resident #2, she revealed she was. She stated she was also aware of the incident with Resident # 1 and Resident #3. She stated, "I did not really think about it. If I thought about it I would have reported it." She stated, "Sometimes you get to the point where you have been here too long that some behaviors become so normal that you don't really notice. It is like you cannot see the trees for the forest. But I am going to work on that a little bit better." Review of the Care Plans for Resident #1 revealed no updates following the [DATE] incident in the front lobby. No Incident Report was located for the [DATE] incident in the front lobby and no investigation was located. Resident #1's behaviors continued as demonstrated by Resident #1's Psychiatric follow-up note dated [DATE] by the NP. The NP revealed, "In common area today arguing with another resident. Increased anxiety and anger. Redirected with resistance.... Increase in sexually inappropriate behaviors, verbal/grabbing aids. 'Are you gonna get in bed with me?'" Resident #1's [DIAGNOSES REDACTED]." Review of Resident #1's SW's Quarterly Assessment notes, dated [DATE] revealed, "was informed that resident exhibits increasing behaviors such as almost got into a fight in the dining room, was observed picking up food with hands and then throwing it on his tray. Also several employees have reported resident exhibiting inappropriate sexual behaviors around him the last couple of days ... Noted that resident was in common living area today, arguing with another resident, increased anxiety and anger ....Increased sexually inappropriate behaviors, verbal/grabbing aides." The physician increased the resident's [MEDICATION NAME]. Interview with the SW on [DATE] at 1:38 PM regarding her Note dated [DATE] revealed they were trying to protect the residents from Resident #1 by keeping him in public, common areas to watch him, having "psych" to talk with him and adjusting his medications. Interview on 07/ ,[DATE] at 11:45 AM with Activity Director revealed she had worked in the facility the last three years and she knew Resident #1. She revealed Resident #1 liked to work a bead puzzle and liked to go outside. She stated she had never been asked to create a list of diversion activities for staff to use on Resident #1. She stated she had never been asked to talk with the CNAs or give them any instructions on diversional activities for Resident #1. Interview on [DATE] at 10:57 with LVN L revealed she has not been given a list of diversional activities to try with Resident #1. She had instructed the CNAs working with Resident #1 to bring him to the front lobby by the nursing station when he was a problem. Interview on [DATE] at 4:15 PM with CNA N revealed when she had problems with Resident #1 she would tell the charge nurse. When asked if was given any help from nursing when she reported he behavior she revealed " A couple of times but generally they just said to chart it. " CNA N was asked if behaviors ocurred, when they always documented on the kiosk. She responded, "No." She explained that Resident #1's behaviors were mostly all the time; they just were not always documented. When asked if she had been given any diversional activities to try with Resident she revealed " No. I just generally brought him up to the front lobby. " Her only instructions were to " take him to get coffee, put him in the front lobby by the TV and just try to occupy him. " Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate three days, verbally abusive one day, physically abusive one day, wandering behaviors three days, and resisting care one day for a total of nine days. No behavior was documented for [DATE], the date of the incident in the front lobby with Resident #1 trying to fondle an unknown resident. Review of the clinical record, NN and the SW notes did not reveal any monitoring of Resident #1 had occurred after the [DATE] incident in the front lobby. e) Resident #1 ' s behaviors continued as follows: Review of Resident #1's Psychiatric follow-up dated [DATE] by the NP revealed, "tried to run over a nurse with w/c (wheelchair). Resident is now wandering into other rooms. Nurse is very concerned about residents change in behavior. The resident [DIAGNOSES REDACTED]." Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate six days, verbally abusive two days, physically abusive three days, wandering behaviors two days, and resisting care one day for a total of 14 documented behaviors. No behaviors were noted for [DATE], the date Resident #1 tried to run over a nurse with a wheelchair. Review of Resident #1's current Care Plan per the DON revealed, "Inappropriate sexual behaviors" dated [DATE]. The Approaches included: "1. Psych services as needed. 2. Adm (administer) medications as need. 3. Monitor where abouts of res (resident). 