Every finding on record at Parkwood Health & Rehabilitation

Based on observation, interview, record review and facility policy review, the facility failed to ensure drug records were in order and an account of all drugs was maintained and periodically reconciled for 4 out of 12 residents who received narcotic medications, out of the total sample of 23 residents. The findings include: Review of the facility policy titled, [NAME] Healthcare Medication Administration Policy, dated 01/05/2025, revealed the facility was to follow the five rights of medication administration. Per review the five rights included the: right resident, right medication, right dose, right route, right time and must be confirmed at the following stages during medication administration. Continued review revealed the stages included: before removing the medication from the container, matching the label against the medication administration order, after preparing the dose and before returning the medication to storage, and double checking that all information was accurate and properly documented. During observation on 01/07/2026 at 9:08 AM, of a medication cart located on the Northeast hallway of the facility, the State Survey Agency (SSA) Surveyor requested a narcotic medication reconciliation of the cart be performed, and Licensed Practical Nurse (LPN) 1 agreed to do that. Per observation, LPN 1 looked at the cards that held the narcotic medications and stated how many tablets were left for each resident with the SSA Surveyor verifying the count in the narcotic binder, located on the medication cart. Continued observation revealed the most current remaining count for each resident receiving narcotic medication on the facility's Northeast hallway was performed. Observation revealed the following: R15's Oxycodone drug card contained 15 tablets; however, the narcotic form noted 16; R17's Gabapentin 400 milligram (mg) pill bottle contained two pills; however, the narcotic form stated one, R17's Oxycodone 15 mg drug card contained 16 tablets; however, the narcotic form noted 17. Further observation revealed R33's Lorazepam 1mg drug card contained 15 tablets; however, the narcotic sheet noted 16; and R39's Oxycodone/Acetaminophen 5/325mg drug card contained 20 tablets; however, the narcotic sheet noted 21. In interview with LPN 1 on 01/07/2026 at approximately 9:30 AM, he stated he had not documented the accurate narcotic count prior to administering the narcotic medication and that was why the count was off. He reported the standard procedure was to document the narcotic drug count on the narcotic sheet inside the binder once the medication had been administered to the resident to reflect an accurate amount when comparing the narcotic drug card and narcotic book. In interview on 01/08/2026 at 5:35 PM, the Director of Nursing, (DON) stated the narcotic binder was to be compared to the actual narcotics for reconciliation daily. He stated the unit managers and nurses were to do a narcotic count every time the cart key was passed from one nurse to another. The DON reported the unit managers went behind the nurses to ensure reconciling was being done correctly on a daily basis. He said if a nurse found the narcotic count did not match the narcotic binder count, the nurse should try to find the medication and/or try to account for it on the narcotic sheet. The DON stated if the nurse was unable to find the medication or was unable to account for it, then the nurse should call him. He explained he would call the facility's Nurse Consultant, and we would open up an investigation. The DON said a nurse should look to ensure they followed the doctor's medication order by checking the resident's medication administration record (MAR). He reported the standard procedure for administering residents' medications was to verify the five rights and check the medication against the MAR. The DON stated the nurse should document having given a resident's narcotic medication after administration. He further stated a negative outcome for not properly reconciling narcotics to the narcotic documentation form in the binder was possible drug diversion. In interview on 01/08/2026 at 5:46 PM, the Administrator stated how often the narcotic binder was be compared to the narcotic medication was according to facility policy. She stated reconciling of the narcotic medications was also according to facility policy. The Administrator said the DON or designee would be the staff member to ensure the reconciling of narcotic medications was being done correctly. She explained she expected staff to follow the policy if a narcotic count did not match the amount documented in the binder. The Administrator reported the standard procedure for administering medications, including narcotic medication, was to administer the medication to the resident according to the physician's order in the facility's electronic point click care.

Based on observation, interview, and facility policy review, the facility failed to ensure all medications and wound care products used in the facility were stored and labeled in accordance with professional standards, with the potential to affect 25 out of 25 residents receiving wound care. The findings include: Review of the facility's policy titled, Medication Storage, undated, revealed drugs and biologics were to be stored in the packaging, containers or other dispensing systems in which they were received. Per policy review, only the issuing pharmacy was authorized to transfer medications between containers. Continued review revealed the nursing staff were responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. Further review revealed the facility was not to use discontinued, outdated, or deteriorated drugs or biologics, and all such drugs should be returned to the dispensing pharmacy or destroyed. During observation on 01/06/2026 at 2:30 PM, of a wound care treatment cart located on the rear hallway by nurses' station revealed the following: one tube of Mupirocin ointment with no opened date and not in an individualized bag; one tube of Fluorouracil 5% topical chemotherapy cream with no opened date, no cap on it, and it was not stored in an individualized bag. Continued observation revealed one tube of Medihoney ointment with an expiration date of 09/01/2025, which was not stored in an individualized bag. Per observation, there was also one bottle of sterile water with no opened date or expiration date; one package of Gentell collagen wound filler, opened, unsealed, exposed to air, undated; and one package of lemon glycerin swab sticks, that had expired 06/2024. Further observation revealed four packages of Skintegrity hydrogel impregnated 4x4 gauze with an expiration of 11/2022; one bottle of Dakin's Solution quarter strength undated; one container of Sani Cloth super large wipes with an expiration of 07/2025; one package of Calcium Alginate dressing that was opened, unsealed with no opened date; and one package of Kerrafoam gentle border with an expiration of 10/01/2024. In interview on 01/06/2026 at 2:42 PM, the Wound Care Nurse (WCN) stated she was the person responsible for maintaining the treatment cart; however, she was new to the position and was being trained by the former WCN this week on how to manage the treatment cart. She reported she did not know how often the treatment cart was to be gone through to ensure there were no expired medications or products and that all medications/products were properly labeled. The WCN further stated she thought the treatment cart should be gone through weekly or daily. She further stated the expired medications, wound care products and undated items stored in the treatment cart was not acceptable. In interview on 01/06/2026 at 2:48 PM, the Minimum Data Set (MDS) Nurse stated she was the former WCN and was currently precepting the new WCN on her new role. She stated it was the current WCN's duty to manage the treatment cart and ensure all medications and wound care products were labeled and stored unexpired as according to professional standards. The MDS Nurse said she did not know how often the treatment cart was to be gone through because she also worked two to three other additional roles at the facility. She further stated it slipped her mind to check the treatment cart because she did not look at products she did not use. In interview on 01/08/2026 at 5:35 PM, the Director of Nursing, (DON) stated his expectation for maintaining the treatment carts was for them to be gone through and restocked regularly, with all residents medications individually bagged and clean, and the necessary items easily accessible. He said the staff member responsible for maintaining treatment carts was technically the current WCN. The DON stated the WCN was to ensure the treatment carts did not have expired items, or opened medications and products without dates which were not contained in a protective bag. He said the treatment carts should be checked daily, and a negative outcome for residents who needed wound care and received administration of expired wound care products to their wounds would be potential infection to the resident's wound. The DON said the wound care products were not guaranteed past their expiration dates, and all medications and wound care products should have opened dates on them. In interview on 01/08/2026 at 5:46 PM, the Administrator stated the expectation for maintaining the treatment carts was to follow a standard we could use, find their guidance and follow whatever that was. She said the nurses were responsible for maintaining the treatment carts and ensuring they did not have expired items or opened medication and products without dates and that all were contained in a protective bag. The Administrator reported she was not a clinician and did not know what a potential negative outcome for residents who needed wound care and received administration of expired wound care products to their wounds would be as that was out of her scope of practice.

Based on interview, record review and review of facility policy and procedure, the facility failed to ensure resident participation in the development of the comprehensive care plan for 3 of 8 residents (Resident (R)16, R94, and R72) out of the total sample of 23 residents. The findings include:Review of the facility policy titled, Care Planning - Comprehensive Person -Centered, undated revealed, To the extent practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process. Per policy review All reasonable efforts were to be made for the resident/resident representative to be informed in the language he/she could understand regarding his/her total health status, including but not limited to, his or her medical condition. Review of the facility policy titled, Resident's Rights, dated 11/01/2024, revealed residents had a right to be fully informed of, and participate in, his/her treatment. Further policy review revealed those rights included: the right to be fully informed in a language he/she could understand about his/her total health status, including but not limited to his or her medical condition.1). Review of R16's clinical record revealed the facility admitted the resident on 09/16/2025. Further review revealed however, no documented evidence in the comprehensive care plan, progress notes and signature noting R16 had been present at care plan meetings. The facility was unable to provide documented signature sheets of those in attendance at care plan meetings or proof that translation service was provided to update R16's care plan. During interview on 01/07/2026 at 10:52 AM, via translation by Translator 1 via a telephonic translation service, R16 stated she was from [NAME]. She reported she had not received any documents from the facility written in the Spanish language and said the care team did not use the translation line to speak with her. R16 said the documents she had been given were written in English, and she had to ask a Spanish speaking aide to help her translate the documents. She stated she had not attended any care plan meetings. R16 further stated Spanish speaking staff or a translator application (app) through a web browser on her phone was how she communicated her needs. She additionally said communication was an issue, and she felt frustrated.During interview on 01/05/2026 at 10:40 AM, CNA 1 stated she tried to translate documents for R16 because the documents were written in English. She reported the business office person and the Social Worker tried to explain the forms to her so she could explain the documentation to R16. She further stated she dis not always know how to translate the forms though.2). Review of R94's clinical record revealed the facility admitted the resident on 12/18/2025. Continued review revealed however, no documented evidence in the comprehensive care plan, progress notes and signature noting R94 had been present at any care plan meetings. The facility was unable to provide documentation of those in attendance at care plan meetings or proof that translation services were provided to update R94's care plan. During interview on 01/07/2026 at 11:08 AM, translated by Translator2, R94 stated the documents he received from the facility had been written in English. He said, I cannot see well, even if I could read English. R94 reported it would help if the written documentation he received was written in Spanish and/or read to him. He further stated he had never been in a care plan meeting, and said he felt overlooked due to the communication barriers.3). Review of R72' s clinical record revealed the facility admitted the resident on 05/25/2025. Additional review revealed however, no documented evidence in the comprehensive care plan, progress notes and signature sheet noting R72 had been present at care plan meetings. The facility was unable to provide documented signature sheets of those in attendance at care plan meetings or proof that translation service was provided to update R72's care plan. During interview on 01/07/2026 at 11:22 AM, translated via telephonic translator the resident representative of R72 stated she had not been consulted regarding the resident's care plans. She said the documents she signed and/or had received regarding her husband's care had only been written in English. She stated she had given verbal consents for things on the phone. She stated staff did not use the translation line for communicating with her. R72's representative explained she usually communicated via the translator app on her phone. She further stated she would like more communication from the facility via a translator and written in her own language. During interview on 01/08/2026 at 10:24 AM, the admission Coordinator stated at times she had Certified Nurse Aide (CNA) 1 translate English written documents for Spanish speaking residents. She stated if someone signed something they did not understand they could receive inadequate care or could be exploited. When the SSA Surveyor asked her if the facility tested bilingual aides they used to interpret for Spanish speaking residents on things such as vocabulary, medical, and legal terms, before they used those aides, she stated she did not know if that was being done. During interview with Registered Nurse (RN) 1 on 01/08/2026 at 2:20 PM, when asked how she communicated with non-English speaking residents, she stated I use Google translate, bilingual staff and sometimes family. She reported she had not had a situation where the communication was in an emergency. The RN said she rarely worked on that hall and had not really been told anything about using the interpreter until yesterday. During interview on 01/08/2026 at 11:56 AM, the MDS Coordinator stated the Minimum Data Set (MDS) was a checks and balance system. She said staff should ask questions of the residents or responsible party each time the MDS Assessment was performed, and the assessments could be modified as necessary. The MDS Coordinator stated, Everybody plays a part in it. (the MDS Assessments). She further stated, when asked how she communicated with non-English speaking residents, she would use a translator service provided by the facility when conducting MDS Assessments with non-English speaking residents going forward. The MDS Coordinator also stated, This will make sure everything is correct.During interview on 01/08/2026 at 4:49 PM, with the Director of Nursing (DON), he stated The MDS Coordinator does the comprehensive care plan. The floor nurses have the ability to make changes, but it is usually the interdisciplinary (IDT) team or MDS nurse will change it. He said the care plan was changed with any change in a resident's condition or care. When asked how staff communicated with non-English speaking residents, he stated There are several bilingual staff members. We have had a translation line in place, and a lot of family members come in and insist on doing this. The DON reported We do not allow the bilingual staff to translate medical or legal documents. He stated, when asked if bilingual staff had to do competency testing for medical and legal vocabulary, he stated no testing was done to check competency for translation. The DON further stated he would not be using staff to translate going forward. The DON additionally said a possible negative outcome of not using a translation service for non-English speaking residents, was misinterpretation in communication of necessary information. During interview with the Administrator on 01/08/2026 at 5:50 PM, she stated, nursing was responsible for residents' care plans. She said We have communicated with the residents that are not English speaking in a manner according to our policy. The Administrator explained the facility had a translation service, staff used cue card, pantomime, and some residents preferred to use family and staff members. She stated the negative outcome for not being able to communicate with non-English speaking residents was process failure. The Administrator further said, Every system we have is policy. My expectations is that the policy is followed. She reported the facility had systems that monitor compliance over our policies to ensure they are being followed, and everything that did not follow policy is not desirable.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the facility failed to ensure resident assessments accurately reflected a resident's status for 1 of 3 residents reviewed for MDS accuracy out of the total sample of 23 residents, (Resident (R)16).The findings include:Review of the CMS MDS 3.0 RAI Manual version 1.20.1, revealed the instructions for completing the ethnicity category was to ask the resident to select the category or categories that most closely corresponded to their ethnicity from the list in question A1005. Review further revealed, Only use medical record documentation to code A1005, Ethnicity if the resident is unable to respond and no family member, significant other, and/or guardian/legally authorized representative provides a response for this item.Review of R16's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/22/2025, revealed the facility assessed the resident's ethnicity as Mexican; however, R16's ethnicity was Cuban. During interview on 01/07/2026 at 10:52 AM, R16 stated she came to the United States on a visa from [NAME] and had not received any documents from the facility in the Spanish language. R16 said the care team did not utilize the translation phone to speak with her about her care or during the assessments. She reported she had not attended any care plan meetings. The resident stated she made her needs known as well as she could through bilingual staff if they were available but mainly relied on a translator app on the phone if bilingual staff were not working. She further stated she wanted to communicate in a method she understood, so she could understand what information was being given her, and so she could be understood. During interview with the admission Coordinator on 01/08/2026 at 10:24 AM, she stated the demographic information the electronic health record (EHR) had in it was pulled directly from the hospital paperwork received. She further stated the MDS was updated as each member of the care team completed their assessment portions of the RAI. During interview on 01/08/2026 at 11:56 AM, the MDS Coordinator stated, MDS is a checks and balance system. Questions should be asked each time the assessment is performed, and the assessments can be modified. Everybody plays a part in it. She said she was now going to look at the MDS of each resident to ensure their demographics were correct. The MDS Coordinator reported while she had been transitioning to the role of MDS Coordinator, many people had been assuming parts of the role until she could fully step into the position. She further stated, I am auditing for correct documentation. [NAME] issues, continuity of care can be greatly impacted by incorrect information.During additional interview on 01/08/2026 at 12:35 PM, the MDS Coordinator stated upon investigating R16's inaccurate ethnicity information she, pulled off the old social services form the facility used to use. She said however, the social services (SS) employee who completed that form was no longer an employed at the facility. The MDS Coordinator further stated the demographic information now pulled from an MDS form rather than the social SS form due to the updates in the electronic health record computer program. When the State Survey Agency (SSA) Surveyor asked her if a proper MDS Assessment should include an actual face to face interview with the resident, she did not provide an answer.During interview on 01/08/2026 at 4:49 PM, the Director of Nursing (DON) stated, The MDS Coordinator does the comprehensive care plan. The floor nurses have the ability, but it is usually the interdisciplinary (IDT) team or MDS nurse who made changes. He said the MDS was changed with any change in the resident's condition or care. The DON reported he was not familiar with the MDS processes, as the MDS Coordinator handled that. He stated he expected the MDS nurses to review all documentation and assess the resident in person. The DON further stated if a MDS was not filled out correctly and was inaccurate, it could cause incorrect billing, or medical services which would cause me to go to prison.During interview with the Administrator on 01/08/2026 at 5:50 PM, she stated, I do not do anything with editing residents' MDS Assessments; however, I do use data. She said We ensure the data is correct by following our data and process. We have a triple check system. The Administrator explained the negative outcome if an MDS was inaccurate was process failure. She reported Every system we have is policy. My expectations that the policy is followed. We have systems that monitor compliance over our policies to ensure they are being followed. The Administrator further stated the facility had a process and a policy, and everything that did not follow the policy was not desirable.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision for one of 31 sampled residents (Resident (R) 13). The facility implemented their procedures and a correction plan, and after review of records and interviews it was determined the facility implemented their correction plan as alleged with a completion date of 05/07/2025, prior to survey entry. The findings include: Review of the facility's policy titled, Elopement/Missing Person undated, revealed It is the intent of the facility to provide a safe and home-like environment for all residents and to provide adequate supervision and assistance to prevent accidents. Review of the Logbook Documentation provided by the facility from 03/31/2025 to 09/19/2025 revealed that prior to the week of the elopement on 05/06/2025, the only documented checks were for the Front Entrance, the Northeast Hall, the Northwest Hall, the Southeast Hall, the Southwest Hall, the Dining Room, and the Time Clock Room. The week following the elopement a new section was added called Courtyard Gate. Additionally, it was noted that these checks were only documented five days per week. Review of the monthly calendar revealed the checks were completed weekdays only with no documented evidence to support the checks were completed on weekends. Review of the facility's timeline of the events surrounding R13's elopement revealed that R13 entered the vending machine room on 05/06/2025 at 7:48 PM. At 7:59 PM, R13 left facility grounds through the courtyard gate. A CNA noted that he was missing at 8:16 PM. The nurse was notified at 8:19 PM. R13 was located by staff member outside a store 0.4 miles from the facility at 8:32 PM. Review of weather conditions during this timeframe for 05/06/2025 revealed the evening was mild without precipitation and with temperatures in the 60's to low 70's. Record review revealed the facility admitted R13 on 11/29/2023 with diagnoses that included bipolar disorder, paranoid schizophrenia, depression, and anxiety. Review of the resident's Minimum Data Set (MDS), with an Assessment Reference date of 04/21/2025, revealed R13 was assessed to have a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severely impaired cognition. Review of R13's Comprehensive Care Plan (CCP), dated 05/06/2025, revealed the resident was care planned for demonstrating movement behavior that may be interpreted as wandering, pacing, or roaming related to the diagnosis(es) of metabolic encephalopathy, schizophrenia, bipolar, cognitive communication deficit, depression, psychosis, and problems understanding the immediate environment. Further review of R13's CCP, dated 05/06/2025, revealed the resident's symptoms were manifested by: Attempting to leave the facility without a responsible escort (elopement), becoming agitated, oppositional and combative when re-directed. Interventions included preventative strategies such as Assess for potential elopement/unauthorized departure risk, and Post a picture of the resident at/near the front desk and/or nursing station in a discrete place identifying possible elopement risk; staff would be notified of risk potential, and Make rounds/room checks per facility protocol to minimize chance of unauthorized leave.Review of the witness statement on 05/06/2025 from R13 revealed that R13 told the Administrator that he just went to the store to buy some cigarettes and a soda. Review of the witness statement on 05/06/2025 from R30 revealed that this resident told the Administrator that R13 exited the facility via the door in the vending machine room after R30 opened that door for R13. Review of the facility's staff witness statements from 05/06/2025 revealed a Certified Nursing Assistant (CNA)14, who was unable to be interviewed during this investigation, attested that when she came into work on the night of 05/06/2025 she was told R13 was missing. She wrote in her statement that the search had started, and she left and went to the nearby store and saw the resident standing outside the store. She further attested that she asked R13 to get into her car, but he refused so she called the nurse, and they came and got the resident. Review of CNA16 witness statement, dated 05/06/2025, revealed she had taken the resident out to the courtyard to smoke, and they had returned inside the facility. She stated she then heard the alarm, went to check, and R13 was gone. She stated a head count was completed, and the search was initiated. Interview with Licensed Practical Nurse (LPN) 1 on 09/30/2025 at 2:01 PM, revealed she had already left work for the day (of the elopement) but got a phone call from LPN 4 telling her that R13 was missing. She stated she came back to work to help look for him. LPN 1 stated that R13 was known to go to a nearby store, often with his sister when she would sign him out. She reported the resident was found at the same store, down the road from the facility. Review of LPN4's witness statement, dated 05/06/2025, revealed that she attested that a CNA came and informed her that R13 was missing. She stated she immediately began the elopement protocol, completed a head count, and searched the courtyard and then around the premises of the facility. Further review of the statement revealed that when she was unable to locate the resident, she called the Unit Manager and notified her. Interview on 12/02/2025 at 12:38 PM with LPN4 revealed that at the time of the elopement on 05/06/2025 R13 had a sitter. She reported that the sitter let him into the courtyard to smoke but left to take a phone call and when the sitter came back, she was unable to locate R13 and that initiated the elopement protocol. She reported that there were two nurses in the facility at the time of the elopement on 05/06/2025 including herself, and they searched the courtyard and there was no lock on the ground. She reported that she asked the resident how he got out, and he stated that he got through the gap in the fence, telling her I pushed it and got out. LPN 4 reported that R13 had lost some weight and was able to fit through a gap because the fence was in very poor condition at the time. She stated R13 was gone from the facility for a minimum of 30 minutes to an hour maximum, and that he was located at the store down the road. She stated R13 was returned to facility and was assessed to have no injuries or concerns. When asked about the facility stating that another resident, R30, had opened the door for R13 when he eloped. LPN 4 stated, That resident can't even get up out of bed on his own and is in a wheelchair; he wasn't in there. Review of LPN9's witness statement, dated 05/06/2025, revealed that LPN9, now retired, attested he was told R13 was not in the building, so he searched for the resident on a nearby highway. He stated that he spoke to the Administrator and was advised to check the stores at the other end of the Avenue. He wrote that he found R13 at the store and brought him back to the facility. In an interview with the Maintenance Director on 11/26/2025 at 10:56 AM, he stated that maintenance checked the locks and doors daily and documented this in a log, while the weekend manager on duty performed the checks on weekends. After the elopement, he stated the padlock to the courtyard gate was found on the ground. The Maintenance Director reported testing it several times; it functioned normally for the first two or three attempts but then intermittently failed to latch on subsequent tries. He stated that lawn care workers had been on-site around that time, though he was uncertain if it was on 05/06/2025 or the day before. He clarified that contracted workers were not responsible for locking up behind themselves, as he or his assistant always secure the area after outside workers complete their tasks. The Maintenance Director then stated that at the time of the 05/06/2025 elopement, the courtyard fence and lock were different than what they were now. The fence was vinyl and secured with a combination padlock. Following the incident, the Maintenance Director consulted both local and state fire marshals about updating these structures and ultimately made modifications based on their recommendations. The fence was replaced with a wooden fence and a welded frame gate, and the lock was upgraded to a MagLock-described as a coded lock like those used at the facility's entrances. Interview with the Director of Nursing (DON), on 11/24/2025 at 2:00 PM revealed that he was not employed until September of 2025, so he was not present for R13's elopement on 05/06/2025. Per interview, he stated the elopement policy instructs staff to respond if the resident was not found within 10 minutes. He stated two staff members was to go outside going in opposite directions looking for the resident, and if the resident was not found the police would be notified. He stated that if a resident does trigger in the assessment as an elopement risk, then the resident would be care planned for an elopement risk. He stated that staff would know a resident was at risk for elopement by looking in the elopement binders at each desk and by shift report. In an interview with the Administrator on 11/24/2025 at 2:48 PM, the Administrator stated staff would know someone was an elopement risk because we have elopement binders that have all the residents listed that are deemed at risk for elopement. She stated that if a resident was assessed at risk for elopement, they would be care planned for elopement. Regarding the elopement on 05/06/2025, she stated the facility was not aware of the faulty lock and that the lock was the replaced with a new one that same night. She stated that the time frame around elopement was put together based on witness statements. She reported that R13 eloped because he exited into the courtyard when another resident was going outside (courtyard is a secure area) but he was able to manipulate the lock on the gate and get it open. She stated that this was why the lock was replaced. The facility implemented the following steps as their plan of correction:Review of a receipt that the facility shared with surveyors revealed that on 05/06/2025 at 9:36 PM, a new combination padlock was purchased from The Home Depot. Review of records revealed documentation of training provided to staff on elopement procedures and elopement drills. Interview with the Administrator on 11/24/2025 at 2:00 PM revealed education was provided after to residents after the incident to let them know not to let other residents outside. She reported that the facility also actually changed the process for going into the courtyard, and that they no longer use the room from which he exited as the point of entrance into the courtyard. She stated that R13 was assessed upon return and had no injuries. She also reported that the facility did a full-scale elopement drill at the time of R13's elopement on 05/06/2025, and an employee found him at the dollar store down the street and brought him back. All applicable persons were notified of the elopement (his family, OIG). She also reported that education was provided to staff after R13's elopement and this was QAPI'd. Review of R13's medical record revealed that 05/06/2025 at 9:23 PM the resident had a pain assessment and a skin assessment completed. The resident had no complaints of pain at that time, and only had place noted to the left side of his face where he had picked his skin. R13 was placed on 1:1 supervision after his return to the facility. The resident's care plan reflected a revision on 05/06/2025 to add this intervention of 1:1 supervision.Record review of the facility's records of actions after R13's elopement on 05/06/2025 revealed that the facility did provide records of Elopement Training that began on 05/06/2025 and included the contents of the education provided and sign-in sheets for the education and the competency tests that were taken by staff. Records also reflected that the facility began Elopement Drills on all shifts on 05/08/2025. In addition, there was a sign-in list for the AdHoc QAPI meeting that took place on the night of 05/06/2025 after R13's elopement.