4. Redirect when behavior happens and document. 5. Provide diversional activities." The Care Plan reflected it was reviewed on [DATE], [DATE], and [DATE] and that the problem was " ongoing. " The Care Plan did not identify any " diversional activities " for the staff to use with Resident #1. The Care Plan reflected the notation "(MD V) to see on round." dated [DATE]. The Care Plan did not reflect any other notations. Review of the Incident Reports revealed no incident report or investigation had been conducted following the [DATE] incident with Resident #1 trying to run over a nurse with his wheel chair. Review of Resident #1's SW's Quarterly assessment dated [DATE] revealed, "Resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care." Interview with the SW on [DATE] at 1:38 PM regarding her SS Note dated [DATE] for Resident #1 revealed they had updated the care plan for the Resident #1 in January. She stated, "What more could we have done?" She revealed the care plan was updated for inappropriate behavior, they were monitoring the resident for his location and MD V was involved in his care. She revealed she had not witnessed these incidents. The SW stated she had seen him reach out and touch an arm or a leg in the "knee area." She stated, "If my mother was here and he had been targeting my mother and they couldn't keep him away from her, I would move her." When asked if she saw his behavior as escalating in frequency, she revealed it would vary with medication adjustment. She stated she was not aware Resident #1 was refusing his medications and stated, "I don't think I recall being told that." Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was documented as being socially inappropriate six days, physically abusive two days, wandering behaviors one day, and resisting care four days, for a total of 13 days. There was no other documentation of the Resident #1 ' s behaviors. Review of the February 2012 CHR Behavior Detail Report revealed Resident #1 had documented behaviors as socially inappropriate one time, verbally abusive three times for a total of four days. There was no other documentation of the Resident #1 ' s behaviors. Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was socially inappropriate one day, verbally abusive one day, physical abusive one day, resisting care two days, for a total of four days. . There was no other documentation of the Resident #1 ' s behaviors. Review of Resident #1's SS notes dated [DATE] revealed the resident had been combative, cursing and hitting at CNAs. The SS notes indicated the physician ordered [MEDICATION NAME] (antianxiety). f) Review of Resident #1's SS Notes dated [DATE] revealed, "Resident threw a cup of coffee on aide this morning. Resident also seen going into other resident's room and was redirected out of their room. Resident is invasive to other residents privacy and staff reports that the startles others when he comes up behind then and tried to touch/grab at them. Resident had been counseled several times for inappropriate behavior but he mumbles and asks if it is smoke time." Review of Resident #4's Admission Record dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on [DATE] at 3:45 p.m. with the DON revealed on or around [DATE] Resident #1 had gone into Resident #4's room when the resident was in her room and closed the door. Review of Resident #1's SS Notes dated [DATE] revealed, "that resident went into another resident's room and startled her, she was in (the) bathroom and she could not get out and had to pull (the) call light to get him out of her room." The note indicated the physician changed Resident #1's antipsychotic medication to [MEDICATION NAME]. Review of Resident #1's Nurse's Notes dated [DATE] at 3:00 PM revealed, "resident placed on one hour surveillance monitoring due to wandering into other residents rooms as well as making inappropriate sexual comments and gestures toward other residents and staff. Nursing staff notified." Resident #1's Nurse's Note dated [DATE] at 3:20 PM reflected "resident overheard telling another male resident that he was going to 'stir up some[***]' Residents were separated." Interview with CNA F on [DATE] at 11:30 PM revealed he had worked at the facility for two years and knew Resident #1. He revealed Resident #1 was verbally, sexually suggestive, but he did not know of the resident being aggressive. He stated Resident #1 did wander into other residents' rooms and close the door, due to his confusion. During an interview on [DATE] at 1:25 PM, NA D described Resident #1's behaviors as "nasty." She stated Resident #1 had grabbed her breast. She stated at another time he had asked her to lay (sic) with him. Another time, he put his hands on her buttocks. When asked if she reported these behaviors to anyone, she revealed she could