Based on interview, record review, review of facility policy, and review of a facility investigation, the facility failed to have an effective system in place to ensure resident safety for one (Resident (R) 140) of two sampled residents reviewed for elopements. On 09/04/2022, R140 eloped from the facility unescorted and unsupervised, and required police intervention to locate the resident and return him to the facility. On 06/28/2024, the Administrator and Director of Nursing (DON) were provided a copy of the CMS IJ Template and notified that the failure to ensure residents were provided supervision and protected from further elopement, constituted immediate jeopardy at F 689. The Immediate Jeopardy (IJ) at F 689 also constituted Substandard Quality of Care at 42 CFR 483.25. The IJ was determined to exist on 09/04/2022 when the facility discovered R140 had eloped from the building. The facility completed the following: 1. Resident 140 no longer resides in the facility. Resident was returned to facility by police at 22:29 on 09/04/2022. A head-to-toe assessment was completed by a licensed nurse on 09/04/2022, the nurse practitioner was notified by a licensed nurse on 09/04/2022, and SBAR [Situation, Background, Assessment Record] was completed on 09/04/2022 by a licensed nurse. (A) An elopement assessment was completed by a licensed nurse on 09/04/2022. (B) Ad Hoc QAPI [Quality Assurance Performance Improvement] meeting was held with the Administrator, Medical Director, Director of Nursing, Admissions Coordinator, Social Services Director, Dietary Manager, Human Resources Director, Housekeeping Director, Activities Director, and Therapy Director on 09/04/2022. (C) One-on-one supervision was initiated, and the care plan was updated by the Interdisciplinary Team (IDT) Director of Nursing, Social Services Director, Therapy Director, and clinical managers on 09/04/2022. (D) The resident Representative was notified in person of the incident by a licensed nurse on 09/05/2022. (E) Every shift behavior monitoring for exit-seeking behavior was continued per MAR and TAR [Medication Administration Record and Treatment Administration Record] on 09/04/2022 until discharge. The resident had a wanderguard placement prior to the incident on 09/04/2022 and was added to the care plan at the time by a licensed nurse. (F) Resident 140 was seen by NP [Nurse Practitioner] and/or physician on 09/06/2022. (G) One-on-one monitoring was placed on orders on 09/08/2022. (H) Resident was monitored by Social Services from 09/06-09/08/2022. (I) Resident 140 was reviewed by IDT for changes in behavior on 09/06/2022. 1. How other residents having the potential to be affected by the same deficient practice will be identified, and what corrective action will be taken: An elopement assessment was completed for 81 residents on 09/04/2022 to 09/06/2022 by licensed nurses. There were 3 residents at risk for elopement at the time the assessment was completed with elopement care plans in place. There were zero new residents identified at risk for elopement at the time the assessments were initiated and completed. Training What measures will be put into place and what systemic changes will be made to ensure that the deficient practice does not re-occur? Clinical and agency clinical staff were educated regarding elopement policy and elopement drill beginning 09/04/2022 and completed on 09/12/2022. Education was completed by the Director of Nursing, ADON [Assistant Director of Nursing], MDS [Minimum Data Set] nurse, other nurse managers, and the Dietary Manager. Any staff who fails to comply with the points of the in-servicing would be further educated and /or progressively disciplined as indicated up to termination. As an ongoing practice, an elopement assessment was completed upon admission, quarterly and as needed related to changes in the resident's exit-seeking behaviors. Discussion at clinical meetings of changes in behaviors with review of orders, review of MARs/TARs, care plan review, nurse' notes review, and reports by staff. Care plans will be updated as needed based on these reviews by the clinical leadership and IDT. Individual resident's care plans will be reviewed at least quarterly for needed updates as part of the resident's quarterly care plan conference. 1. How the corrective actions will be monitored to ensure the deficient practice does not reoccur, (i.e., what Quality Assurance Program will be put into place and by what date the systemic changes for each deficiency will be completed). Resident 140 was reviewed by IDT for changes in behavior on 09/13/2022, 09/21/2022, 09/27/2022, 10/04/2022, 10/25/2022, 11/01/2022, 11/04/2022, 11/08/2022, 11/15/2022, 11/29/2022, 12/05/2022, and 12/16/2022. One on Two monitoring on 09/23/2022 and changed to every 15-minute checks on 11/04/2022 with care plan revisions by licensed nurse, which remained until discharge. Ad Hoc QAPI meeting was held with the Administrator, Medical Director, and Interdisciplinary Team (IDT) on 09/04/2022. (C) Elopement Drills conducted daily for 14 days by the Administrator, Director of Nursing, Housekeeping Supervisor, and /or the Maintenance Director. The QAPI Committee included but not limited to the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, MDS Nurse and Medical Director will review the results. An extended survey was initiated on 07/02/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 07/03/2024. Based on the findings of this survey, it was determined the immediate jeopardy was removed and the deficient practice was corrected as alleged on 09/13/2022, prior to initiation of the investigation. Therefore, the IJ was determined to constitute Past Jeopardy. The findings include: A review of the facility policy titled Elopement Guideline, dated 04/05/2023, revealed it was to provide a safe and secure environment for all residents. In the event of resident elopement, the facility would implement its policies and procedures immediately to locate the resident in a timely manner. Elopement was defined as a situation in which a resident leaves the premises or a safe area without staff knowledge and necessary supervision. A review of the facility's undated policy titled, Regarding Missing Residents and Elopement revealed all residents were provided adequate supervision to meet each resident's nursing and personal care needs. All residents would be assessed for behaviors or conditions that put them at risk of elopement. All residents assessed to be at risk of elopement would have this issue addressed in their plan of care. A review of the electronic medical record (EMR) revealed that R140 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and alcohol dependence. A review of the EMR elopement risk assessment dated [DATE] revealed R140 had a low risk score of zero for elopement. A review of an EMR wandering risk assessment dated [DATE] revealed that R140 was at low risk for wandering. A review of the Admission MDS, with an Assessment Reference Date (ARD) of 08/02/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident was severely cognitively impaired. Per the MDS, the resident used a walker or a wheelchair, and needed physical assistance of one person for ambulation and locomotion. The MDS showed no wandering behaviors as of the date of this assessment. A review of the EMR progress noted dated 08/07/2022 revealed R140 had been wandering during the night. Per the note, at 5:59 AM, Resident also noted to wander as reported to me by his CNA [Certified Nurse Aide] tonight. Although there was no information in the progress note to indicate exit seeking behavior, a review of the EMR care plan revealed the care plan was updated that same date (08/07/2022) to show that the resident was now actively wandering and may be in other beds or close to exits. In response, interventions were added to place the resident on 15-minute location checks until a physician-ordered wander guard device arrived and placed on the left ankle. A review of the EMR physician's orders dated 08/10/2022 revealed the wander guard device was placed to the left ankle. Placement and function of the wander guard per physician orders was verified per documentation on the MAR. A review of Progress Notes revealed that on 08/18/2022, the resident reported that he was not feeling well. He went out to the emergency room (ER) on 08/19/2022 and returned on 08/20/2022 with no medical diagnosis identified; however, upon return R140 continued to state he did not feel well. On 08/25/2022, R140 was diagnosed as COVID-19 positive and was moved to the COVID Unit on the Southeast Hall. A wandering risk assessment dated [DATE] revealed the resident was now at high risk for wandering, due to a history of wandering and the placement of the wander guard device. This assessment showed the resident was now independent with locomotion in his wheelchair. Further review of the EMR revealed that on 08/31/2022, R140 was moved to a room on the Southwest Hall that was approximately 60 feet from an emergency exit door. A review of the EMR progress note (SBAR), dated 09/04/2022, revealed that at approximately 10:15 PM, Licensed Practical Nurse (LPN) 15, heard the alarm on the Southwest exit door, (which was equipped with a wander guard alarm) sounding. R140 was not in his room and the wheelchair was next to the bed. Staff were alerted and an elopement protocol was enacted. Police were notified and they found the resident, who was returned to the facility at approximately 10:29 PM. R140 was dressed appropriately for the weather and sustained no injuries in response to the elopement. Per the SBAR, the resident stated he was going home, and was placed on one-to-one supervision. Review of the facility investigation revealed that on 09/04/2022, sometime between 10:00 PM to 10:15 PM, R140 exited the facility through the Southwest emergency door, setting off the alarm. Per the investigation, the resident was found at a convenience store which was .6 tenth of a mile from the facility, downhill on a two-lane road. The facility stated the root cause was the resident's desire to go home. Review of the investigation revealed that the facility did not identify how long the alarm had been sounding before staff responded to it. A review of the facility form titled Confidential Witness Statement dated 09/04/2022, revealed LPN15 was in another resident's room to provide care and exited that room sometime between 10:10 PM to 10:15 PM. At that time, she heard the Southwest Door alarming. When she heard the alarm, she asked why the door was alarming and an unnamed resident stated that a tall male went out the door. Per the witness statement, LPN15 started searching the residents' rooms and did not find R140, whose wheelchair was still in his room. She alerted the other staff to search and notified the DON by 10:21 PM. Another nurse called 911 to notify the police of the elopement. At 10:28 PM the administrator was notified and at approximately 10:29 PM, the police returned R140 to the facility. Review of facility records revealed LPN15 was no longer employed at the facility and was unavailable for interview. Review of the witness statements for the other three staff who were assigned to the Southwest Unit that night revealed that all staff were either in resident rooms or on break and had not heard the alarm on the Southwest Door sound. The witness statements indicated that they were unaware that R140 had eloped from the facility until LPN15 identified the issue. Review of witness statements from staff working on the other units revealed that they, also, failed to hear the alarm sound when R140 eloped through the Southwest Hall door. A review of former Social Services progress notes found in the electronic medical record dated 09/06/2022, 09/07/2022, and 09/08/2022, revealed R140 did not remember leaving the facility. Per the resident's closed record, R140 was discharged from the facility on 12/16/2022 and was not available for an interview. Interview with R61 on 07/02/2024 at 9:30 AM revealed he was the resident who saw R140 go out the door and the alarm sounded. He stated he told staff he saw R140 go out the door. R61 could not remember how long the alarm had been sounding prior to staff responding. In an interview with LPN2 on 06/28/2024 at 1:15 PM, he stated he did not remember R140. LPN2 stated the emergency door alarmed if a resident tried to go out the door wearing the wander guard device. In an interview with CNA14 on 06/28/2024 at 2:27 PM, she stated she was one of the staff working on the Southwest Unit on the night that R140 eloped. She stated that she did not recall specifically where she was at the time, and did not hear the alarm sounding, CNA14 stated she was unaware that R140 had eloped. CNA14 stated R140's room was located near the south nurses' station to observe him for wandering the unit and she checked on R140 hourly. Attempts to interview the additional staff who were present on the night of 09/04/2022 were made; however, calls to these staff were not returned. In an interview with the DON on 06/28/2024 at 3:50 PM, she stated she was not the DON when R140 eloped; however, since 2022, the facility had assessments and interventions for elopement in place to ensure residents were safe and elopement does not reoccur. In an interview with the Administrator on 06/28/2024 at 11:05 AM, she stated she was not the Administrator at the time of R140's elopement and the Quality Assurance plan has ensured there have been no other elopements since 2022.