not remember. She stated she knew she should have, but "I am not sure if I did or not." She stated redirecting Resident #1 was difficult; the resident had to be told several times before he would respond. She also revealed Resident #1 would "always go into other residents' rooms. He would lay (sic) down in their bed." She stated documentation of all residents' behaviors was done on the CNA Care Tracker kiosk. At that time Resident #1's [DATE] Behavior Detailed Report was reviewed with NA D and revealed NA D had not documented any behaviors for Resident #1. NA D confirmed she had failed to document Resident #1's behaviors. On [DATE] at 3:15 PM, LVN I revealed she worked the 7:00 AM to 3:00 PM shift four to five days per week. She stated Resident #1 was in a wheelchair; he did not walk but was mobile in his wheelchair without assistance. LVN I stated he wandered the building, in and out of rooms. She stated when Resident #1 went into other residents' rooms, sometimes the staff would have to go and get him. She stated, "You had to watch him constantly" because of his wandering. LVN I stated the other residents did not want him in their rooms and sometimes would threaten to hurt him to get him to leave. During an interview with CNA J on [DATE] at 11:35 AM, CNA J was queried about Resident #1's behavior with other residents. CNA J revealed, "There were a couple of residents who already knew who he was and knew to stay away from him." CNA J stated other residents were afraid of him because of the "touching" and wandering into their rooms. She stated on several occasions, Resident #1 wandered into residents' rooms and startled them by waking them up. When asked if Resident #1 knew what he was doing when he exhibited the inappropriate behavior, CNA J stated, "Some of the time, yes. Some of the time, I don't know." When asked if Resident #1 knew what he was doing was wrong, she stated, "Yes." No diversional activities were noted to be offered to Resident #1 in the SW notes, or the NN or the CHR Behavioral Detail Report even though behaviors were noted on [DATE], [DATE] and [DATE]. Review of Resident #1's Nurse's Note dated [DATE] at 3:00 PM revealed Resident #1 was found in Hall Three (Resident's room was located on Hall one), and was redirected to Hall One. The Notes reflected, "very disruptive and doesn't follow commands or direction well due to decreased cognitive status." Review of the facility's Incident and Accident Reports from [DATE] until current revealed no Incident Reports involving Resident #1. Review of the Residents Care Plan revealed no additions to the Care Plan were noted after the [DATE] incident with Resident #4. Review of the [DATE] CHR Behavior Detail Report revealed Resident #1 was verbally abusive two days, wandering four days, socially inappropriate two days, for a total of eight days of the month. No wandering behaviors were noted on [DATE] (the date of the incident with Resident #4). Review of the most recent Care Plan for Resident #1 revealed no additions to the care plan after the [DATE] incident of cornering Resident #4 in her bathroom and continued wandering behaviors. No diversional activities were listed on the care plan for the staff to use with Resident #1. Resident #1's Nurse's Note dated [DATE] at 2:00 AM reflected, "Occ (occasional) sexual advances toward staff." Resident #1's Nurse's Note dated [DATE] at 1:55 AM reflected, "Very occ sexual advances toward staff at times." Resident #1's Nurse's Note dated [DATE] at 12:35 AM reflected, " ...calls staff 'baby cakes' occasionally." Review of Resident #1's closed clinical record revealed a 15 Minute Surveillance Log dated [DATE] with documentation of every 15 minutes checks conducted beginning at 3:00 PM that day and they were discontinued on [DATE] at 10:00 PM. Review of the facility's Incident and Accident Reports from [DATE] until current revealed no Incident Reports involving Resident #1. Resident #1's Nurse's Notes dated [DATE] did not reflect the reason the Surveillance Log was initiated. Interview on [DATE] at 3:15 PM with LVN I revealed she remembered the Surveillance Log was completed for Resident #1 for [DATE] through [DATE], but she did not recall the events that triggered the Surveillance Log. g) Review of Resident #5's MDS assessment dated [DATE] revealed the resident was an [AGE] year-old female admitted to the fa