Based on observation, interview, record review, and review of facility policy and food storage reference material, the facility failed to store food in accordance with facility policy and accepted standards of food service/management. Foods were not dated and/or labeled when opened. The deficient practice had the potential to affect 85 of 89 residents who consumed food stored and /or used in this kitchen. The findings include: A review of the facility policy titled Food Storage, dated 03/25/2012, revealed food is stored and prepared in a clean safe sanitary manner that will comply with state and federal guidelines. Per the policy, containers for bulk items are leakproof, non-absorbent, and sanitary, with tight-fitting lids. In addition, the policy stated that containers are labeled with their content and date. A review of the website www.Servesafe.com revealed a poster titled How to Store Food, dated 2019, which stated to label and date all food. The poster noted that safe food handling practice was: First in and first out (FIFO). Review of a Roster/Matrix form provided by the facility during the survey revealed that four of 89 residents received nutrition via a tube, with the other 85 residents consuming their food orally. Observation of the kitchen on 06/23/2024 at 12:35 PM during the initial tour revealed a shelf in the walk-in refrigerator contained a steam table pan covered in foil with no date or label. Observation of the dry storage revealed a clear container with a red top and white particle substance with no open date or label. Observation of open oatmeal and farina packages revealed they were not dated when opened. In addition, there were two saran-wrapped packages of elbow noodles with no open date, two open packages of buttermilk mix, and two open brown sugar in saran wrap with no open date. Five containers of seasonings in dry storage had no open date. In an interview with the [NAME] on 06/28/2024 at 9:30 AM, she stated that she was Servesafe certified. The [NAME] stated that when food was opened, staff were to label the food with the current date and then, throw it away in three days. The [NAME] stated that food without a label and/or date was to be thrown away because it is not known how long the food was opened and this can make residents sick. In an interview with Dietary Aide (DA) 1 on 06/28/2024 at 9:37 AM, she stated opened food item were to have the current date and item. Food without a label and no date was to be thrown out because it is not known how long it had been on the shelf. In an interview with DA 2 on 06/28/2024 at 9:39 AM, she also stated that food was to be dated and labeled when opened, and discarded if there was no label or date. In an interview with the Dietary Manager on 06/28/2024 at 10:07 AM, she stated all food in dry storage must have a label and open date. If a food item does not have a label or open date, it must be thrown out because the food can be spoiled, and they do not know the length of time it was on the shelf. In an interview with the Director of Nursing (DON) on 06/28/2024 at 10:59 AM, she stated her expectation was for dietary staff to label, date, and rotate food based on its date.

Based on observation, interview, record review and policy review, the facility failed to implement an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections for two of 76 sampled residents (Resident (R)11 and R35). Staff failed to perform hand hygiene when indicated, as well as failed to handle and dispose of a soiled dressing in a manner to prevent the possible spread of infection. In addition, the facility failed to ensure that required Personal Protective Equipment (PPE) was readily available and worn by staff when providing care for a resident who was on Enhanced Barrier Precautions (EBP). The findings include: 1. Review of the facility policy, Clinical Standard and Guidance Infection Prevention and Control Guidelines, dated 08/25/2019 and reviewed 01/26/2024, revealed, It is the policy of the facility that a comprehensive system is in place that prevents, identifies, investigates reports, records and controls infections and prevent the development and transmission of communicable disease processes for residents/care providers, staff, visitors and others within the facility. Review of the Hand Hygiene Guidance policy, dated 02/10/2024, revealed that, Hand hygiene is the single most efficient means of preventing the spread of infection. Wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water when hands are visibly dirty or are visibly soiled with blood or other body fluids such as urine or feces. Wash hands before eating, after eating and after using the restroom with a non-anti-microbial soap and water or an anti-microbial soap and water. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations. Review of the Electronic Medical Record (EMR) revealed that R11 had a Stage IV pressure ulcer to the sacrum which was identified on 04/22/20/24. On 06/24/2024, the Wound Care Physician gave an order for treatment of the sacral wound, with staff to Cleanse wound with normal saline, apply alginate and cover with medi-honey. Cover with silicone foam border dressing every day. Observation, during a wound care observation for R11 on 06/24/2024 at 2:11 PM, revealed the Infection Control Registered Nurse (IC/RN) placed her large set of keys and a clean dressing on a PPE box inside the door of the room. She then put on clean gloves without first performing hand hygiene. The IC/RN next removed R11's soiled dressing and threw it in the resident's trash can. The IC/RN then failed to perform hand hygiene after degloving. She then took a pen out of her pocket and wrote a date on the dressing. The IC/RN next picked up the clean dressing off of the PPE container and opened the dressing on the resident's bed with no barrier underneath. The IC/RN proceeded to spray the wound with cleanser; however, as she was holding the resident on his side, she let go of him to wash her hands, allowing the resident to roll back onto his wound, and contaminate it. She then put gloves on again, picked up the dressing from the bed and placed it on the wound. The IC/RN then contaminated the brief and bedding as she pulled up the brief and bedding without removing her soiled gloves. After pulling up the brief and linens, she then degloved without performing hand hygiene. The nurse then left the room, leaving the soiled dressing in the trash in the resident's room. After the dressing change, an interview with the IC/RN revealed there was nothing she would do differently. The IC/RN stated that at another facility, she used wax paper as a barrier; however, there was nothing here to use. She stated she considered the resident's bed linens and the PPE storage box were clean and thought putting the clean dressing on those areas was OK. An interview with the Director of Nursing (DON) on 06/27/2024 at 2:43 PM revealed she expects all staff to follow the infection control policy and hand hygiene policies as written. Per the DON, hands are to be washed before, during, and after any dressing changes. Also, a barrier is to be used on the overbed table in resident's rooms to prevent contamination of supplies, and this can be a plastic bag or a clean towel. She further stated she expected staff to keep any personal items, like keys, in the staff's pockets. The DON stated that all soiled dressings are to be bagged and removed from the resident's room after wound care and if the resident cannot stay in any position for wound care, staff should get another staff member to assist them. An interview with the Administrator on 06/28/2024 at 2:34 PM revealed she expected staff to follow the policies and procedures of infection control regarding correct hand hygiene. 47798 2. Review of a facility policy titled, Enhanced Barrier Precautions Guideline, dated 07/12/2022 and reviewed 04/12/2024, revealed the facility would ensure that additional and appropriate PPE was utilized, when indicated, to prevent the spread of Multidrug-resistant organisms (MRDOs). Per the policy, EBP was defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of MDROs in the form of blood or body fluids, onto the hands and/or the clothing of the rendering care giver. Record review of a face sheet revealed the facility admitted R35 on 03/15/2024. Per the face sheet, the resident's diagnoses included Ogilvie syndrome and colostomy status. Review of R35's comprehensive care plan, dated 10/30/2023, revealed the resident was on EBP due to the colostomy. Observation of R35's room on 06/23/2024 at 1:04 PM revealed a sign on the wall at the head of the bed stating the resident was on EBP. However, there was no PPE container (which included gowns) in the room, behind the resident's door, or in the hall. During an observation of colostomy care provided to R35 by Licensed Practical Nurse (LPN) 9 on 06/26/2024 at 2:45 PM, LPN9 did not wear a gown during the procedure. In addition, LPN9 failed to perform handwashing after the care was provided, prior to exiting R35's room. During an interview with LPN9 on 06/26/2024 after the 2:45 PM care was completed, she stated she did not know she was supposed to wear a gown when she did colostomy care. LPN9 further stated she thought she had washed her hands when she finished providing care but if she didn't, she should have. During an interview with Certified Nursing Assistant (CNA)10 on 06/24/2024 at 1:55 PM, she stated if a resident was on any type of precautions, there would be a sign posted above the bed or on the door. CNA10 stated she would need to wear a gown and gloves for residents on EBP and there should be a PPE cart in the hallway. Interview on 06/24/24 2:23 PM with the DON revealed that all EBP care plans are kept in a binder at the nursing station, and she is currently trying to get all the care plans scanned into the EMR. Per the DON, residents on EBP or any precautions should have a sign up at the head of their bed or on their door, The DON stated staff would need to wear a gown and gloves to provide care for these residents. The DON stated there should be a cart in the hall or on the back of the resident's door stocked with PPE. At this time, the DON went to the rooms of two resident (R16 and R31) who were on EBP, and confirmed there was no PPE tray on those resident's doors. The DON stated that, Maybe it [the PPE tray] fell down and I'll check with maintenance to see if they have an order to put one back up. The DON stated she did not know why there was not a PPE available for staff use. During an interview with CNA10 on 06/26/2024 at 7:00 PM, she stated she was not sure what EBP was. CNA10 further stated she received a report from the off going shift and that is how she would know how to care for a resident. CNA10 stated if a resident was in isolation, she would wear a gown and gloves. Additionally, CNA10 stated gowns were usually in a clear box outside of the resident's room with other types of PPE. During an interview with CNA13 on 06/26/2024 at 7:30 PM, she stated she would suit up prior to entering a room for a resident on EBP. CNA13 stated there should be a sign on the resident's door and PPE should be placed outside the resident's room. CNA13 further stated she had not been educated on EBP and thought this meant that a resident would need more barrier cream applied. During an interview with LPN11 on 06/26/2024 at 7:51 PM, she stated she did not know what EBP was and there were no signs posted that she was aware of. LPN11 further stated that PPE was in bins outside of the resident rooms. During an interview with Registered Nurse (RN) 6 on 06/28/2024 at 10:00 AM, she stated she had received education related to EBP approximately two weeks ago and again this morning, after the issue with a lack of EBP was identified during the survey. RN6 stated staff was required to wear gown and gloves when providing direct contact care for resident's on EBP. RN6 stated there was usually a cart with PPE in the hall or in the resident room and it was always accessible. During an interview with the Assistant Director of Nursing (ADON) on 06/27/2024 at 3:15 PM, she stated was responsible for training staff on EBP and would train based on facility policy. The ADON stated when a resident was on EBP, there would be a sign posted on the resident's door or over their bed. The ADON further stated if the resident was on EBP, a PPE bin or cart would be placed outside of the doorway or in an over the door bin. The ADON stated she expected PPE to be readily accessible and for staff to be aware and knowledgeable of what PPE to use and what they were using it for. During an additional interview with the DON on 06/28/2024 at 10:15 AM, she stated she was also the acting Infection Preventionist (IP). The DON stated EBP education was provided as well as skills check offs quarterly and as needed. The DON stated the expectation that PPE was always accessible and available for staff to use. The DON again stated PPE should be on the halls in a cart or bin or behind the resident's door. The DON further stated staff was expected to follow facility policy, be knowledgeable of what EBP were and to wear the appropriate PPE when a resident was on barrier precautions. During an interview with the Administrator on 06/28/2024 at 10:07 AM, she stated the ADON was responsible for staff education, which was weekly, monthly, and quarterly and was ongoing. She further stated her expectation was that PPE would always be available for staff, who would follow policy and wear the appropriate PPE when providing care.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide a clean and homelike environment for residents. Bathrooms and hallways had a strong odor of urine. Floors were soiled, sticky, stained and/or rusted. Bathrooms were not clean. The failure to maintain a clean, homelike environment had the potential to affect Resident (R) 10, R44, and R31, as well as all other residents residing on two of the three facility halls, with 15 resident rooms on each hallway. The findings included: Review of the facility's policy titled, Landmark-Clinical Standard and Guidance: Resident Rights Guidelines, effective date 07/12/2023 and last reviewed 04/12/2024, revealed the resident's comfort, safety, and overall welfare must be promoted, protected, and enhanced at all times. Review of the facility's policy titled, Landmark-Clinical Standard and Guidance: Homelike Environment Guidance, effective date 06/20/2023 and last reviewed 04/12/2024, revealed that it is the policy of the facility to ensure that the environment provided by the facility is safe, sanitary, functional, and comfortable. All room contents to include clothes, furniture, devices, linens, bedspreads, privacy curtains, window coverings, wall hangings, wallpaper, and floors should be clean and in good repair. Review of the facility's policy titled, Landmark-Clinical Standards and Guidance: Resident Room Clean Policy, effective date 02/17/2021 and last reviewed on 02/16/2024, explained the procedure for cleaning a resident's room, which including mopping floors. 1. a. Observation on 06/23/2024 at 12:27 PM of the facility revealed the hallway which contained Rooms 106 -116 smelled of urine. Further observation on 06/23/2024 at 12:59 PM revealed that the shared bathroom between rooms [ROOM NUMBERS] smelled like urine. At 1:04 PM on 06/23/2024 it was observed that the hallway containing Rooms 121 -135 smelled strongly of urine. At 1:06 PM on 06/23/2024 observation of room [ROOM NUMBER] revealed the room had a strong urine smell and the floors were dirty. The floors had black marks and a clear, dry, sticky substance on them. At 1:46 PM on 06/23/2024, it was observed that room [ROOM NUMBER] smelled strongly of urine. The floors were dirty. There were black smudges on the floor and a large, dried puddle of urine from a resident's indwelling catheter, which had leaked onto the floor. Paper towels and other paper debris littered the floor on the side of the room near the window. The floor in room [ROOM NUMBER] was observed on 06/23/2024 at 1:57 PM to be dirty and looked like it had not been mopped recently. b. Observation on 06/24/2024 at 11:45 AM revealed that room [ROOM NUMBER] still smelled strongly of urine; however, the dried puddle of urine had been mopped up. The hallway with Rooms 121 -135 still had a strong smell of urine. c. Observation on 06/25/2024 at 8:49 AM revealed that the hallway containing Rooms 121 - 135, smelled strongly of urine. In an interview on 06/25/2024 at 9:36 AM, Certified Nursing Assistant (CNA) 3 confirmed that the hallway with Rooms 121 -135 smelled like urine. d. Observation on 06/26/2024 at 8:31 AM revealed that the hallway with Rooms 121 - 135 once again smelled strongly of urine. Observation later at 9:05 AM on the hallway that contained Rooms 108 -116, revealed it also smelled of urine. e. An interview with R10 on 06/27/2024 at 10:25 AM revealed that she felt like the entire facility smelled like urine, especially the hallway that housed Rooms 121 -135. An interview with Housekeeper (HK) 1 at 9:58 AM on 06/25/2024 revealed that the common areas (such as the hallways and dining rooms) and residents' rooms and bathrooms were cleaned daily. A later interview with another housekeeper, HK 2, on 06/25/2024 at 1:40 PM, also revealed residents' rooms and bathrooms were cleaned daily. On 06/26/2024 at 8:31 AM, during a second interview with HK 1, he stated that it sometimes smelled bad in the morning. Although members of the survey team verified the urine smell at this time, HK1 stated that he did not think that the hallway containing Rooms 121 through 135 smelled like urine. On 06/26/2024 at 8:33 AM in an interview with CNA 2, she stated that she did not think the hallway smelled like urine even though members of the survey team verified there was a strong smell of urine. An interview with Licensed Practical Nurse (LPN) 1 on 10:27 AM on 06/27/2024 confirmed the odor of urine and added that the odor was much better today than usual. She stated that up front, when you entered the facility, it sometimes had a strong smell of urine. An interview with the Director of Nursing (DON) on 06/27/2024 at 10:29 AM revealed that R75, who resided on one of the halls which smelled of urine, refused to send her undergarments to the laundry. Instead, the resident washed them out and hung them up in her room to dry. She did not use soap on the undergarments, only water, and, per the DON, this was the reason that the hallway containing her room, continually smelled like urine. Interview with the Administrator on 06/26/2024 at 2:10 PM revealed that she was unaware of the urine smell. When asked if she felt the smell of urine constituted a homelike environment, she stated no. 47798 2. a. During an observation on 06/23/2024 at 4:01 PM, R44's bathroom had a quarter-sized brown substance on the floor beside the toilet, as well as a brown substance smeared on the wall located above the toilet paper holder. Review of R44's Quarterly Minimum Data Set (MDS) Assessment, dated 06/06/2024, revealed the facility assessed R44 to have a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. During an interview with R44 on 06/23/2024 at 4:01 PM, he stated his biggest concern at the facility was with housekeeping services. R44 confirmed his bathroom currently had stool (feces) on the floor and smeared on the wall. R44 stated the stool had been in the bathroom for at least two or three days. R44 stated the housekeeping staff was in his room every day; however, the housekeeper did not speak good English and would just look at him and not respond when he would voice his concerns. During an interview with Housekeeper (HK) 4 on 06/24/2024 at 1:53 PM, she stated she spoke limited English. The Administrator was present during the interview and assisted by using a translator app. HK4 stated she was responsible for cleaning R44's bathroom and cleaned them every day and even every hour. HK4 stated she did not see the brown substance on the floor or wall. At that time, the Administrator told HK4 to clean the brown substance from R44's bathroom floor and wall. Additional observation of R44's bathroom on 06/24/2024 at 2:25 PM revealed the brown substance had been cleaned off of the wall above the toilet paper holder; however, there was still a quarter-sized brown substance on the floor beside the toilet. The DON was made aware that R44's bathroom was not clean, and she stated she would send another Housekeeper to clean it. The DON stated rounds were done by other staff this morning and she did not think the brown spots were there. b. Review of a Quarterly MDS Assessment, dated 05/13/2024, revealed the facility assessed R31 to have a BIMS score of 15/15, indicating the resident was cognitively intact. During an interview with R31 on 06/26/2024 at 2:35 PM, she stated housekeeping does not clean well. She stated a female housekeeper that did not speak English would have to be told by residents that she needed to sweep prior to mopping. R31 further stated the housekeeper did not clean the vanity or mirrors and therefore, her roommate would often do that. During an interview with CNA12 on 06/26/2024 at 7:00 PM, she stated she did not feel like the facility was not clean or homelike for the residents. During an interview with CNA13 on 06/26/2024 at 7:30 PM, she stated the facility was very dirty, actually filthy and she did not think housekeeping staff was doing very much. CNA13 stated there had been feces in the bathroom floors and when she reported to housekeeping staff, nothing would be done. During an interview with HK3 on 06/28/2024 at 9:49 AM, he stated he would clean resident rooms and bathrooms one to two times daily depending on the condition of the rooms. He stated deep cleans were done by schedule and would be logged into a book; however, daily cleans were not logged. HK3 stated he thought the facility could be cleaner. HK3 further stated they did not have an acting manager and the Administrator oversaw the housekeeping staff. Logs referenced by HK3 were reviewed. The facility's document titled, Quality Control Inspection-Housekeeping, revealed random daily spot checks of 34 residents' bathrooms over a three-week period from 05/23/2024 through 06/12/2024. The spot checks showed nine of the inspected bathrooms had to be re-cleaned. Review of facility's Deep Clean Room Schedule and Carpet and Hard Floors Cleaning Schedule revealed that the facility only had these check off sheets for the months of January and April of 2024. Neither the Deep Clean Room Schedule nor the Carpet and Hard Floors Cleaning Schedule from January were signed or dated by the Administrator. For the month of April, the Deep Clean Room Schedule for April was not signed and dated (to indicate that it was complete.). During an interview with the Administrator on 06/28/2024 at 10:07 AM, she stated she thought the facility was clean and homelike for the most part. The Administrator stated she expected housekeeping to maintain a homelike and clean environment for the residents. 3. Observation at 1:20 PM on 06/23/2024 an observation of the bathroom shared between rooms [ROOM NUMBERS] revealed the floors of the bathroom had rust stains on them from the rusting door jamb of the bathroom door. Observation on 06/23/2023 at 1:28 PM revealed the floors in the bathroom shared by rooms [ROOM NUMBERS] also had rust stains from the rusting door frames of the bathroom door. It was observed on 06/23/2024 at 1:39 PM and 1:43 PM that the flooring under the window in rooms [ROOM NUMBERS] were stained with rust and discolored with water stains. At 1:46 PM on 06/23/2024, observation of the floor under the window and in the bathroom shared by rooms [ROOM NUMBERS] revealed rust stains from the rusting bathroom door's door jamb. On 06/23/2024 at 1:57 PM, the bathroom for room [ROOM NUMBER] and 131 had rust stains on the floor and rust on the door jamb leading into the bathroom. On 06/26/2024 at 8:55 AM, interview with the Maintenance Director revealed that he was unaware of the rust on the floors in the rooms and bathrooms in Rooms 121,123, 125, 127, 128, and 129 and was unaware of the rust on the door jambs for these rooms. He stated that the facility was in the process of repainting and remodeling. An outside company had been hired to do the remodel; however, they had only done part of the remodel prior to quitting. He also stated that there were no plans to replace the flooring, but housekeeping could try and remove the rust. During an interview with the DON on 06/27/2024 at 10:29 AM, she was asked about the rust on the flooring and on the door jambs and stated that maintenance was in the process of remodeling, and both were to be replaced.