Based on interview and record review, the facility failed to use the results of the assessments to develop the resident's comprehensive plan for one (Resident #1) of four residents reviewed for care plans and to update the care plan when Resident #1's behaviors escalated. 1. Resident #1 had multiple incidents of sexual aggression toward female residents beginning on 08/31/11 and continuing through the spring of 2012, culminating in the sexual assault of a female resident (Resident #5) on 05/24/12. 2. The last updated care plan for Resident #1 was completed on 01/04/12. The resident continued in his behaviors of sexual touching of female staff, sexual language with staff, and wandering in and out of resident rooms after the 01/04/12 care plan, however his care plan was not updated to reflect additional interventions by staff. 3. The Care Plans for the facility residents were kept in a locked cabinet in the DON's office and not accessible to the staff for review. These failures resulted in Resident #5 being sexually assaulted by Resident #1 An Immediate Jeopardy (IJ) was identified on 07/10/12. While the IJ was removed on 07/12/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could have affect the other 52 female residents, who resided in the facility, by placing them at risk for sexual assault, sexual harassment, embarrassment, Depression, anxiety, anger, fear and a decreased quality of life. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on 07/09/12. Review of the MDS dated [DATE] for Resident #1 reflected he was a [AGE] year old male, re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed as having short and long term memory problems and being severely impaired in his ability for daily decision making with disorganized thinking patterns. He was assessed as having verbal behavioral symptoms directed at others occurring 1-3 days each week which would significantly intrude on the privacy or activity of others. The resident was indicated to have wandering behaviors which occurred 4-6 times weekly, but less than daily and indicated the wandering significantly intruded on the privacy or activities of others. Resident #1 had three incidents of inappropriate touching of a female resident prior to the 01/04/12 care plan. He had an incident on 08/31/11 of running his hand under the skirt and up the leg of a resident in a Geri chair in the front lobby, an incident, undetermined date, of running his hand up the pant leg into the crotch of a female resident in a Geri chair in the assisted dining room, and an incident of "fondling" a female resident in the front lobby on 11/08/11. Resident #1's most current Care Plan dated 01/04/12 reflected "inappropriate sexual behaviors" on 01/04/12. Approaches included. 1. Psych services as needed. 2. Administer medications as need. 3. Monitor where abouts of resident. 4. Redirect when behavior happens and document. 5. Provide diversional activities. Additions to the care plan dated reflected "(MD V) to see on round." On 01/05/12 the BDR (Behavior Detail Report) reflected Resident #1 was "socially inappropriate - as I was pushing (the) resident out of the office he said 'going to give me a kiss.'" No changes to the care plan were noted after the 01/05/12 BDR notation. On 01/09/12 the BDR reflected Resident #1 had "socially inappropriate behavior." No changes to the care plan were noted after the 01/09/12 BDR notation. On 01/10/12 the BDR reflected Resident #1 was "socially inappropriate." No changes to the care plan were noted after the 01/10/12 BDR notation. On 01/15/12 the BDR reflected Resident #1 was "wandering." No changes to the care plan were noted after the 01/15/12 BDR notation. On 01/16/12 the BDR reflected Resident #1 was noted as being "physically abusive and grabbed _____(CNA) on her buttocks when she was changing his brief." No changes to the care plan were noted after the 01/16/12 BDR notation. On 01/22/12 the BDR reflected Resident #1 was "resisting care." No changes to the care plan were noted after the 01/22/12 BDR notation. SS Notes for a "Quarterly Assessment" of Resident #1 dated 01/26/12 reflected "Resident exhibits some inappropriate behaviors at times, grabs at staff inappropriately when they try to give ADL care." No changes to the care plan were noted after the 01/26/12 SS quarterly assessment for Resident #1. On 01/27/12 the BDR reflected Resident #1 was documented as "Resisting care" in the BDR notes. No changes to the care plan were noted after the 01/27/12 BDR notation. On 01/28/12 the BDR reflected Resident #1 was "resisting care." No changes to the care plan were noted after the 01/28/12 BDR notation. On 02/01/12 the BDR reflected Resident #1 was "howling down the hall after supper. Was saying 'Let me kiss you baby and let me do you a finger job.'" No changes to the care plan were noted after the 02/01/12 BDR notation. On 02/17/12 the BDR reflected Resident #1 was "verbally abusive and socially inappropriate." No changes to the care plan were noted after the 02/17/12 BDR notation. On 02/26/12 the BDR reflected Resident #1 was "verbally abusive." No changes to the care plan were noted after the 02/26/12 BDR notation. On 03/24/12 the BDR reflected Resident #1 was "physically abusive, socially inappropriate and resisting care." No