50000 Based on interview, record review and review of the facility policy, the facility failed to develop a comprehensive person-centered care plan for one (Resident (R) 85) of 76 sampled residents. that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Care Area Assessments (CAA) that triggered for care planning, as well as other areas such as medical needs, goals, and discharge planning, were not included in R85's comprehensive care plan by the required completion date (no later than 21 days from admission). The findings include: Review of the facility policy titled Baseline, comprehensive, resident centered care plan guideline dated 09/01/2017 and reviewed 04/12/2024, revealed the comprehensive care plan expands on resident's baseline care plan to include risks, goals and interventions using person centered plan of care approach to meet the medical, physical functioning, nursing, mental and psychosocial needs of a resident. Further review of the policy revealed the comprehensive care plan should be finalized with seven days of completion of the full comprehensive minimum data set (MDS) assessment and will include discharge planning. Review of the face sheet for R85 revealed she was admitted to the facility on [DATE] with pertinent diagnoses of adult failure to thrive, malfunction of tracheostomy stoma, and history of blood clots. A baseline care plan for R85, dated 05/05/2024, was completed within 48 hours of admission to facility and addressed the resident's initial goals, functional status, health conditions, dietary, therapy and social services. Review of the comprehensive Minimum Data Set (MDS) for R85, dated 05/09/2024, revealed a brief interview of mental status (BIMS) score of 14/15, meaning intact cognition. The Care Area Assessments (CAA) triggered for the following areas of concern: The Communication trigger revealed R85 had impaired ability to make herself understood through verbal and non-verbal expression of ideas/wants. The Functional Ability trigger revealed R85 needed partial/moderate assistance with showering and bathing, and supervision or touching assistance with lower body dressing, personal hygiene, chair/bed to chair transfer, sub/shower transfer, walking 10 feet, and partial/moderate assistance with walking 50 feet with two turns, and walking 150 feet. The Fall trigger revealed R85 was at fall risk related to received antidepressant medications on one or more of the last seven days. The Nutritional status trigger revealed R85 had a low body mass index (BMI). The Psychotropic drug use trigger revealed R85 received antidepressant medications on one or more of the last seven days. The Urinary incontinence trigger revealed R85 had occasional urinary incontinence. The Pressure Ulcer/injury trigger revealed R85 had frequent bowel incontinence. The MDS documented that all CAA triggers were reviewed and addressed in the care plan on 05/16/2024 and signed by the facility's MDS nurse, who also signed as the person completing the care plan decision process on 05/23/2024. Based on the resident's date of admission, the comprehensive care plan was scheduled to be completed no later than 05/23/2024. Review of the care plan on 06/25/2024 revealed that it did not address the triggered areas of Communication, Functional Ability, Falls, Psychotropic Drug Use, Urinary Incontinence, or Pressure Ulcer/Injury. The care plan also failed to address medical needs related to the resident's care related to the tracheostomy/stoma. In addition, it failed to address the resident's goals and/or plans for discharge. Interview conducted with R85 on 06/24/2024 at 8:58 AM revealed she has been in the facility for about six weeks, and in that time, had a swallow study, received tracheostomy care, and reported that staff often had a hard time understanding what she says due to having a tracheostomy and use of a speaking valve. R85 stated she was unaware of what her plan of care is, did not know how long she will be in the facility, and did not know plans for discharge. Interview conducted with the Assistant MDS Coordinator on 06/26/2024 at 3:00 PM revealed that she has been in her current position for about six weeks and received training from the facility's MDS Coordinator and a nurse from the corporate office and attended a few training seminars. The Assistant MDS Coordinator was unable to recall the time frame requirements for completion of comprehensive care plans. Interview conducted with the facility MDS Coordinator on 06/26/2024 at 3:13 PM revealed that she has been in her current position for 13 months. The MDS Coordinator stated she completes the MDS assessment within five to seven days of admission and then has a total of 14 days from admission to complete the comprehensive care plan. The MDS Coordinator stated she is responsible for the completion of the nursing portion of the comprehensive care plan and other department heads complete their portion. In further interview, the MDS Coordinator stated she prints a list monthly of new residents and does a check list to ensure all care plans have been completed. When asked to produce R85's comprehensive care plan (addressing all areas noted above), she stated that it was not there, adding, I take full responsibility on the comprehensive not being there, it should have been done by the end of May.

Based on observation, interview, record review and policy review, the facility failed to provide the necessary care and services to ensure that two (Resident (R) 49 and R 58) of two sampled residents reviewed for activities of daily living/communication did not decline in their ability to communicate. The residents were not provided communication tools in accordance with their plans of care. The findings include: 1. Review of R49's face sheet revealed he was admitted to the facility on [DATE] with diagnoses which included parkinsonism, dysarthria and anarthria (slurred and raspy speech and inability to articulate words), occlusion and stenosis of right middle cerebral artery, cognitive communication deficit, and hemiplegia and hemiparesis (paralysis and/or weakness on one side of the body). Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated a severe cognitive deficit. Per the MDS, the resident had unclear speech, but was usually understood. Review of the Comprehensive Care Plan for Impaired Communication dated 02/19/2024, revealed a goal that, I will be able to communicate with staff daily and as needed. Interventions included to utilize appropriate augmentative devices like communication boards/cards, large print signs, and writing pad. The intervention also stated to help the resident acquire and learn to use appropriate devices. Review of the Speech Therapist Evaluation and Plan of Treatment, dated 03/01/2024, revealed the resident has reached his maximum level of potential and been verbally educated and trained on word retrieval strategies. Per this Plan of Treatment, communication picture pages were left in the resident's room in help the resident communicate basic wants/needs to family/staff. The resident verbalized understanding of what had been discussed. Observation on 06/23/2024 at 2:30 PM revealed R49 and the resident's sister (F49) were playing a game of Yahtzee when the survey team entered the resident's room. Observation of the resident's room revealed no evidence of communication picture pages or a communication board in the resident's room. Although the MDS had documented the resident was severely cognitively impaired, during an interview on 06/23/2024 at 2:30 PM, the resident was able to answer questions by nodding and saying yes or no. Interview with both R49 and the resident's sister revealed they had not seen anything left in the room for communication. During an additional interview with R49 in the resident's room on 06/25/24 at 1:31 PM, he appeared to have awareness/cognition of the conversation. When asked if he could understand the questions, he stated yes. When asked if he could write, he stated yes. The resident was observed to have flaccid paralysis to the left side. When asked if he was right or left-handed, R49 raised his right hand, and stated yes when asked if he would benefit from a dry erase board for communication. 2. Review of R58's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included dysarthria following cerebral infarction, dysphagia following cerebrovascular disease, and major depressive disorder. Review of the annual MDS, dated [DATE], revealed the resident had a BIMS score of 9/15, which indicated moderate cognitive decline. Per the MDS, the resident had unclear speech, but was usually understood. Review of the Comprehensive Care Plan, dated 02/09/2024, revealed the resident had an alteration in ability to communicate related to impaired speech. Per the care plan, the problems were evidenced by: ability with transmission of information. Resident is able to communicate via steno pad in order to clarify his needs, but reports speech was affected by stroke occurring last year. The resident will communicate through verbal/non-verbal means through the next review. Intervention included for staff to Assess the resident's communication strengths and deficits. Emphasize abilities. Utilize appropriate augmentative devices, i.e., eyeglasses, magnifying glass, hearing aid, listen aider (power ear), communication board/cards, large print signs, writing pad, etc. Help the resident acquire and learn to use appropriate devices. Make sure augmentative devices are in good working order. Review of a therapy discharge note, dated 03/01/2024, revealed the resident was discharged due to reaching maximum functional potential. Per this note, the resident, understands yes/no questions at 60% accuracy with moderate cues with training on auditory processing strategies to increase comprehension for the communication of basic wants/needs to family/staff. Resident discriminates pictures in a field of 4 with moderate cues with training on word retrieval strategies in increase communication of basic wants/needs to family/staff. States goals not met due to the resident reached maximum level of potential. During an interview on 06/24/24 at 12:38 PM, R58 was difficult to understand. Observation of the resident's room at this time revealed no evidence of a communication board or pen and paper in the room. R58 motioned to use the surveyor's pen and pad to write a note with. The resident had legible writing skills and was able to communicate this way throughout the interview. An additional observation and interview on 06/25/24 at 10:53 AM in R58's room revealed no communication aids at bedside. When asked if the facility had ever had any aids to help him communicate with (including a board to write on), he said No. When asked if it benefit him to have something in his room to communicate with, he responded. Yes. An interview on 06/25/2024 at 2:38 PM with the Speech Therapist revealed she has worked with both R49 and R58. She stated she had placed large picture signs and communication boards in each resident's room and did not know why the communication aids were not in the rooms now. During an interview with Licensed Practical Nurse (LPN) 5 on 06/27/2024 at 10:30 AM, she stated she is able to understand R58 pretty good but sometimes, she has to have him write something down. LPN5 added, I know I have to take something into the room for him to write on since nothing seems to stay in his room. LPN5 was also familiar with R49 and stated that, If I ask [R49] a question, the answer has to be written down since he says yes sometimes and means no. She stated the communication boards as well as paper and pencils are never in the rooms. During an interview with the Director of Rehabilitation on 06/28/2024 at 12:56 PM, he stated each of the therapists tries hard to keep devices and tools for each resident who requires them for communication. However, he added, they have a hard time keeping the communication devices/tools in the residents' room as, things disappear and are hard to replace at times. The Director of Rehabilitation added that after the resident is discharged from therapy, he is not sure when or where the devices go. He stated he expects the nursing staff to make sure those communication devices are in the resident rooms and to communicate with the therapist if something needs to be replaced. The Director of Rehabilitation stated after the resident has been discharged from therapy service, We do not usually see the resident again unless a referral is completed. Then we evaluate the resident for further services. An interview with the Director of Nursing on 06/28/2024 at 1:26 PM revealed she expects the nursing staff to make sure the resident has the aids needed for communication, adding that she takes pencils and pads of paper back to the residents if they are running low. During an interview on 06/27/2024 at 10:48 AM with the facility administrator, she stated the facility had no policy on activities of daily living regarding communication devices for residents with communication deficits with speech communication tools. An additional interview with the Administrator on 06/28/2024 on 2:34 PM revealed she expects the staff to follow the rehabilitation care plans to provide communication devices to ensure residents can communicate with staff, friends, family, and other residents.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure two (2) of sixteen (16) sampled residents, Residents #7 and #14, received the care and services necessary for the prevention and treatment of [REDACTED].#7. Observation of Resident #7's skin assessment on 04/08/2021, revealed Resident #7 had a Stage II pressure ulcer which had not previously been identified. In addition, observation of Resident #14's wound care treatment revealed the licensed nurse treated only three (3) of the resident's four (4) previously identified pressure ulcers. Observations on 04/09/2021, revealed the licensed nurse failed to administer all the resident's Physician ordered treatments. The licensed nurse stated she did not consider the area on the resident's coccyx a wound even though the Wound Care Physician had documented it as such. In addition, the nurse stated she was not aware there was a Physician ordered treatment for [REDACTED]. The findings include: Review of the facility's policy titled, Skin Observation/Assessment (Showers/Baths), not dated, revealed the facility would ensure each resident was provided with showers and baths during which the caregiver would observe the resident's skin. Per the policy, the skin observation was to include observing for bruises, red areas, open areas, scratches, abrasions, blisters, discoloration, pressure ulcers, scars, as well as any other skin conditions. The policy revealed only licensed nurses could assess a resident's skin. Continued review revealed nurses would perform residents' skin assessments at least weekly (or as indicated). According to review, the caregiver completing the resident's bath or shower would note on the Shower Sheet any observations made during shower or bath which appeared to be new or worsening. Further review revealed the Shower Sheet was to be given to the nurse in charge who was to follow up with a documented skin assessment to address the caregiver's finding(s). Review of the facility policy titled Preventive Skin Care, not dated, revealed it was the intent of the facility to provide preventive skin care through careful washing, rinsing, and drying of a resident's skin to keep them clean and comfortable, and free of pressure sores. Further review revealed good skin care was to be provided by staff on each shift, and as necessary. Review of the facility' Job Description for Registered and Licensed Practical Nurses, undated, revealed the nurses were to review residents' care plans to ensure appropriate care was being rendered. In addition, the Nurses were to ensure the Nurses' Notes reflected the care plan was being followed when nursing care or treatment was provided for the resident. 1. Review of Resident #7's clinical record revealed the facility admitted the resident on 02/26/2014, with [DIAGNOSES REDACTED]. Review of the facility's Quarterly Minimum Data Set (MDS) Assessment for Resident #7 dated 02/06/2021, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score nine (9) which indicated he/she had moderate cognitive impairment; however, was interviewable. Further review revealed the resident was assessed, under Section M0210 of the MDS, to not have one (1) or more unhealed pressure ulcers at a stage one (1) or higher. Review of the facility's Roster Matrix (a form used to list all current pertinent care categories), provided by the facility on 04/06/2021, revealed Resident #7 had no documented evidence of pressure ulcers noted. Review of the Wound Care Physician's weekly evaluations dated 01/18/2021 to 02/22/2021, revealed Resident #7 had a history of [REDACTED]. Continued review revealed the two (2) wounds were marked as resolved by 02/15/2021. Per review, Resident #7 had a history of [REDACTED]. Further review revealed the resident was noted to also have a history of a Stage 2 wound in the sacrum area which was initially evaluated on 02/01/2021 and resolved as of 02/22/2021. Telephone interview, on 04/07/2021 at 6:34 PM with Resident #7's son, revealed he thought facility staff had not been getting the resident out of bed often enough. Per interview, he thought Resident #7 had also been left in stool soiled briefs soiled for too long a couple of times recently. Continued interview revealed he was concerned Resident #7 could have skin breakdown as a result of not being gotten up out of bed and from being left in the soiled briefs. He stated he talked with Resident #7 by phone to check on him/her. Further interview revealed he had left messages for the facility's Administrator on at least two (2) or three (3) occasions related to his concerns; however, she had not yet returned his calls. Interview, on 04/08/2021 at 8:35 AM with Resident #7, revealed the resident did not think he/she had skin breakdown on his/her bottom. Per interview, staff applied a barrier cream when they changed his/her adult brief. The Surveyor requested Resident #7's three (3) most recent nursing skin assessments, and the facility's Assistant Director of Nursing (ADON)/ Wound Care Nurse (WCN) provided three (3) skin assessments dated 02/09/2021, 12/29/2020, and 10/02/2020. She stated those skin assessments were the most recent ones available for the resident. Review of the skin assessment dated [DATE] revealed Resident #7 had existing loss of skin integrity identified; however, there were no new areas of skin breakdown identified at the time of that assessment. Observation, on 04/08/2021 at 8:45 AM, of Resident #7's skin assessment performed by the ADON/WCN, revealed an open area observed on the resident's right buttock. The ADON/WCN stated the area was open and had some shearing (a wound which occurred as the result of body tissues being moved in opposite directions) as well. Per the ADON/WCN, there was also a red, blanchable area on the resident's left buttock. The ADON/WCN informed Resident #7 he/she had an open area on his/her right buttock. Further observation revealed when the ADON/WCN touched the right buttock open area, and asked Resident #7 if it hurt, the resident stated it did not hurt. Further review of Resident #7's clinical record revealed the ADON/WCN's documented progress note which noted the resident had denied pain in the area of the pressure ulcer wound. Continued review of the note revealed the ADON/WCN had contacted the Physician who directed staff to continue with the Zinc Oxide Cream application, as previously ordered. Review of the Weekly Wound Evaluation dated 04/08/2021, completed by the ADON/WCN after Resident #7's skin assessment, revealed the nurse had classified the open area as a Stage 2 pressure ulcer. Per review the ADON/WCN had documented the measurement of the open area she had identified during the skin assessment on 04/08/2021 as 0.4 centimeters (cm) x (by) 0.4 cm x 0.1 cm. Interview on 04/08/2021 at 11:00 AM, and 04/12/2021 at 2:12 PM with the ADON/WCN, revealed she had notified Resident #7's Physician of the pressure ulcer area she had observed during the skin assessment on 04/08/2021. She stated the Physician had continued the current order for application of Zinc Oxide Cream to Resident #7's buttocks every shift, and for staff to monitor for any changes; however, had not ordered an additional treatment for [REDACTED]. Continued interview revealed the ADON/WCN had not seen shower sheet documentation to have been turned in by the State Registered Nurse Aides (SRNA's) when bathing Resident #7 since she started working at the facility in February 2021. The ADON/WCN revealed she and the Director of Nursing (DON) had identified a failure with completion of the SRNA's shower sheet documentation currently in place to note resident skin changes and they had been working to resolve the issue. Per interview, collection folders for the shower sheets had been placed at the facility's two (2) Nurse's Stations. She stated however, no formal training with the SRNA's had been conducted yet regarding ensuring the completion and submission of shower sheet documentation which noted the SRNA's observations of residents' skin during their shower/bath. According to the ADON/WCN, the facility's licensed nurses also needed to be educated on ensuring completion of documentation as well. Further interview revealed the ADON/WCN, and DON were currently auditing residents' records to determine if other residents were missing the routine nursing skin assessments as Resident #7. In addition, the ADON/WCN stated the nursing skin assessments and the SRNA's shower sheet documentation were both methods important for identifying and monitoring any new or existing resident skin breakdown. 2. Review of Resident #14's clinical record revealed the facility admitted the resident on 11/27/2020, with [DIAGNOSES REDACTED]. Review of the facility's Quarterly MDS Assessment for Resident #14, dated 03/05/2021, revealed a score of two (2) on the BIMS section indicating the resident was severely cognitively impaired and not interviewable. Further review revealed the resident was assessed (in Section M0300 of the MDS) to have one (1) Stage 2 pressure ulcer and two (2) Stage 3 pressure ulcers. Review of the facility's Weekly Wound Log dated 04/06/2021 revealed Resident #14 was noted to have four (4) in-house acquired pressure ulcers. Continued review revealed the pressure ulcers were identified on 02/16/2021 as follows: a right buttock pressure ulcer wound, with measurements of 3.0 cm x 2.0 cm x 0.2 cm; a right plantar foot pressure ulcer wound with measurements of 0.8 cm x 0.7 cm x 0.3 cm; a right heel pressure ulcer wound with measurements of 3.7 cm x 2 cm x 0.3 cm; and a coccyx pressure ulcer wound which measured 0.4 cm x 0.2 cm x 0.2 cm. Review of the Wound Care Physician's weekly wound evaluation note dated 04/06/2021 for Resident #14 revealed the Physician identified four (4) pressure ulcer wounds. Continued review revealed the pressure ulcers were staged and measured as follows: A Stage 3 pressure ulcer on Resident #14's coccyx; a Stage 3 pressure ulcer on the right buttock, which was documented as improved; a Stage 3 pressure ulcer on the right distal plantar/lateral foot documented as improved; and a Stage 4 pressure ulcer on the right proximal plantar foot documented as improved. In addition, the Physician noted her goal for Resident #14's coccyx wound was healing as evidenced by a decrease in the surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Review of Resident #14's April 2021 Treatment Administration Record (TAR) revealed treatment orders for the resident's coccyx and right buttock pressure ulcer wounds. Continued review of the TAR revealed the treatment included cleaning the right coccyx and right buttock pressure ulcer wounds with normal saline (NS), pat dry, apply Calcium Alginate (a specialized wound dressing) to the pressure ulcers, and then secure the area with adhesive foam. Further review revealed the treatment order specified treatments were to be administered daily and as necessary if the dressing became soiled or fell off. In addition, review of the TAR revealed treatment orders for Resident #14's right foot pressure ulcer which included cleansing the right plantar heel and right lateral foot with NS, pat dry, apply honey fiber (a specialized wound dressing) to the areas, cover with an abdominal (ABD) pad, and wrap with Kerlix one (1) time per day for wound healing. Observation and interview on 04/09/2021 at 11:15 AM, revealed Licensed Practical Nurse (LPN) #1 provided the treatments ordered for Resident #14's right buttock pressure ulcer and the two (2) right foot pressure ulcers. Continued observation revealed however, LPN #1 did not complete the ordered treatment for [REDACTED].#14's coccyx. The Surveyor asked to observe Resident #14's low back/coccyx area, and the LPN turned the resident in order to observe that area. LPN #1 observed there was a small open area on the resident's coccyx. Further observation revealed no dressing was in place covering the open area. LPN #1 stated she was aware of the open area on Resident #14's coccyx; however, she was not aware the Physician had ordered a treatment for [REDACTED].#14's coccyx was considered a pressure ulcer. She stated she thought it was just a dimpled area and that was why she had not applied a treatment to the area. In an additional interview, on 04/09/2021 at 2:55 PM with LPN #1, she revealed she had not thought the area on Resident #14's coccyx was a pressure ulcer wound. Per interview, she had checked Resident #14's TAR, after the Surveyor had questioned her regarding the existence of a wound on Resident #14's coccyx. She stated when she checked the resident's TAR there was a treatment ordered and noted on it for the coccyx pressure ulcer wound. According to LPN #1, she first became aware of the treatment order for the pressure ulcer on Resident #14's coccyx after she checked the TAR. She revealed after seeing there was an order, it just made her sick to find out there was a treatment she had not performed. LPN #1 stated she just had not seen that particular order before that day. She revealed, the open area on Resident #14's coccyx was not a wound. Further interview revealed the open area on the resident's coccyx looked more like a dimple or skin indention to her. LPN #1 stated however, licensed nurses should complete all ordered wound treatments for residents to prevent worsening of a wound, and to promote healing of the identified skin condition. Interview, on 04/12/2021 at 11:12 AM with the Wound Care Physician, who evaluated and treated Resident #14's wounds, revealed the resident's coccyx pressure ulcer wound was a very small open area over an area of scarred skin from a previous healed wound on the resident's low back. Per interview, the pressure ulcer wound on Resident #14's coccyx had a small sinus tract (a narrow opening underneath the skin which can extend in any direction through soft tissue resulting in dead space with the potential for abscess formation). The Physician revealed the coccyx area was vulnerable for reopening as it was atop some scar tissue from an old healed wound site. Continued interview revealed she had ordered a daily treatment for [REDACTED].#14's pressure ulcers. She stated if the older wound area had healed superficially and complete healing had not occurred, there would be an increased likelihood the area could have a new wound occur or the old wound could reopen. The Wound Care Physician further revealed in an ideal world all pressure ulcer wounds would be avoidable; however, Resident #14 was sometimes resistant to being repositioned by staff and had he/she had a history of [REDACTED]. Interview on 04/12/2021 at 2:12 PM with the ADON/WCN, revealed LPN#1 told her she had not been aware the area at Resident #14's coccyx was a pressure ulcer wound which had a Physician ordered treatment. Per interview, the pressure ulcer wound on Resident #14's coccyx had opened over some scar tissue from an older healed wound. The ADON/WCN stated she personally accompanied the Wound Care Physician during her weekly rounds of the facility's residents. Continued interview revealed she was personally aware of the open area on Resident #14's coccyx, and the Wound Care Physician had ordered a treatment for [REDACTED]. She stated LPN #1 might not have completely read all the orders on Resident #14's TAR, and therefore, just missed the order for treating the resident's coccyx pressure ulcer wound. Further interview revealed the licensed nurses were to always read the orders on a resident's TAR prior to providing the necessary pressure ulcer care. She further revealed if the licensed nurses read all the orders, it would ensure they knew exactly how many wounds/pressure ulcers a resident had, and treatments would be provided as ordered to treat all identified areas. Interview on 04/12/2021 at 8:31 AM with the Director of Nursing (DON), revealed if Resident #14 had four (4) pressure ulcer wounds with Physician orders for treatment, then all four (4) pressure ulcer wounds should have received the Physician ordered treatments. Per interview, the licensed nurses were to review the Physician's treatment orders prior to entering a resident's room to ensure the nurse was aware of the number of wounds to receive treatment. The DON further stated if a licensed nurse had questions or needed clarification regarding a resident's wound status, he/she was to contact the ADON/WCN and/or the resident's Physician. Interview on 04/12/2021 with the Administrator, revealed LPN #1 should have known about the pressure ulcer wound on Resident #14's coccyx, and should have provided the Physician ordered treatment to promote healing of the open area. Per interview, the ADON/WCN accompanied the Wound Care Physician during her weekly rounds of the facility's residents. The Administrator stated the ADON/WCN reviewed all the treatment orders listed on each resident's TAR to ensure the orders were accurate and addressed all a resident's wounds. Continued interview revealed all new Physician orders, including wound care treatment orders, were reviewed by staff in the facility's daily clinical meetings. She revealed when reviewing the orders, staff also ensured the treatment orders were correctly noted on each resident's TAR, so the nurses performing the treatments were aware of the care to be provided each day. According to the Administrator, the status of all residents' wounds was reviewed during the facility's Quality Assurance (QA) meetings to determine if the quality measures in place were meeting expectations for wound progress and healing. Further interview revealed the DON and ADON/WCN were new to the facility beginning in February 2021. The Administrator further revealed the DON and ADON/WCN were working to ensure all residents' weekly skin assessments were completed as per policy. Additionally, the Administrator stated ensuring the completion of the skin assessments was at least one method for identifying any newly developed resident skin issues and enabled the nurses to address any new issues with the Physician and obtain new skin treatment orders as needed.

Based on interview, record review, and policy review, it was determined the facility failed to ensure family members were notified within the required time frame after a resident's positive COVID-19 [DIAGNOSES REDACTED].#2 and #5. The findings include: Review of the facility's policy titled, Change in Condition Notification, dated 12/2014, revealed in the event of a non-life threatening but significant change in a resident's condition, the facility would notify the Physician. Further review revealed a resident's responsible party/family member would be notified of a resident's change in condition unless otherwise directed in the resident's chart or by the Interdisciplinary Plan of Care (IPOC). 1. Review of Resident #2's clinical record revealed the facility admitted the resident on 11/22/2010 with [DIAGNOSES REDACTED]. Continued review revealed Resident #2's Guardian was also his/her #1 Emergency Contact with the Guardian's contact information listed. Review of the Progress Notes for Resident #2 revealed a Note dated 11/17/2020, which documented the resident had a positive COVID-19 test result dated 11/17/2020. However, continued review of the Progress Notes dated 11/17/2020 to 11/26/2020, revealed no documented evidence the facility notified Resident #2's Guardian/#1 Emergency Contact regarding the resident's [DIAGNOSES REDACTED]. Further review revealed the Director of Social Services (DSS) documented an entry in Resident #2's Progress Notes dated 11/17/2021 at 07:16 PM which noted his/her Guardian/#1 Emergency Contact was notified of a resident room change for him/her. Interview, on 04/12/2021 at 10:51 AM with the DSS revealed she had notified Resident#2's Guardian/#1 Emergency Contact of a room change for the resident from the yellow zone to the red zone via an electronic mail (E-mail) message. The DSS stated she would not have notified Resident #2's Guardian/#1 Emergency Contact of the resident's positive or negative Covid-19 test result. Per interview, she was only responsible for notifying residents' Guardians/Emergency Contacts of resident room changes. The DSS further revealed the facility's former Director of Nursing (DON) had been responsible for ensuring residents' Guardians/Emergency Contact/family members were notified when a resident tested positive for COVID-19. 2. Review of Resident #5's closed clinical record revealed the facility admitted Resident #5 on 11/10/2020, with [DIAGNOSES REDACTED]. Continued review revealed Resident #5's sister was listed as his/her #1 Emergency Contact with her contact information noted. Further review of the record revealed Resident #5's COVID-19 laboratory test result dated 11/16/2020 3:05 PM. Review of the COVID-19 lab test revealed Severe Acute Respiratory Syndrome [MEDICAL CONDITION] 2 (SARIS-CoV-2) had been detected which was an abnormal finding. Further review of Resident #5's clinical record revealed a Progress Note, dated 11/17/2020, documented the date of the COVID-19 test result. Further review of the Progress Notes dated 11/17/2020 to 11/26/2020, revealed no documented evidence facility staff had notified Resident #5's #1 Emergency Contact/sister of the resident's COVID-19 infection. Interview on 04/06/2021 at 7:30 PM with Resident #5's #1 Emergency Contact/sister revealed the resident ended up COVID-19 positive and in the facility's Red Zone the second week after the facility admitted him/her. Per interview, the facility had not notified her Resident #5 had converted to a positive COVID-19 status. According to the #1 Emergency Contact/sister she had found out by accident about the resident's positive COVID-19 status. Further interview revealed when she had gone to have a window visit with Resident #5 at the facility, she learned the resident had been transferred to the facility's Red Zone hallway which was where the positive COVID-19 residents resided. Interview on 04/07/2021 at 10:00 AM with the DSS revealed once a resident was able to transfer out of the Red Zone Hallway, where COVID-19 positive residents resided, to the Yellow Zone Hallway, where residents resided for post Covid-19 monitoring, she notified a resident's Emergency Contact/Guardian/family member of the resident's change in status and room change. Further interview revealed however, the facility's former DON had been responsible for notifying a resident's Emergency Contact/Guardian/family member when a resident first tested positive for COVID-19. Interview on 04/10/2021 at 4:13 PM with Licensed Practical Nurse (LPN) #4 revealed the former DON told staff she would notify a resident's Emergency Contact/Guardian/family member when the resident tested positive for COVID-19 infection. However, per LPN #4 he was not sure the former DON had always followed through with making those notifications to a resident's Emergency Contact/Guardian/family member. Continued interview revealed nursing staff were supposed to notify a resident's Emergency Contact/Guardian/family member when a resident tested positive for COVID-19. He stated after notification was made to a resident's Emergency Contact/Guardian/family member, the person performing the notification was to document it in the resident's clinical record in a Progress Note, unless otherwise specified by the resident. Interview on 04/12/2021 at 8:30 AM with the DON revealed the facility's current process was if a resident tested positive for COVID-19 the Assistant Director of Nursing (ADON), herself, or in their absence, the Administrator notified the resident's Emergency Contact/family member or Power of Attorney (POA) of the resident's COVID-19 positive test result. Per interview, the staff member was to also document the Emergency Contact/family member or POA notification in the resident's clinical record in a Progress Note. She stated staff was required to notify a resident's Emergency Contact/family or POA no later than 5:00 PM the next day after the facility received confirmation of a resident's positive COVID-19 lab test result. The DON further revealed facility staff were to inform a resident's Emergency Contact/family member or POA of any change in a resident's condition. Interview, on 04/07/2021 at 4:55 PM and on 04/12/2021 at 3:00 PM, with the facility's Administrator revealed the former DON had been responsible for notifying a resident's Emergency Contact/family member or POA when a resident had tested positive for COVID 19. The Administrator revealed the former DON should have documented all her Emergency Contact/family member notifications in the residents' clinical records in a Progress Notes, after informing family members of the residents' positive COVID-19 status. The Administrator stated documenting the notifications in residents' clinical records validated the notification had been made as required. The Administrator further revealed going forward if a resident tested positive for COVID-19, the DSS would notify Emergency Contacts/family members of both the COVID-19 testing results and any necessary room changes.

Based on observation, interview, record review and policy review, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for two (2) of sixteen (16) sampled residents, Residents #7 and #14. Observation of a skin assessment for Resident #7 revealed a previously unidentified pressure ulcer was discovered on Resident #7's buttock. Review of Resident #7's Comprehensive Care Plan revealed the resident was at increased risk for alteration in skin integrity related to his/her physical conditions with interventions which included checking Resident #14's skin during routine care on a daily basis, and during the resident's weekly or biweekly bath/shower. However, the facility was unable to provide documented evidence the State Registered Nurse Aides (SRNAs) had noted skin inspections completed during the provision of routine resident care, or that its licensed nurses had completed the weekly skin assessments as per the care plan interventions for Resident #7's increased risk for alteration in his/her skin integrity. In addition, Resident #14's Comprehensive Care Plan revealed the resident had a care plan for actual skin breakdown with interventions which included to follow the physician's orders [REDACTED]. Resident #14 was noted to have four (4) identified pressure ulcers present with Physician order [REDACTED]. The findings include: Review of the facility's policy titled Clinical Management, Baseline Care Plan, dated 05/2017, revealed the facility would develop a care plan for each resident which included instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care. Further review revealed the facility might develop a Comprehensive Care Plan in place of the baseline care plan if the care plan was developed within forty-eight (48) hours of the resident's admission to the facility. Review of the facility's policy titled Discharge Care Plan Facility Policy, 05/2017, revealed a Comprehensive Care Plan was to be prepared and include the resident's goals for admission and the desired outcomes. Further interview revealed the care plan was to be developed by the interdisciplinary team (IDT), and was to be reviewed and revised after each Comprehensive and Quarterly assessment. Review of the facility' Job Description for Registered and Licensed Practical Nurses, undated, revealed the nurses were to review residents' care plans to ensure appropriate care was being rendered. In addition, the Nurses were to ensure the Nurses' Notes reflected the care plan was being followed when nursing care or treatment was provided for the resident. 1. Review of Resident #7's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 was moderately cognitively impaired and interviewable based on the Brief Interview for Mental Status score. Review of Resident #7's Comprehensive Care Plan dated 11/24/2018, revealed the resident was care planned as at increased risk for alteration in skin integrity related to his/her impaired mobility status, bladder incontinence, comorbidities, and Diabetes diagnosis. Continued review revealed the interventions to prevent skin breakdown included for staff to check Resident #7's skin during routine daily care and during the resident's weekly or biweekly bath or shower. Review of the facility's Roster Matrix (a cumulative record of residents on census, their care needs and identified health conditions), dated 04/06/2021, revealed no indication Resident #7 had any pressure ulcers. Review of the facility's last three (3) skin assessments for Resident #7, provided by the ADON/WCN, revealed they were dated 10/02/2020, 12/29/2020, and 02/09/2021. Review of the last skin assessment dated [DATE] revealed Resident #7 had existing loss of skin integrity identified; however, no new areas of loss of skin integrity were identified on the assessment. Interview on 04/08/2021 at 2:15 PM with the ADON/WCN revealed those were the most recent skin assessments available for Resident #7. She stated she had been unable to find any assessments which had been completed more recently than that for the resident. Observation, on 04/08/2021 at 8:45 AM of a skin assessment performed by the ADON/WCN for Resident #7 revealed the resident had an open area on his/her right buttock. Interview with the ADON/WCN at the time of observation, revealed she confirmed there was an open area on Resident #7's right buttock and she had also observed some shearing of the resident's skin. The ADON/WCN revealed there was also an area on the resident's left buttock which was red but blanchable. Continued observation revealed the ADON/WCN informed Resident #7 he/she had open area(s) on his/her buttock. Continue observations revealed the ADON/WCN touched the open area on Resident #7's right buttock and asked the resident if he/she felt pain; however, the resident denied any discomfort. Further interview with the ADON/WCN revealed she would measure the wound(s) on Resident #7's right buttock and notify the Physician regarding the open area(s). Review of the facility's shower sheet documentation for Resident #7, provided by the ADON/ WCN, which were completed by the SRNA's when bathing the resident revealed she had not seen any current shower sheet documentation turned in by the SRNA's, as per the resident's care plan, since she started to work at the facility in February 2021. Per interview, she and the Director of Nursing (DON) had identified a failure with the SRNA's completing the shower sheet documentation and had been working to resolve the issue. The ADON/WCN stated the resident skin assessments performed by the nurses and the completed Nurse Aide Shower Sheet documentation were methods which assisted in identifying new resident skin breakdown and ensuring monitoring of existing breakdown. According to the ADON/WCN, recently there had not been a system in place to ensure the SRNA's were monitoring and documenting resident skin changes as per the resident's care plan intervention. Interview, on 04/09/2021 at 12:36 PM with SRNA #4, revealed when she found any open areas or red spots on a resident's skin, she told the resident's nurse. SRNA #4 stated the nurses might inspect a resident's skin during his/her scheduled shower or bath. Per interview, over the past three (3) weeks she had been told to document any new resident skin issues observed on a shower sheet which had a diagram of a body on it. She further revealed she was supposed to sign and date the shower sheet and turn it into the nurse caring for the resident that day. Interview, on 04/11/2021 at 6:15 PM with Registered Nurse (RN) #2, revealed she had worked at the facility approximately eighteen (18) months. She stated the facility's former DON had not provided any guidance on the use of the shower documentation. Per interview, for quite some time she had seen the shower sheets used for documenting the condition of a residents' skin. Continued interview revealed the ADON/WCN had recently passed out sheets for the SRNAs to complete when they provided resident skin care; however, for the most part, the SRNAs would inform the nurse if they noticed a change in a resident's skin. Interview, on 04/12/2021 at 8:31 AM with the DON, revealed since the facility was unable to provide the documentation to prove Resident #7s skin was inspected routinely for changes in integrity, the resident's skin care integrity care plan had not been implemented as expected. 2. Review of Resident #14's Admission Record revealed the facility admitted the resident on 11/27/2020 with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly Minimum Data Set (MDS) Assessment, dated 03/05/2021, revealed the resident scored two (2) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) section which indicated he/she was severely cognitively impaired and not interviewable. Review of Resident #14's Comprehensive Care Plan revealed the resident was care planned for actual impairment of the resident's skin integrity. Continued review revealed the skin impairment care plan listed multiple interventions which included following the Physician's treatment orders for the resident's wound(s). Review of the Wound Care Physician's weekly Wound Evaluation Note revealed a Note dated 04/06/2021, which noted Resident #14 had four (4) pressure ulcers which the Physician had identified. Continued review of the Note revealed the resident's pressure ulcer wounds were staged as: A Stage 3 pressure ulcer on his/her coccyx; a Stage 3 pressure wound of the right buttock which the Physician had noted as improved; a Stage 3 wound of the right distal plantar/lateral foot also noted as improved; and a Stage 4 pressure wound of the right proximal plantar foot which was additionally noted as improved. Review of the facility's Weekly Wound Log, dated 04/06/2021 completed by the ADON/WCN, revealed Resident #14 had four (4) in-house acquired pressure ulcers identified. Continued review of the Log revealed Resident #14's four (4) pressure ulcers were identified and measured as follows: A coccyx wound measuring 0.4 centimeters (cm) x (by) 0.2 cm x 0.2 cm a right buttock wound identified on 02/16/2021 measuring 3.0 cm x 2.0 cm x 0.2 cm; a right heel wound measuring 3.7 cm x 2 cm x 0.3 cm; and a right plantar foot wound identified on 02/16/2021 measuring 0.8 cm x 0.7 cm x 0.3 cm. Observation on 04/09/2021 at 11:15 AM, revealed Licensed Practical Nurse (LPN) #1 performed Resident #14's treatments to his/her right buttock wound and the wounds identified on Resident #14's right foot. Continued observation revealed however, the nurse failed to apply the treatment to Resident #14's coccyx wound as ordered by the Physician. The surveyor requested to observe Resident #14's coccyx and low back area, and the nurse turned the resident observing a small area on the resident's coccyx which had no dressing in place. Interview with LPN #1 at the time of the observation revealed she had been aware of the area on Resident #14's coccyx; however, had not been aware the Physician had given treatment orders for the wound. Continued interview revealed she had thought the area on the resident's coccyx was just a dimpled place and was not aware the Physician considered it a wound. The LPN further revealed that was why she had not applied a treatment. Interview on 04/12/2021 at 11:12 AM, with the Wound Care Physician revealed she had ordered a daily treatment for all four (4) of the pressure ulcers she had evaluated on Resident #14 which included the coccyx pressure ulcer. Further interview revealed the Physician stated the pressure ulcer on the resident's coccyx was a small opening over an area of scarred skin. Interview on 04/11/2021 at 3:50 PM LPN #5, revealed each Physician ordered treatment for a resident's pressure ulcer was to be listed on his/her Treatment Administration Record (TAR). She stated the treatments were to be administered as ordered for each identified wound. Per interview, the nurses were to complete skin assessments weekly for every resident at the facility. She said the due date for a resident's skin assessment was automatically populated on the resident's Medication Administration Record [REDACTED]. According to LPN #5, recently the ADON/WCN provided nurses with a daily list of which residents needed a skin assessment on a given day. Further interview revealed a resident's care plan identified goals for care and provided interventions for achieving the goals listed. She further revealed the resident's care plan was to be current and followed by staff. In addition, she stated if new skin breakdown was identified through an assessment or otherwise, staff was to update the resident's care plan with that information, if necessary. Interview, 04/12/2021 at 1:14 PM with the MDS Coordinator, revealed a resident's Comprehensive Care Plan was a working document which changed as a resident's condition changed. She stated the care plan was to communicate the resident's goals for best outcomes. Continued interview revealed the selected interventions on the care plan were to assist and guide staff with meeting the resident's care needs with accuracy and consistency. The MDS Coordinator stated if staff were not completing the necessary documentation to prove Resident #7's skin was monitored routinely for changes, then his/her skin integrity care plan was not being fully implemented by the staff as expected. The MDS Coordinator further revealed if the nurse had not completed treatments for all four (4) of Resident #14's pressure ulcers, then the nurse had not fully implemented the resident's skin impairment care plan. Interview, on 04/12/2021 at 8:31 AM with the DON, revealed if the licensed nurse had not administered treatments to all four (4) of Resident #14's pressure ulcer wounds, then the nurse had not followed the physician's orders [REDACTED].#14's pressure ulcer wounds she had also failed to fully implement the resident's care plan intervention for following Physician treatment orders for all the resident's pressure ulcer wounds. She stated since she had assumed the role of DON in February 2021, she had identified inconsistencies in the completion of resident skin assessments. Further interview revealed therefore, she had started auditing all residents' records to determine how many residents had not received a weekly skin assessment. Interview on 04/12/2021 at 3:00 PM with the Administrator, revealed the DON and the ADON/WCN were responsible for ensuring the facility's nursing staff followed physician's orders [REDACTED]. She revealed the ADON/WCN accompanied the Wound Care Physician during her evaluation of each resident on her caseload. Per interview, during those opportunities with the Physician, the ADON/WCN reviewed the resident's MARs and TARs to ensure nurses were providing treatments as ordered. The Administrator stated the Interdisciplinary Team (IDT) members reviewed residents' care plans during the facility's daily clinical meetings and were to update the plans as necessary to reflect each resident's ongoing needs. Further interview revealed all licensed nurses had access to residents' Comprehensive Care Plans and needed to review them to ensure they were performing resident care as expected and care planned.