changes to the care plan were noted after the 03/24/12 BDR notation. On 03/26/12 the BDR reflected Resident #1 was "verbally abusive." No changes to the care plan were noted after the 03/26/12 BDR notation. On 03/31/12 the BDR reflected Resident #1 was "resisting care, verbally abusive." No changes to the care plan were noted after the 03/31/12 BDR notation. Resident #1's SS Notes dated 04/09/12 reflected "informed resident had been combative, cursing and hitting at CNA's (sic)." The response was for Resident #1 to receive [MEDICATION NAME]. No changes to the care plan were noted after the 04/09/12 SS notation. Resident #1's SS Notes dated 04/10/12 reflected "resident threw a cup of coffee on aide this morning. Resident also seen going into other resident's room and was redirected out of their room. Resident is invasive to other residents privacy and staff reports that he startles others when he comes up behind then and tried to touch/grab at them. Resident had been counseled several times on inappropriate behavior but he mumbles and asks if it is smoke time." No changes to the care plan were noted after the 04/10/12 SS notation. On 04/11/12 the BDR reflected Resident #1 "corners a resident in the restroom." Resident #1's SS Notes dated 04/11/12 reflected "that resident went into another resident's room and startled her, she was in (the) bathroom and she could not get out and had to pull (the) call light to get him out of her room." During an interview with the SW on 07/12/12, she identified the cornered resident as Resident #4. No changes to Resident #1's Care Plan were made after the 04/11/12 BDR notation, the SW notes or the Nursing Notes concerning the incident with Resident #1 cornering Resident #4 in her bathroom. Resident #1's Nursing Notes dated 04/12/12 and timed at 3:00 PM reflected the resident was placed on one hour monitoring because he was wandering into other residents' rooms and making inappropriate sexual comments and gestures toward other residents. Resident #1's Nursing Notes dated 04/12/12 and timed at 3:20 PM reflected the resident was heard telling another male resident that he (Resident #1) was going to "'stir up some[***]" with him. The residents were separated and the SW was notified. On 04/12/12 the BDR reflected Resident #1 was "verbally abusive. At 4:30 PM (was) going into resident rooms and was taken to the lobby. ___ (CNA) Found him in room [ROOM NUMBER]." No changes to the care plan were noted after the 04/12/12 BDR notation. On 04/18/12 the BDR reflected Resident #1 was "socially inappropriate. Made sexual comments about aids and other residents as they pass by." No changes to the care plan were noted after the 04/18/12 BDR notation. Nursing Notes for Resident #1 dated 04/21/12 at 0200 reflected "Occ (occasional) sexual advances toward staff." No changes to the care plan were noted after the 04/21/12 nursing notation. Nursing Notes for Resident #1 dated 04/22/12 at 0155 reflected "Very occ (occasional) sexual advances toward staff." No changes to the care plan were noted after the 04/22/12 nursing notation. On 04/22/12 the BDR reflected Resident #1 was "socially inappropriate." No changes to the care plan were noted after the 04/22/12 BDR notation. On 04/24/12 the BDR reflected "Resident (#1) almost went into room [ROOM NUMBER] but was redirected by staff." No changes to the care plan were noted after the 04/24/12 BDR notation. On 04/25/12 the BDR reflected Resident #1 was "going into other residents rooms. Verbally abusive." No changes to the care plan were noted after the 04/25/12 BDR notation. Nursing Notes for Resident #1 dated 04/26/12 at 0035 reflected "calls staff 'baby cakes' occasionally. " No changes to the care plan were noted after the 04/26/12 nursing notation. On 04/27/12 the BDR reflected Resident #1 was "going in and out of other residents rooms and getting into their beds and urinating on their beds." No changes to the care plan were noted after the 04/27/12 BDR notation. Review of the 15 Minute Surveillance Log for Resident #1 dated 04/30/12 revealed 15 minutes checks were conducted on the resident beginning at 3:00 PM. The log reflected the checks continued every 15 minutes until 05/02/12 at 10:00 PM, then were discontinued." No changes to the care plan were noted after the 04/30/12 - 05/02/12 surveillance log was discontinued. The Nursing Notes for 04/30/12 for Resident #1 reflected no justification for the behavior monitoring sheets to be completed between 04/30/12 - 05/02/12. Interview on 06/21/12 at 3:15 PM with LVN I revealed she remembered Behavior Monitoring sheets were completed for Resident #1 from 04/30/ 12 through 05/02/12. She looked through the nursing notes and could not find a justification for the monitoring sheets to be completed and had no recollection of events that might have