Based on observation, record review, facility investigation and facility policy review, it was determined the facility failed to protect residents from staff exploitation and misappropriation of property at one (1) of two (2) nurses' stations, South Nurses' Station. The facility discovered in Registered Nurse (RN) #2's possession, after her shift, six (6) pink [MEDICATION(S)] ten (10) milligram (mg) tablets, and two (2) green tablets of [MEDICATION(S)] (an opiod used to treat pain) fifteen (15) mg, which matched the three (3) resident narcotic prescription cards. The findings include: Review of the facility's policy titled, Abuse Prevention Program, updated 01/19/17, revealed the policy identified prevention related to the misappropriation of resident property. In addition, the policy stated the facility will not knowingly employ any individual convicted of resident abuse, neglect, mistreatment or misappropriation of resident property. Interview with Licensed Practice Nurse (LPN) #3, on 11/02/2020 at 10:59 AM, revealed she observed a staff's personal bag under the nurses' station desk, with pink narcotic forms and patient information cards. She stated she had concerns once she visualized the pink narcotic sheets were in the bag as the facility filed the forms in the narcotic binder. She and LPN #5 transported the bag to the Director of Nurses (DON). Attempted telephonic interviews with LPN #5, on 11/02/2020 at 9:40 AM and 2:39 PM, and on 11/04/2020 at 1:26 PM, without success. Review of her written statement, dated 09/05/2020, revealed an open tote bag was under the desk (South Nurses Station) with visible pink resident narcotic sheets and medication packaging around 11:00 AM. Continued review of the statement revealed she notified the DON of the opened tote bag with the visible pink narcotic sheets and medication packaging. She stated she was advised by the DON to bring the tote bag to the DON's office. LPN #5's statement revealed RN #2 was in a resident's room at approximately 11:00 AM. Review of the clinical record for Resident #1 revealed the facility admitted him/her on 08/21/2020 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the pharmacy provided thirty (30) tablets of [MEDICATION(S)] 10 mg, on 08/23/2020. Observation of Resident #2, on 10/22/2020 at 4:30 PM revealed the door to the resident's room was open to the corridor. He/she was in the bed with his/her head of the bed raised. Resident #2 had closed eyes, and appeared asleep. The wheelchair with a seat cushion was next to bed. The room lighting turned off. The television remained on. His/her roommate was present in the room. Review of the clinical record for Resident #2 revealed facility admitted him/her on 02/11/14 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed pharmacy provided ninety (90) tablets of [MEDICATION(S)] 10 mg, on 08/29/2020. Observation of Resident #3, on 10/22/2020 at 4:50 PM, revealed he/she remained in quarantine status on the yellow unit without concerns identified. Review of the clinical record for Resident #3 revealed facility admitted him/her on 07/09/2020 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Use Record (CDUR) revealed pharmacy provided one hundred and eighty (180) tablets of [MEDICATION(S)] 15 mg, on 08/24/2020. Attempted telephonic interviews with Registered Nurse (RN) #2, on 11/02/2020 at 9:18 AM, 9:29 AM, and on 11/04/2020 at 11:29 AM, without success, and inability to leave a return call request. Interview with the Director of Nurses (DON), on 11/02/2020 at 3:08 PM, and at 4:38 PM, revealed two (2) nurses, LPN #3 and #5 notified her of a blue and white striped bag at the South Nurses Station, opened and containing visible pink narcotic sheets. She stated there were three (3) pink narcotic sheets and the two (2) Patient Health Information (PHI) portion of the medication blister packs were present without searching the bag. She stated she notified her Administrator (no longer at the facility) of the potential diversion, and called the police. She stated the police arrived for further investigation. The DON stated they located RN #2 in another resident's room and RN #2 acknowledged the bag was her personal bag. The police ask RN #2 to empty her pockets, which revealed eight (8) tablets of medications. RN# 2 revealed she was taking (ingesting) either two (2) fifteen (15) mg tablets, or three (3) ten (10) milligram (mg) tablets of [MEDICATION(S)] (an opiod) every hour while working. The identified tablets were six (6) pink [MEDICATION(S)] ten (10) milligram (mg) tablets, and two (2) green tablets of [MEDICATION(S)] fifteen (15) mg, in her possession. She stated RN #2 was drug tested and was positive for amphetamines, methamphetamines, and opiates. Continued interview with the Director of Nurses (DON), on 11/04/2020 at 4:08 PM, revealed the RN#2 was in possession of the six (6) pink [MEDICATION(S)] ten (10) milligram (mg) tablets, and two (2) green tablets of [MEDICATION(S)] fifteen (15) mg. The medications in her possession matched the three (3) resident's narcotic prescription cards she also had in her possession. She stated this was exploitation to the three (3) residents, Resident #1, #2, and #3 by the nurse taking the residents medication. Interview with the Administrator, on 11/06/2020 at 5:22 PM, revealed the prior administrator provided oversight of the drug diversion investigation, and has since retired. She stated she had not reviewed the case. She further explained she was aware the Director of Nurses (DON) had notified the police and worked on the investigation related to Registered Nurse (RN) #2's drug diversion. She revealed she was aware the prior administrator substantiated the occurrence but she was not aware of any ongoing audits, and not aware of any other issues with drug diversions. She stated the pharmacy completed an audit; however, the faciliyt had not reviewed the findings. The aAdministrator stated RN #2 took the medication from the medication cart; therefore, this was exploitation of the resident's medications taken.

Based on observation, record review, facility investigation review, and facility policy review it was determined the facility failed to ensure residents medications at one (1) of two (2) nurses' stations, South Nurses Station remained secured without narcotic diversion. On 09/05/2020, the facility staff observed a staff member's personal bag under the South Nurses Station desk with the pharmacy provided pink narcotic sheets visually exposed, and it was determined belonging to the nurse from the off-going night shift, Registered Nurse (RN) #2. Additionally, the facility discovered three (3) narcotic prescription cards in RN #2's personal bag. The facility determined RN #2 had six (6) pink [MEDICATION(S)] ten (10) milligram (mg) tablets, and two (2) green tablets of [MEDICATION(S)] fifteen (15) mg, in her possession. Additionally, the facility failed to complete the narcotic accountability record with a second nurse signature, or the date received for ten (10) of thirty-six (36) narcotic prescribed accountability records reviewed. The findings include: Review of the facility's pharmacy policy, ID2 Controlled Substances, and IIA7 Controlled Substances, revised November 2018, revealed medication included in the Drug Enforcement Administration (DEA) classification as controlled substance were subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal, state laws, and regulations. An accurate accountability of the inventory of all controlled drugs was maintained at all times. Upon the administration of a controlled substance, the licensed staff member administering the medication immediately entered the date and time of administration on the medication administration record (MAR), and on the accountability record, the amount administered, and the remaining quantity were documented on the accountability record. Initials of the staff member administering the dose were completed after the medication was administered on the MAR and the accountability record. Accountability records for current controlled substance must be with the MAR, or in a designated book. A controlled substance accountability record was prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications. Upon dispensing, or receipt of a controlled substance the accountability record included name of resident, prescription number, name, and strength, dosage form of medication, date received, quantity received, and name of persons receiving medication supply. Completed accountability records were submitted to the Director of Nursing, and kept on file at the facility. 1. Interview with Licensed Practical Nurse (LPN) #3, on 11/02/2020 at 10:59 AM, revealed she observed a personal bag under the nurses' station desk on South unit, much later in the morning. LPN #3 stated she visualized the pink narcotic paper sheets in RN #1's personal bag and realized this required immediate reporting to the Director of Nurses (DON). She stated she and LPN #5 transported the bag to the Director of Nursing (DON). She revealed she had concerns once she visualized the pink narcotic sheets, as those belong in the narcotic binder. Attempted telephonic interviews with LPN #5, on 11/02/2020 at 9:40 AM and 2:39 PM, and on 11/04/2020 at 1:26 PM, without success. However, review of her written statement, dated 09/05/2020, revealed an open tote bag was under the desk (South Nurses Station) with visible pink resident narcotic sheets and medication packaging around 11:00 AM. Continued review of the statement revealed she notified the DON of the opened tote bag with the visible pink narcotic sheets and medication packaging and the DON advised her to bring the tote bag to the DON's office. Review of the clinical record for Resident #1 revealed facility admitted him/her on 08/21/2020 with the diagnoses of Chronic Pain Syndrome, Acute Kidney Failure (AKF), and Diabetes Mellitus Type II. Further review revealed pharmacy provided thirty (30) tablets of [MEDICATION(S)] 10 mg, on 08/23/2020. Review of the clinical record for Resident #2 revealed facility admitted him/her on 02/11/14 with the diagnoses of [CONDITION(S)] with [CONDITION(S)], and Chronic Pain Syndrome. Continued review revealed pharmacy provided ninety (90) tablets of [MEDICATION(S)] 10 mg, on 08/29/2020. Review of the clinical record for Resident #3 revealed facility admitted him/her on 07/09/2020 with the diagnoses of Spinal Stenosis, and [CONDITION(S)] of the Vertebra. Continued review revealed pharmacy provided one hundred and eighty (180) tablets of [MEDICATION(S)] 15 mg, on 08/24/2020. Attempted telephonic interviews with Registered Nurse (RN) #2, on 11/02/2020 at 9:18 AM, 9:29 AM, and on 11/04/2020 at 11:29 AM, without success, and no option to leave a return call request. Interview with the Director of Nurses (DON), on 11/02/2020 at 3:08 PM and at 4:38 PM, revealed two (2) nurses, LPN #3 and #5 notified her of a blue and white striped bag at the South Nurses Station, opened and with visible pink narcotic sheets. She stated there were three (3) pink narcotic sheets and the two (2) Patient Health Information (PHI) portion of the medication blister packs were present without searching the bag. The DON stated she notified her Administrator (no longer at the facility), and called the police. RN #2 identified the bag was her personal bag. RN #2 initially stated she held on to the narcotic sheets until the end of her shift, and then left them in medical records. However, with further questioning, RN #2 changed the information to taking (ingesting) either two (2) fifteen (15) mg tablets, or three (3) ten (10) milligram (mg) tablets of [MEDICATION(S)] every hour while working. The police asked RN #2 to empty her pockets, which revealed eight (8) tablets of medications. The identified tablets were six (6) pink [MEDICATION(S)] ten (10) milligram (mg) tablets, and two (2) green tablets of [MEDICATION(S)] fifteen (15) mg, in her possession. She stated RN #2 was drug tested and was positive for amphetamines, methamphetamines, and opiates. 2. Review of the Accountability Record for RX# 33, dated 07/24/2020, revealed the facility staff did not complete the record with the date received from pharmacy. Review of the two (2) Accountability Records for RX# 25, both dated 09/22/2020, revealed the facility staff did not complete the record with the date received from pharmacy. Review of the Accountability Record for RX# 01, dated 10/08/2020, revealed the facility staff did not complete the record with the date received from pharmacy. Review of the Accountability Record for RX# 59, dated 10/02/2020, revealed the facility staff did not complete the record with the date received from pharmacy. Review of the Accountability Record for RX# 01, dated 10/21/2020, revealed the facility staff did not complete the record with the date received from pharmacy. Review of the two (2) Accountability Record for RX# 89, dated 10/15/2020, revealed the facility staff did not complete the record with two (2) receiving nurse signatures when received from pharmacy. Review of the Accountability Record for RX# 98, dated 10/15/2020, revealed the facility staff did not complete the record with two (2) receiving nurse signatures when received from pharmacy. Review of the Accountability Record for RX# 56, dated 10/17/2020, revealed the facility staff did not complete the record with two (2) receiving nurse signatures when received from pharmacy. Review of the Accountability Record for RX# 32, dated 10/19/2020, revealed the facility staff did not complete the record with two (2) receiving nurse signatures when received from pharmacy. Review of the two (2) Accountability Record for RX# 81, dated 10/22/2020, revealed the facility staff did not complete the record with two (2) receiving nurse signatures when received from pharmacy. Review of the facility's drug screening of Registered Nurse #2, dated 09/05/2020, and revealed she was positive for [MEDICATION(S)], [MEDICATION(S)], and opiates. Continued interview with the DON, on 11/04/2020 at 4:04 PM, revealed the Pharmacy completed an audit of the narcotics in September after the diversion. She stated she received the audit results later in the same month. The DON stated she had not shared the findings with others in the facility nor had the facility implemented any changes as a result of the audit. She stated the narcotic accountability sheets should be signed by two (2) nurses, and dated with the date of arrival. Interview with the Administrator, on 11/06/2020 at 5:22 PM, revealed she became aware of the drug diversion incident after a few weeks into this employment during a review with her regional support about the status of recent investigations and she had not reviewed the case. She stated she was not aware of any ongoing audits, nor any other issues with drug diversions. She stated the pharmacy completed an audit; however, the facility had not reviewed the findings.

Based on interview, record review, facility policy review, and review of an abuse investigation, it was determined the facility failed to ensure residents were free from abuse for one (1) of forty-four (44) residents, Resident #11. Interviews revealed a staff member yelled and cursed at the resident, made fun of the resident, threatened the resident, and exposed herself to the resident. In addition, the facility failed to protect Resident #11 and other residents from potential further abuse when the alleged perpetrator was allowed back in the facility. Interview with the Social Services Director, on 06/23/19 at 11:40 PM, revealed Resident #13 was still angry and agitated over the situation when she interviewed the resident on 03/27/19. Review of the Resident #13's clinical record revealed the Interim Director of Nursing (IDON) documented, on 03/27/19 at 12:30 PM, the resident was tearful, loud and cussed during their discussion of the abuse incident. The facility's failure to have an effective system in place to ensure residents were free from abuse has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 06/20/19, and was determined to exist on 03/26/19. The facility was notified of the IJ on 06/20/19. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/23/19, which alleged removal of the IJ on 06/23/19. The State Survey Agency (SSA) verified the IJ was removed on 06/24/19, prior to exit on 06/24/19. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes The findings include: Review of the facility's policy, Abuse Prevention Program, undated, revealed it was the facility's policy to prevent abuse, neglect, mistreatment, and misappropriation of resident property. The facility defined verbal abuse as any use of oral, written, or gestured language, which willfully included disparaging and derogatory terms to the resident. The facility defined sexual abuse included sexual harassment, sexual coercion, or sexual assault. The facility defined misappropriation as the deliberate use of the resident's belongings or money without the resident's consent. In addition, the policy stated the facility should protect residents and immediately bar any staff suspected of abuse or misconduct from any further contact with residents of the facility, and suspend the staff member from duty, pending the outcome of the investigation. Review of the facility's Residents Rights, undated, revealed residents had the right to be free from abuse. Staff should implement procedures that protected residents from abuse, mistreatment, and misappropriation. Review of the Resident #11's clinical record revealed the facility admitted the resident on 11/16/18, with [DIAGNOSES REDACTED]. Review of Resident #11's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of one (1) staff for toileting and personal hygiene. Review of the Resident #13's clinical record revealed the Interim Director of Nursing (IDON) noted, on 03/27/19 at 12:30 PM, the resident had been tearful during both interviews today; in addition, during the first interview he/she got loud and cussed. However, was not cussing at the IDON but was repeating what had occurred on 03/26/19 and how upset he/she was over the situation. Interview with Resident #11, on 05/07/19 at 2:43 PM and 5/11/19 at 9:21 AM, revealed on 03/26/19, Certified Nursing Assistant (CNA) #13 provided incontinent care and one thousand dollars ($1000) of his/her money went missing. The resident stated he/she had the money in bed with him/her during care and saw the CNA take the money. The resident yelled at the CNA to bring the money back but the CNA ran down the hall. The resident called his/her case manager and the case manager called the police. In addition to taking the money, the resident stated CNA #13 yelled and cursed at him/her, made fun of him/her being incontinent, and exposed herself by pulling up her shirt and pulling down her pants to the resident. CNA #13 threatened the resident when she told him/her she would bring her sons to the facility and inferred the sons would hurt the resident. In addition, CNA #13 told him/her she knew who shot the resident (leaving the resident paraplegic) and she would tell them where the resident was. The resident further stated the CNA left the facility after the incident, but then returned and claimed she had to get a purse she left in another resident's room down the hall. Observation with Resident #11, on 06/20/19 at 4:30 PM, revealed the resident was in bed with pillows propped behind his/her back and head playing a video game. Resident #11 utilized his/her call light and requested staff to bring him/her food from dietary department because he/she was unable to independently ambulate without staff placing him/her to his/her wheelchair. Resident #11 had a rotunded stomach and could not move his/her lower extremities. Interview with Resident #11 revealed CNA #13 took advantage of him/her because she knew he/she could not independently get up and defend himself/herself. The resident said she could have hurt me. Resident #11 also stated when CNA #13 exposed herself, it offended him/her. According to Resident #11, when CNA #13 denied taking the money he/she became upset because he/she witnessed her take the money when the resident heard her open the container the money was in. Resident #13 further stated he/she called his/her Case Manager because he/she knew the Case Manager could help him/her calm down. Attempted telephone interview with CNA #13, on 05/10/19 at 8:39 AM, revealed the phone number was disconnected. Review of the facility's Investigation of Resident #11's allegation of abuse, dated 03/26/19, revealed the facility interviewed CNA #13 and the CNA denied taking the resident's money but admitted to cursing at the resident and stated after she left the facility with the police, she returned to the facility to get a backpack she left in another resident's room. In addition, the facility interviewed CNA #5 who revealed another resident reported to her a CNA came to his/her room and placed something under some clothing on a chair during the 2:30 PM to 10:30 PM shift on 03/26/19. The resident told her the same CNA came back between 11:30 PM to 11:50 PM and told the resident she had forgot her purse in the resident's room, but the resident said he/she never saw a purse. Telephone interview with CNA #8, on 05/10/19 at 8:55 AM, revealed on 03/26/19, CNA #13 and Resident #11 were exchanging words and the CNA told the resident she was going to get the people that shot him/her, bring them through the back door, and have them finish him/her off. In addition, CNA #13 said she was going to get her sons to come to the facility. CNA #8 stated CNA #13 remained in the building after the police left and continued to make remarks to Resident #11 while the police waited outside. She stated CNA #13 denied she took the resident's money but CNA #8 heard CNA #13 on the phone saying she was going to buy her son some new shoes with the money and laughed. She further stated verbal abuse caused mental injury and made a person feel like no one cared and it could cause depression. Interview with CNA #8, on 06/22/19 at 12:15 PM, revealed all current and/or previous staff knew the entry/exit code to the back door by Resident #11's room and could enter the facility at any time. She said she worked at the facility for over a year and the entry/exit code had never changed. (The back door was approximately 44 feet from the resident's room.) Interview with CNA #10, on 05/10/19 at 10:54 PM, revealed on 03/26/19, CNA #13 gave her report on the residents and CNA #13 was angry regarding Resident #11 allegation CNA #13 stole his/her money. CNA #13 left and about 11:00 PM or 12:00 AM, she returned to the facility saying she forgot something and went into a resident's room. She stated Resident #11 was at the nurses' station at the time and CNA #13 teased the resident, and stuck her tongue out at the resident when she walked past him/her. Interview with Licensed Practical Nurse (LPN) #8, on 05/10/19 at 2:46 PM and 4:58 PM, revealed she cared for Resident #11 on 03/26/19, and around 9:30 PM, she went into Resident #11's room and the resident and CNA #13 were yelling and cursing at each other. LPN #8 stated the CNA told the resident he/she was a liar and she did not take the resident's money. The LPN repeatedly told the CNA to leave the resident's room but the CNA did not leave and the resident and CNA continued to yell at each other. CNA #13 then pulled up her shirt, turned around, pulled her pants down, and exposed her bare buttock to the resident. After exposing herself, the CNA left the resident's room and LPN #8 made notification calls. While she was on the phone with the Administrator, the police arrived and spoke to Resident #11 and CNA #13, which was about 10:00 PM or later. LPN #8 stated staff should protect residents from abuse; however, when she left the facility after her shift, she saw CNA #13 at the front entryway of the facility but did not notify anyone of CNA #13's return. LPN #8 stated when an abuse allegation was made against staff; staff had to leave the facility pending the investigation, and was not allowed back in the building. She further stated stealing was misappropriation, and the CNA yelling and cursing at the resident was verbal and mental abuse. Interview with LPN #2, on 05/09/19 at 3:35 PM, revealed on 03/26/19, she heard CNA #13 yell and act very hostile and upset. LPN #2 stated Resident #11 accused CNA #13 of stealing money and CNA #13 was belligerent and said to the resident she (CNA #13) knew who shot the resident and she could have them come back and do damage again. Interview with CNA #14, on 06/22/19 at 9:48 AM, revealed she worked on the day of the alleged incident and heard CNA #13 on conversing on the cell phone outside of a resident's window telling someone to come to the facility right now. CNA #8 stated Resident #11 became tearful and appeared distraught for a couple of days after the incident. She said the facility was the residents home and they were supposed to be able to trust the people who provided care for them. According to CNA #14, the facility had not changed the lobby door entry/exit code since last year. Interview with the Assistant Director of Nursing (ADON), on 05/11/19 at 11:15 AM, revealed LPN #8 called her the night Resident #11 alleged CNA #13 took his/her money and reported CNA #13 and Resident #11 was yelling at each other but did not recall if LPN #8 told her about CNA #13 exposing herself to the resident. She stated CNA #13 left the building with the police, but then returned and entered the facility to pick something up. The ADON stated staff asked the CNA what she was doing there and the CNA said she forgot something and went to retrieve it. The ADON further stated she did not know what the facility did to prevent CNA #13 from coming back and entering the building. The ADON stated CNA #13's behavior was abusive and the facility did not permit staff to act inappropriately to residents, no matter what a resident did or said. Interview with the Social Services Director (SSD), on 06/23/19 at 11:40 PM, revealed she interviewed Resident #11, on 03/27/19, regarding the incident of abuse. She stated CNA #13 came into provide incontinent care with another aide; and while staff had Resident #11 turned over on his/her side the resident heard the tin can, which he/she kept his/her money in, click closed. She stated when the staff turned him/her back over he/she asked for the tin can and CNA #13 would not give it back. The SSD stated the resident told her he/she started cursing CNA #13 and the aide cursed back. The SSD stated Resident #11 was still angry and agitated over the situation on 03/27/19; however was calmer on 03/28/19, due to the facility reimbursing the money allegedly misappropriated. Interview with the Interim Director of Nursing (DON), on 05/11/19 at 12:07 PM, revealed staff notified the former Administrator and the ADON on 03/26/19 about the incident involving Resident #11 and CNA #13 and the ADON instructed LPN #8 to have CNA #13 leave the facility and not come back. However, the CNA came back after shift change. The Interim DON stated CNA #13 admitted to threatening and cursing at Resident #13 and admitted she pulled up her shirt and pulled down her pants in front of the resident. In addition, CNA #13 admitted she came back into the facility to get her workbag from one of the resident's rooms. She revealed the facility had not protected residents from further abuse and misappropriation due to the CNA's ability to come back and enter the facility. Telephone Interview with the Interim Director of Nursing (IDON), on 06/24/19 at 7:00 PM, revealed she interviewed Resident #11, on 03/27/19 and 03/28/19, regarding the incident and the resident was obviously upset, angry and at times tearful. She stated the resident seemed calmer on 03/28/19, after the facility provided him/her with a check for one thousand dollars. Interview, on 05/10/19 at 4:04 PM and 05/11/19 at 12:54 PM, with the Regional Director of Operations (RDO) revealed on 03/26/19, CNA #13 went into Resident #11's room to provide incontinent care and the CNA allegedly took the resident's money. She stated she was not aware the CNA threatened the resident. The RDO stated when she spoke to Resident #11; he/she was only distressed about the money and not the CNA's behavior, cursing and exposing herself, and since the resident was not distressed over the CNA's behavior, the behavior was not abuse but was inappropriate, and she no longer worked at the facility. The RDO stated the facility failed to protect residents from further abuse when CNA #13 returned to the facility, entered another resident's room, and no one called the police to report the CNA had returned. The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to reenter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the Vice President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The Vice President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), Admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not returned the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire related to the abuse policy that the Administrator completed and returned to her. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO trained her on the facility's abuse policy. The Administrator stated she also received abuse training from the Director of Education at Regional Office Quarterly Meeting conduct on 05/11/19. Review of the RDO's email correspondence to all administrators in the region, dated sent on 06/14/19 at 9:25 PM, revealed she sent an email telling the administrators that surveyors were verifying facility investigations began immediately and that they were thorough. She attached the Abuse Policy, Incident Report Form, and an Example of Investigation Summary for them to refer to when completing abuse investigations. 8. Review of the facility's Social Services Behavior Assessment forms for Resident #11, dated 03/26/19, 03/27/19, and 03/28/19, revealed the previous ADON assessed the resident's behavior on 03/26/19, as angry about money stolen; on 03/27/19, as tearful and stated found out his/her aunt was ill; and on 03/28/19 with no negative behaviors. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #11 on 05/10/19, and he/she displayed and voiced no co

Based on interview, record review, and facility policy review, it was determined the facility failed to implement its abuse policy to ensure residents were protected from abuse for one (1) of forty-four (44) residents, Resident #11. Resident #11 alleged abuse by Certified Nursing Assistant (CNA) #13. The facility did not follow its policy to ensure Resident #11, and other residents, were protected from potential further abuse when CNA #13 was not immediately removed from the facility and was allowed back into the facility before the investigation was completed. In addition, review of the CNA's personnel file, and six (6) other employee files, revealed the facility did not follow its policy to complete reference checks prior to hire. The facility's failure to have an effective system in place to implement its abuse policy to ensure residents were protected from abuse has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 06/20/19, and was determined to exist on 03/26/19. The facility was notified of the IJ on 06/20/19. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/23/19, which alleged removal of the IJ on 06/23/19. The State Survey Agency (SSA) verified the IJ was removed on 06/24/19, prior to exit on 06/24/19. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Abuse Prevention Program, undated, revealed it was the facility's policy to prevent abuse, neglect, mistreatment, and misappropriation of resident property. The facility would protect residents and immediately bar any staff suspected of abuse or misconduct from any further contact with residents of the facility, and suspend the staff member from duty, pending the outcome of the investigation. In addition, prior to a new employee starting a working schedule, a reference check from the previous employer(s) would be initiated in accordance with the facility policy. The facility did not provide a policy for pre-employment reference checks. 1. Interview with Resident #11, on 05/07/19 at 2:43 PM and 5/11/19 at 9:21 AM, whom the facility deemed interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) on 02/22/19, revealed on 03/26/19, CNA #13 stole his/her money, cursed at and made fun of him/her, threatened physical harm, and exposed herself to the resident. According to the resident, CNA #13 left the facility after the incident, but returned and claimed she had to get a purse she left in another resident's room down the hall. Interview with Resident #11, on 06/20/19 at 4:30 PM, revealed when CNA #13 came back to the facility she stuck her tongue out at the resident as she walked pass him/her and he/she watched her enter a resident's room next to his/her room. Resident #11 stated he/she told LPN #8 which room CNA #13 went into. Review of the facility's Investigation of Resident #11's allegation of abuse, dated 03/26/19, revealed CNA #13 admitted to cursing at Resident #11. In addition, after the CNA left, she re-entered the facility. Interview with CNA #8, on 05/10/19 at 8:55 AM, via telephone revealed on 03/26/19, CNA #13 remained in the building after the police left and continued to make remarks to Resident #11 while the police waited outside. Interview with CNA #10, on 05/10/19 at 10:54 PM, revealed on 03/26/19, she got report on the residents from CNA #13 and CNA #13 left, then about 11:00 PM or 12:00 AM, she returned to the facility saying she forgot something and went into a resident's room. She stated Resident #11 was at the nurses' station at the time and CNA #13 teased the resident, and stuck her tongue out at the resident when she walked past him/her. Interview, on 5/10/19 at 2:46 PM and 4:58 PM, with Licensed Practical Nurse (LPN) #8 revealed on 03/26/19 at around 9:30 PM, Resident #11 alleged CNA #13 stole his/her money. She witnessed the CNA yell and curse at the resident, and she exposed herself to the resident. The LPN repeatedly told the CNA to leave the room and clock out but the CNA did not and continued to yell at the resident. LPN #8 stated the police came and spoke to Resident #11 and CNA #13, which was about 10:00 PM or later, and the CNA was directed to leave. She stated when she finished her shift and left the facility, she saw CNA #13 at the front entryway of the facility getting out of a car. The LPN stated she continued to walk to her car and went home without notifying anyone of CNA #13's return to the facility. Review of the facility's clock times for CNA #13 revealed on 03/26/19, she clocked in at 2:30 PM and clocked out at 11:00 PM. Interview with the Assistant Director of Nursing (ADON), on 05/11/19 at 11:15 AM, revealed on 03/26/19, CNA #13 left the building with the police, but then returned and entered the facility to pick something up. The ADON stated the nurse asked the CNA what she was doing there and the CNA told the LPN she forgot something and went to retrieve it. When the nurse asked what she forgot, the CNA told the nurse to mind her own business and walked out the front door. Interview with the Interim Director of Nursing, on 05/11/19 at 12:07 PM, revealed the facility had not protected residents from further abuse due to the CNA's ability to come back and enter the facility. Interview, on 05/10/19 at 4:04 PM and 05/11/19 at 12:54 PM, with the Regional Director of Operations (RDO) revealed the facility failed to protect residents from further abuse when CNA #13 returned to the facility and no one called the police to report the CNA had returned and entered another resident's room. 2. Review of CNA #13, and six (6) other personnel files, revealed there were no reference checks for the employees, per the facility's abuse policy. Interview with Human Resources (HR)/Payroll Assistant, on 05/11/19 at 10:42 AM, revealed department managers were responsible for performing reference checks for potential employees; however, no one was responsible for verifying to ensure the checks were completed and in the personnel file. She stated the Staffing Coordinator was responsible for notifying her when new staff was approved to begin work at the facility. According to the HR Assistant, the purpose of reference checks was to ensure staff was qualified and safe to work with residents. Interview with the Staffing Coordinator, on 05/11/19 at 11:05 AM, revealed she was not involved in the hiring process. According to the Staffing Coordinator, the HR Assistant notified her when it was okay to schedule new direct care staff. Interview with the Director of Nursing (DON), on 05/11/19 at 2:07 PM, revealed the HR Assistant was responsible for ensuring all new hire information was contained in the personnel file, including reference checks. Interview, on 05/10/19 at 4:04 PM, and 05/11/19 at 12:54 PM, with the RDO revealed the facility failed to protect residents from abuse due to ineffective employee screening during the hiring process, as there were no reference checks on file for CNA #13. Interview with the Interim Administrator, on 05/11/19 at 3:09 PM, revealed it had come to his attention reference checks for new employees had not always been completed. He stated the reference checks were part of the abuse prevention policy, and the facility should have completed the checks to help protect residents from abuse. The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the Vice President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The Vice President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), Admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not returned the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire related to the abuse policy that the Administrator completed and returned to her. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO trained her on the facility's abuse policy. The Administrator stated she also received abuse training from the Director of Education at Regional Office Quarterly Meeting conduct on 05/11/19. Review of the RDO's email correspondence to all administrators in the region, dated sent on 06/14/19 at 9:25 PM, revealed she sent an email telling the administrators that surveyors were verifying facility investigations began immediately and that they were thorough. She attached the Abuse Policy, Incident Report Form, and an Example of Investigation Summary for them to refer to when completing abuse investigations. 8. Review of the facility's Social Services Behavior Assessment forms for Resident #11, dated 03/26/19, 03/27/19, and 03/28/19, revealed the previous ADON assessed the resident's behavior on 03/26/19, as angry about money stolen; on 03/27/19, as tearful and stated found out his/her aunt was ill; and on 03/28/19 with no negative behaviors. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #11 on 05/10/19, and he/she displayed and voiced no concerns of fear or intimidation related to the incident that occurred on 03/26/19. Observation of Resident #11, on 06/22/19 at 4:30 PM, revealed the resident was in bed playing a video game. During interview, the resident smiled continuously even when questioned about the alleged incident of abuse. The resident did not appear intimidated, nor were there any visible bruises or injuries. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she was originally upset regarding the incident, before the facility reimbursed the money. The resident stated the previous Administrator came and questioned him/her about the incident and how he/she felt about it, but since it was usually early in the morning when he/she did not talk much. 9. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she received abuse training from the Regional Director of Education/Nurse Consultant at Regional Office Quarterly Meeting conduct on 05/11/19. She said the training included receiving background and pre-employment reference checks, prior to staff starting their employment; conducting a thorough investigation; keeping resident(s) safe during the investigation; and reporting abuse investigations timely. Telephone interview with the Director of Education/Corporate Nurse Consultant Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. 10. Attempted telephone interview with the previous Maintenance Director, on 06/22/19 at 10:00 AM, revealed surveyor left a voice mail message for him to return call; however, he never returned surveyor's call. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed she assisted the previous Maintenance Director with changing the door entry/exit codes shortly after the annual survey. She said she assisted him by reading the on-line directions while he physically changed the codes. She stated the previous Director of Nursing trained her on abuse on 05/11/19. 11. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made, however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made, however, no one answered and a voice mail message was left to return call. 12. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made; however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made; however, no one answered and a voice mail message was left to return call. Review of the facility's Employee Tracking Audit Tool, not dated, revealed the facility-tracked employees' certification/license, criminal history, references, TB assessments, and abuse registry checks upon hire and annually thereafter. Review of seven (7) sampled employee files, on 06/21/19 at 10:00 AM, revealed the facility employee files contained certification/license, criminal history, references, TB assessments, and abuse registry checks. Interview with the Business Office Manager, on 06/24/19 at 6:00 PM, revealed she began employment with the facility on 11/28/18, and started completing pre-employment checks. She stated she was trained by the RDO to complete reference, criminal background, licensee/certification, abuse registry, and Office of Inspector General checks on all potential employees before allowing them to work in the facility. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she audited all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. In addition, she directed the DON to verify all employee TB assessments were completed. 13. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she was trained by the RDO on abuse reporting and auditing all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. 14. Review of the facility's Resident Interview forms, not dated, revealed the SSD conducted resident interview questionnaires 05/28/19 through 06/06/19, related to how they felt about their treatment, services, and safety at the facility. The forms noted the residents replied they felt safe in the facility. Interview with Social Services Director, on 06/23/19 at 11:40 PM, revealed she interviewed residents and documented the interviews on a Resident Interview form on 05/28/19 through 06/06/19. She stated the residents voiced no concerns related to staff treatment or their overall safety at the facility. Interviews with Resident #35 at 8:10 AM, Unsampled Resident A at 8:15 AM, and Unsampled Resident B at 8:22 AM, on 06/21/19, revealed they felt safe at the facility and had no concerns related to abuse. The residents stated if they felt someone treated them badly they would report it immediately to the nurse on duty or the Administrator. 15. Immediately after the door codes were changed, the Administrator and the Maintenance Director would round to confirm changes of codes were effective. The Maintenance Director documented door code changes on a Door Code Tracking Tool to ensure no prior codes were duplicated. Review of an In-Service Record, dated 06/22/19, revealed the Administrator trained the Maintenance Director on how to re-code door key locks. The training included information from Secure Care Advantage 1000, KABA Simplex 1000 Series, and Door Guard IEI. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed the Administrator/DON/ADON would notify him if they terminated and/or suspended an employee and he would change the door entry/exit codes within two hours of notification. He said they developed a log to track all door code changes and the logs would be housed at each nursing station and in his office. According to the Maintenance Director, the log would be reviewed at QAPI. The Maintenance Director further stated on 06/22/19, he changed all door entry/exit codes and logged them in on the tracking sheet, per the Administrator. The Maintenance Director stated the Administrator trained him on how to change the entry/exit door codes for three (3) door locks and he read the facility's security manual, which also gave direction on entry/exit door codes. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activit