triggered the behavior monitoring of Resident #1. Interview on 06/21/12 at 3:45 PM with the DON and the ADM revealed the monitoring sheets for Resident #1 dated 04/30/12, 05/01/12, and 05/02/12 were started as a proactive monitoring to assess the movements of Resident #1. During the conversation the ADM questioned whether the sheets were in response to the incident with Resident #1 and the DON's relative, Resident #4. The DON said she did not remember starting the sheets after that time. When the DON was questioned, she revealed Resident #1 went into Resident #4's room,when she was in the room and closed the door." No changes to the care plan were noted after the incident with Resident #4 reported by the DON. The Nursing Notes dated 05/01/12 at 1500 reflected the resident was found in Hall Three (Resident #1's room was located in Hall One), and was redirected to Hall One. The resident was recorded as "very disruptive and doesn't follow commands or direction well due to decreased cognitive status." The BDR dated 05/01/12 for Resident #1 reflected he was "wandering." No changes to the care plan were noted after the 05/01/12 nursing notation or the BDR notation. On 05/04/12 the BDR reflected Resident #1 was "verbally abuse." No changes to the care plan were noted after the 05/04/12 nursing notation. On 05/05/12 the BDR for Resident #1 reflected he was "wandering." No changes to the care plan were noted after the 05/05/12 BDR notation. On 05/08/12 the BDR reflected Resident #1 was "verbally abusive." No changes to the care plan were noted after the 05/08/12 BDR notation. On 05/16/12 the BDR reflected Resident #1 was "verbally abusive." No changes to the care plan were noted after the 05/16/12 BDR notation. On 05/20/12 the BDR for Resident #1 reflected he was "wandering, verbally abusive, physically abusive, socially inappropriate behavior/other." No changes to the care plan were noted after the 05/20/12 BDR notation. Interview on 06/21/12 at 11:45 AM with CNA G revealed he had worked in the facility seven months and he had worked with Resident #1 on several occasions. He described Resident #1's behaviors as including sexual remarks about female residents like "Oh look at that ass." These remarks happened at least every other day. CNA G revealed he was a full time employee who worked five days a week. When the resident made inappropriate sexual comments he reported the comments to the nurse and would redirect Resident #1 telling him that they were inappropriate remarks. CNA G revealed his instructions concerning Resident #1 were to "watch" Resident #1. He revealed he was never shown Resident #1's Care Plan, did not know where it was located and was not in the CNA Care tracker. CNA G stated he was never given instructions Resident #1 was to be on one-on-one monitoring. CNA G revealed Resident #1 was making inappropriate sexual comments for about one week prior to the incident with Resident #5. CNA G said he notified the nursing staff that the resident was making the inappropriate comments again. Their response to his report was they instructed him to "watch " Resident #1. He revealed he tracked the behaviors of Resident #1 on the CNA kiosk Care Tracker in the behavior section. CNA G revealed he was the one who discovered Resident #1 in Resident #5's room on 05/23/12. On the day of the incident CNA G was going to get a resident to bring her to the assisted dining room for dinner. He observed Resident #1 sitting outside the Assisted Dining room about halfway down Hall Two. He went to the resident's room which was 3-4 doors past the assisted dining room, put her shoes on, transferred her to the wheelchair and then was bringing her down Hall Two. CNA G noticed Resident #1 was not in the hall and started looking for him, thinking "oh no where is he." Resident #5's room was directly across from the assisted dining room. He looked in residents' rooms as he walked down the hall and saw Resident #1 in Resident #5's room. He observed Resident #1 had parked his wheelchair next to her bed; he was sitting on the edge of her bed. He was surprised Resident #1 could get to the bed because he was always a one person assist transfer. Resident #5 was lying in the bed with the bed covers pulled down and with her night gown pulled up to her chest exposing her stomach. Her brief had been pulled open and she was exposed with her legs spread apart. Resident #1 was observed to have his hand between Resident #5's legs with just his thumb visible. There was no sound being made by Resident #1 or any sounds of distress from Resident #5 observed by CNA G. CNA G went into the room, closed the door and assisted Resident #1 to get up from the bed and transfer back into his wheelchair. Resident #1 appeared hostile to be moved but accepted the redirection. He took Resident #1 up to the Nursing Station to report the incident. Resident #1 was left at the Nursing Station on one to one with the Administrator. The nursing staff went to assess Resident #5. CNA G was asked to write a statement by his supervisor and by the time he left the building at 11:00 PM Resident #1 was no longer in the facility. No additions to the care plan were noted following the 05/24/12 incident with Resident #5. Interview on 06/21/12 at 1:25 PM with NA D revealed she worked with Resident #1 when he was on Hall One. She described his behaviors as being "nasty." One time he grabbed her breasts. A second incident on a different day, he invited her to lay down with him. A third incident on a different date, he put his hand on her buttock and she told him no. When she heard about the incident with Resident #5 she revealed she was not surprised. When asked if she reported the incidents to the charge nurse she revealed she knew she was supposed to report it to the charge nurse, but "I am not sure if I did or not." She said redirection of Resident #1 was difficult, "I had to tell him three to four times." He would "always go into to other residents' rooms. He would lie down in their bed." She revealed she did not know where the Care Plan was located and had not seen it. She was given instructions by the charge nurse to monitor Resident #1 all the time and document where he was and what time he was where in the electronic tracking Kiosk, "We were to type in the behavior and where and when it was occurring." Behavior tracking for Resident #1 was started two months ago. The kiosk behavior monitoring sheets for May 2012 were given to NA D and she confirmed she did not enter any behavior monitoring into the Kiosk for Resident #1. Interview on 06/21/12 at 1:50 PM with CNA H revealed she had worked in the facility since March 2012 and had worked with Resident #1 continuously as her assignment. She revealed Resident #1's behaviors were unpredictable. He would get up in the morning and be OK for breakfast. But then after breakfast he would be argumentative and difficult. He would "cuss me out, saying that 'oh you all are [***] ing with me.'" He was impatient. During care he would put his arm around her. She was present when another CNA was changing Resident #1 and she witnessed him putting his arm around the CNA, grabbing her buttock and saying "You have no ass." When she heard about the incident between Resident #1 and Resident #5 she was not surprised. She revealed when she started working in the facility the other CNAs warned her that she should not go into Resident #1's room alone because he would try to grab her and make vulgar comments. She had not been given any behavior monitoring instructions by the administration or nurses or asked to chart his behaviors in the kiosk. The only instructions she had were that right after breakfast and right after lunch he was to be laid down in his room. The way they said it made her feel she should lay him down first before anyone else. She was never given instructions Resident #1 was to be a one-on-one supervision, had not been shown a Care Plan and did not know where they were located. Interview on 06/20/12 at 11:30 AM with CNA F revealed he had worked in the facility for two years and worked with Resident #1. Resident #1 was moved from several of the halls during the refurbishing of the facility but most currently had lived on Hall One. He described Resident #1 as someone who could not focus on a task, stating "If you worked at it you could get his attention." When asked about inappropriate sexual activities he revealed the resident sometimes talked in a sexually suggestive ways to staff. When asked if he was surprised by the incident on 05/23/12 he revealed the resident would sometimes end up in other residents' beds, but he thought that was by accident not by design. He revealed the resident would often go in and out of others' rooms and would shut the door. On 07/10/12 at 5:40 PM, an IJ was identified. At that time, the ADM was informed of the IJ and a Plan of Removal was requested. The Plan of Removal dated 07/10/12 was accepted on 07/11/12 and reflected: "1. DON or designee will inservice all current staff on management of behaviors and identifying abuse ie: verbal abuse that is against another resident and being able to identify the difference between using foul language in talking and then using foul language toward another resident and reporting it to the abuse coordinator. This was initiated at 6:30 pm with all in house staff and will be conducted with 100% of staff prior to starting of work. This will be completed on or before July 12, 2012. 2. Assessments of all current residents will be conducted by the DON or designee for any current behaviors to ensure they are care planned appropriately and being addressed by staff. This will begin immediately and will be completed by July 11, 2012. Staff will receive a shift to shift report from their charge nurse on any specific resident instructions that need to be followed during their shift. 3. Sexual assessment (copy attached) will be conducted on all residents with potential for sexual activity to identify any further issues that need addressed. Information that is obtained from this assessment will be addressed by the care plan team. A care plan will be initiated to develop specific approaches pertaining to information. This will be initiated by the DON or designee on July 10, 2012 and will be completed on or before July 11, 2012... 5. Administrator and Director of Nurses were re-educated by the Regional Director on July 10, 2012 concerning the Abuse Policy and Procedure, dealing with behaviors and proper follow up. We discussed that they would review and 24 hour report, do a clinical start up, administrative stand up and round in facility to identify issues. Any issues identified will be addressed by care plan team. Follow up on plans should be reviewed quarterly at a minimum...." Reviewof the Inservice records revealed: An inservice on the Types of Abuse and Neglect, How to Deal with Resident Behaviors, Documentation of Bruising, Reporting of Abuse to the Abuse Coordinator was conducted on 07/10/12 at 6:30 (AM or PM not specified) and on 07/11/12 at 7:00 AM with a total of 42 staff members in attendence. On 07/10/12 at 7:45 PM, the Regional Director provided an inservice on the Abuse Policy and Procedure, Identifying Behaviors, Dealing with Behaviors, and Proper follow-up of issues identifed with the ADM and DON in attendence. On 07/10/12 at 8:00 PM, LCSW Y conducted an inservice regarding Abuse with 52 staff members in attendence. Interview on 07/11/12 at 3:00 PM with CNA W revealed she could verbalize the types of abuse, recognition of abuse/neglect and the reporting procedure for possible abuse/neglect. Interview on 07/11/12 at 3:50 PM with CNA X revealed she could verbalize the types of abuse, recognition of abuse/neglect and the reporting procedure for possible abuse/neglect. When queried if she had any inservices on caring for residents with behaviors, she revealed, "We have a few inservices. A few on the computer." During an interview on 07/12/12 at approximately 9:00 AM, the DON revealed no training had been provided to the CNAs regarding managing behaviors. She thought staff received some training on the computer regarding elopement, but she was not sure of that. She stated prior to the IJ, the staff did not conduct any inservices on caring for the wandering residents. Since the IJ was identified, they had inservices regarding Resident #7. The inservices also addressed behavior issues not specific to wandering. Staff were instructed to check for needs not being met that might be increasing the behavior, including food, activities and socialization. She also stated the CNAs were inserviced on documentation and reporting of occurring behaviors. Further interview with the DON on 07/12/12 at 9:30 AM revealed the most current Care Plan for Resident #1 was the 01/05/12 care plan. She revealed the Care Plans were kept in her office and were locked up in the cabinets, when she was out of the building. She stated the nursing staff only had access to the acute care plans at the Nurse's Station and it as the responsibility of the nurses to tell the CNAs what the care plans were for each resident. She revealed it was a "word of mouth" communication of the care plans to the CNAs. Because of this investigation, they are now looking at getting a rolling cart with hanging files so that the care plans can be kept out by the nursing station and accessible to the staff. Interview on 07/12/12 at 11:45 AM with the Activity Director revealed she could verbalize the types of abuse, recognition of abuse/neglect and the reporting procedure for possible abuse/neglect. She also stated she had talked with the DON about activities for residents with behaviors and had implemented an activity apron for Resident #7. Interview on 07/12/12 at 12:15 PM with Payroll/HR revealed she served as a Quality of Life Specialist. She explained the Quality of Life Specialist checked on their assigned residents daily to identify any needs they had. The Payroll/HR could verbalize the types of abuse, recognition of abuse/neglect and the reporting procedure for possible abuse/neglect. She said she received inservices on abuse, smoking policy, wandering residents, and bruising. While the IJ was removed on 07/12/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. The ADM, DON, RD, and Regional Nurse were informed the IJ was removed on 07/12/12 at 1:55 PM. The facility's Midnight Census Report dated 07/09/12 provided by the DON reflected 52 female residents.