Based on interview, facility policy review, review of a facility self-report form, and review of a facility abuse investigation, it was determined the facility failed to report allegations of abuse for one (1) of forty-four (44) residents, Resident #11. Interviews revealed Resident #11 alleged staff stole his/her money, yelled and cursed at him/her, made fun of him/her, threatened harm, and exposed herself to the resident. However, review of the facility's self-report to the State Survey Agency revealed the facility reported the misappropriation of the money and no other abuse issues. The facility's failure to have an effective system in place to report allegations of abuse has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 06/20/19, and was determined to exist on 03/26/19. The facility was notified of the IJ on 06/20/19. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/23/19, which alleged removal of the IJ on 06/23/19. The State Survey Agency (SSA) verified the IJ was removed on 06/24/19, prior to exit on 06/24/19. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Abuse Prevention Program, undated, revealed the facility prevented abuse, neglect, mistreatment, and misappropriation of resident property. The facility defined verbal abuse as any use of oral, written, or gestured language, which willfully included disparaging and derogatory terms to a resident. The facility defined sexual abuse as including sexual harassment, sexual coercion, or sexual assault. The facility's definition of misappropriation included deliberate use of the resident's belongings or money without the resident's consent. The policy further stated employees were required to report any incident, allegation, or suspicion of potential abuse, neglect, or mistreatment to the Administrator or immediate supervisor who would immediately report the allegation to the Administrator. The Administrator or person in charge of the facility was responsible for reporting alleged or suspected cases of abuse to the State Survey Agency, and for reasonable suspicion of a crime, a report would be made to law enforcement officials. Review of the facility's Residents Rights, undated, revealed the facility must promptly and thoroughly investigate all alleged violations, report results to appropriate agencies, and take corrective action. On 05/07/19 at 2:43 PM and 05/11/19 at 9:21 AM, interviews with Resident #11 revealed Certified Nursing Assistant (CNA) #13 provided incontinent care for him/her and he/she saw the CNA take his/her money, on 03/26/19. The resident stated in addition to taking his/her money, CNA #13 yelled and cursed at him/her, made fun of him/her for being incontinent, and exposed herself by pulling up her shirt and pulling down her pants. CNA #13 also threatened physical harm to the resident by insinuating she would bring her sons to the facility and she would tell the people who shot the resident where to find him/her. Review of the facility's Self-Reported Incident Form, Five (5) Day Follow-up/Final Report, dated 03/29/19, revealed a report for exploitation/misappropriation of property. Resident #11 alleged CNA #13 stole one thousand dollars ($1000.00) from him/her. The police searched the CNA and no money was found. The facility was unable to determine if the resident had the money while in the facility but presented the resident with a check. The facility unsubstantiated the allegation. However, the facility did not report to the State Survey Agency the allegation of abuse. Review of the facility's Investigation for Resident #11's abuse allegation, dated 03/26/19, revealed a facility interview with CNA #13 in which she denied taking the resident's money but admitted to cursing at the resident. The interview did not reveal if the CNA was asked about exposing herself or threatening harm to the resident. A documented interview with Licensed Practical Nurse (LPN) #8 revealed CNA #13 pulled up her shirt exposing her bra, and pulled down her pants exposing her buttock to show the resident she did not have anything in her pants. However, the facility did not report the verbal abuse or staff exposing herself to the State Survey Agency. Interview via telephone, on 05/10/19 at 8:55 AM, with CNA #8 revealed on 03/26/19, she heard CNA #13 tell Resident #11 she was going to get the two (2) people who shot him/her and bring them through the back door and have them finish him/her off. In addition, CNA #13 said she was going to get her two (2) sons to come up to the facility. However, this abuse was not reported to the State Survey Agency. Interview, on 05/10/19 at 10:54 PM, with CNA #10 revealed on 03/26/19, CNA #13 left the facility and was gone a while and then about 11:00 PM or 12:00 AM, CNA #13 returned to the facility because she said she forgot something. She stated Resident #11 was at the nurses' station and CNA #13 teased him/her and stuck her tongue out at the resident when she walked past him/her. However, this abuse was not reported to the State Survey Agency. Interview with LPN #2, on 05/09/19 at 3:35 PM, revealed on the night of an incident with Resident #11 and CNA #13, she heard the CNA tell Resident #11 she knew who shot the resident and she could have them come back and do damage again. However, this abuse was not reported to the State Survey Agency. Interview, on 05/10/19 at 2:46 PM and 4:58 PM, with LPN #8 revealed on 03/26/19, she entered Resident #11's room and the resident and CNA #13 were yelling and cursing at each other. As she attempted to get the CNA to leave the room, the CNA pulled up her shirt, which made her bra visible, and turned around and pulled her pants down and exposed her bare buttock toward the resident. The LPN stated the verbal abuse should have been reported. However, this abuse was not reported to the State Survey Agency. Interview, on 05/11/19 at 11:15 AM, with the Assistant Director of Nursing (ADON) revealed LPN #8 called her 03/26/19 and reported Resident #11 alleged CNA #13 took his/her money, and the resident and CNA had been yelling at each other. The ADON did not recall receiving report the CNA exposed herself to the resident, which the ADON stated was abusive behavior. She further stated the facility was required to report to the State Survey Agency if anyone threatened a resident, cursed at a resident, or exposed himself or herself to a resident, and to her knowledge, the facility had not reported those issues. She stated she was not part of the investigation process and the abuse coordinator should have reported appropriately. Interview, on 05/11/19 at 12:07 PM, with the Interim Director of Nursing (DON) revealed staff notified the former Administrator and the ADON on 03/26/19 about the incident involving Resident #11 and CNA #13. The Interim DON stated she was involved in the investigation and conducted interviews with Resident #11 and staff involved. She revealed Resident #11 alleged CNA #13 misappropriated Resident #11's money, and was verbally abusive to the resident, as she cursed at him/her. The CNA pulled up her shirt, pulled down her pants, and exposed herself to try to prove she did not have the resident's money, and the CNA exposing herself was a form of sexual abuse. She further stated she and the Human Resources Coordinator called CNA #13 and the CNA admitted to threatening and cursing at Resident #11 and admitted she pulled up her shirt and pulled down her pants in front of the resident. However, that was not included in the documented interview in the investigation file. The Interim DON further revealed to her knowledge, the Administrator reported the misappropriation and abuse allegations to the State Survey Agency. However, interview with the Regional Director of Operation (RDO), on 05/10/19 at 4:04 PM and 05/11/19 at 12:54 PM, revealed the former Administrator did some of the investigation into Resident #11's and CNA #13's incident by phone and she continued the investigation on 03/27/19. The RDO stated since the resident was not in distress over the CNA's behavior, cursing, and exposing herself, the behavior was not abusive. The RDO was not made aware the CNA had threatened the resident. In addition, when she interviewed Resident #11, she focused on the allegation of the missing money. The RDO stated the facility did interviews with other residents related to misappropriation but did not interview for abuse. The RDO further stated she was responsible for ensuring the investigation was completed before submitting the five (5) day follow-up report to the State Survey Agency. However, the RDO stated she did not report allegations of verbal abuse or threats made by a CNA #13 to Resident #11, and did not report CNA #13 exposed herself to the resident. The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the Vice President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The Vice President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), Admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not returned the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire related to the abuse policy that the Administrator completed and returned to her. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO trained her on the facility's abuse policy. The Administrator stated she also received abuse training from the Director of Education at Regional Office Quarterly Meeting conduct on 05/11/19. Review of the RDO's email correspondence to all administrators in the region, dated sent on 06/14/19 at 9:25 PM, revealed she sent an email telling the administrators that surveyors were verifying facility investigations began immediately and that they were thorough. She attached the Abuse Policy, Incident Report Form, and an Example of Investigation Summary for them to refer to when completing abuse investigations. 8. Review of the facility's Social Services Behavior Assessment forms for Resident #11, dated 03/26/19, 03/27/19, and 03/28/19, revealed the previous ADON assessed the resident's behavior on 03/26/19, as angry about money stolen; on 03/27/19, as tearful and stated found out his/her aunt was ill; and on 03/28/19 with no negative behaviors. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #11 on 05/10/19, and he/she displayed and voiced no concerns of fear or intimidation related to the incident that occurred on 03/26/19. Observation of Resident #11, on 06/22/19 at 4:30 PM, revealed the resident was in bed playing a video game. During interview, the resident smiled continuously even when questioned about the alleged incident of abuse. The resident did not appear intimidated, nor were there any visible bruises or injuries. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she was originally upset regarding the incident, before the facility reimbursed the money. The resident stated the previous Administrator came and questioned him/her about the incident and how he/she felt about it, but since it was usually early in the morning when he/she did not talk much. 9. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she received abuse training from the Regional Director of Education/Nurse Consultant at Regional Office Quarterly Meeting conduct on 05/11/19. She said the training included receiving background and pre-employment reference checks, prior to staff starting their employment; conducting a thorough investigation; keeping resident(s) safe during the investigation; and reporting abuse investigations timely. Telephone interview with the Director of Education/Corporate Nurse Consultant Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. 10. Attempted telephone interview with the previous Maintenance Director, on 06/22/19 at 10:00 AM, revealed surveyor left a voice mail message for him to return call; however, he never returned surveyor's call. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed she assisted the previous Maintenance Director with changing the door entry/exit codes shortly after the annual survey. She said she assisted him by reading the on-line directions while he physically changed the codes. She stated the previous Director of Nursing trained her on abuse on 05/11/19. 11. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made, however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made, however, no one answered and a voice mail message was left to return call. 12. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made; however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made; however, no one answered and a voice mail message was left to return call. Review of the facility's Employee Tracking Audit Tool, not dated, revealed the facility-tracked employees' certification/license, criminal history, references, TB assessments, and abuse registry checks upon hire and annually thereafter. Review of seven (7) sampled employee files, on 06/21/19 at 10:00 AM, revealed the facility employee files contained certification/license, criminal history, references, TB assessments, and abuse registry checks. Interview with the Business Office Manager, on 06/24/19 at 6:00 PM, revealed she began employment with the facility on 11/28/18, and started completing pre-employment checks. She stated she was trained by the RDO to complete reference, criminal background, licensee/certification, abuse registry, and Office of Inspector General checks on all potential employees before allowing them to work in the facility. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she audited all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. In addition, she directed the DON to verify all employee TB assessments were completed. 13. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she was trained by the RDO on abuse reporting and auditing all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. 14. Review of the facility's Resident Interview forms, not dated, revealed the SSD conducted resident interview questionnaires 05/28/19 through 06/06/19, related to how they felt about their treatment, services, and safety at the facility. The forms noted the residents replied they felt safe in the facility. Interview with Social Services Director, on 06/23/19 at 11:40 PM, revealed she interviewed residents and documented the interviews on a Resident Interview form on 05/28/19 through 06/06/19. She stated the residents voiced no concerns related to staff treatment or their overall safety at the facility. Interviews with Resident #35 at 8:10 AM, Unsampled Resident A at 8:15 AM, and Unsampled Resident B at 8:22 AM, on 06/21/19, revealed they felt safe at the facility and had no concerns related to abuse. The residents stated if they felt someone treated them badly they would report it immediately to the nurse on duty or the Administrator. 15. Immediately after the door codes were changed, the Administrator and th

Based on observation, interview, facility policy review, and review of the facility's abuse investigation, it was determined the facility failed to thoroughly investigate an allegation of abuse for one (1) of forty-four (44) residents, Resident #11. Interviews revealed Resident #11 made an allegation Certified Nursing Assistant (CNA) #13 stole his/her money. In addition, the CNA yelled and cursed at the resident, threatened harm to the resident, and exposed herself to the resident; however, review of the investigation revealed it centered on the misappropriation but did not include the verbal and possible sexual abuse. In addition, the facility did not protect Resident #11, or the other residents, during the investigation, as the facility failed to prevent the CNA from re-entering the facility. The facility's failure to have an effective system to thoroughly investigate an allegation of abuse has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 06/20/19, and was determined to exist on 03/26/19. The facility was notified of the IJ on 06/20/19. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/23/19, which alleged removal of the IJ on 06/23/19. The State Survey Agency (SSA) verified the IJ was removed on 06/24/19, prior to exit on 06/24/19. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Abuse Prevention Program, undated, revealed it was the facility's policy to prevent abuse, neglect, mistreatment, and misappropriation of resident property. The facility defined verbal abuse as any use of oral, written, or gestured language, which willfully included disparaging and derogatory terms to the resident. The facility defined sexual abuse included sexual harassment, sexual coercion, or sexual assault. The facility defined misappropriation as the deliberate use of the resident's belongings or money without the resident's consent. Upon learning of an abuse allegation, the Administrator or person in charge of the facility would initiate an incident investigation. The facility investigated any incident or allegation involving abuse or mistreatment and documented all incidents, whether or not abuse occurred, was alleged, or suspected. In addition, any staff suspected of abuse or misconduct was immediately barred from any further contact with residents of the facility and suspended from duty, pending the outcome of the investigation. Review of the facility's Residents Rights, undated, revealed residents had the right to be free from abuse. Staff would implement procedures that protected residents from abuse, mistreatment, and misappropriation. The Resident Rights further stated the facility must promptly and thoroughly investigate all alleged violations, report results to appropriate agencies, and take corrective action. Interview, on 05/07/19 at 2:43 PM and 05/11/19 at 9:21 AM, with Resident #11, whom the facility deemed interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) on 02/22/19, revealed CNA #13 provided incontinent care for him/her on 03/26/19, and he/she saw the CNA take his/her money. In addition, the CNA yelled and cursed at him/her, made fun of him/her for being incontinent, and exposed herself to the resident by pulling up her shirt and pulling down her pants. Resident #11 stated the CNA also threatened physical harm. Interview with Resident #11, on 06/20/19 at 4:30 PM, revealed the facility staff did not prevenent CNA #13 from returning to the facility after she threatened to harm him/her because she came back inside the facility's building after the police left and went into another resident's room. Review of the facility's Investigation into Resident #11's allegation of abuse, dated 03/26/19, revealed a phone interview with CNA #13, conducted by the Interim Director of Nursing (DON), in which the CNA denied taking the resident's money but admitted to cursing at the resident. There was no information about the CNA exposing herself to Resident #13 or threatening harm to the resident. CNA #13 admitted after she left the facility with the police, she returned to the facility to get a backpack she left in another resident's room. A documented interview with Licensed Practical Nurse (LPN) #8, revealed Resident #11 and CNA #13 and had been yelling at each other regarding the resident alleging the CNA stole his/her money. The LPN attempted to direct the CNA to leave the resident's room but the CNA would not leave and then CNA #13 pulled up her shirt and exposed her bra, and pulled down her pants exposing her buttock to show the resident she did not have anything in her pants. Further review of the investigation revealed the facility interviewed other residents regarding misappropriation of property; however, did not interview the residents regarding abuse. Attempted telephone interview with CNA #13, on 05/10/19 at 8:39 AM, revealed the phone number was disconnected. Interview by telephone, on 05/10/19 at 8:55 AM, with CNA #8 revealed she worked on 03/26/19 and around 9:30 PM, she heard CNA #13 threaten Resident #11 that she was going to get the people who shot him/her and bring them to the facility and have them finish him/her off. In addition, CNA #13 threatened she was going to get her sons to come to the facility, insinuating harm to the resident. CNA #8 stated CNA #13 remained in the building after the police left and continued to go back to Resident #11 and made remarks while the police waited outside. CNA #8 further stated no one from the facility interviewed her and no one asked her for a written statement regarding the incident. Interview with the Social Services Director (SSD), on 06/23/19 at 11:40 AM, revealed Resident #11 said he/she knew who had shot him/her and they would come back to finish him/her off, if they were aware of his/her location. In addition, the SSD stated Resident #11 was still agitated and angry when she spoke to him/her on 03/27/19 and 03/28/19, regarding the abuse incident. Observations of the back door by Resident #11's room made with the Maintenance Director, on 06/22/19 at 10:50 AM, revealed to enter/exit the door a key code entry was required. The door was located approximately 44 feet away from Resident #11's room and there was three (3) residents' rooms between the door and Resident #11's room. Interview with the Maintenance Director, on 06/22/19 at 10:50 AM, revealed he began employment with the facility a week ago and was in the process of learning how to change the entry codes on the facility key coded entry/exit doors, by reading the operation manuals. He stated he did not know when the codes were previously changed and what any of the previous code numbers were because the facility's previous Maintenance Director had not kept a log. Further interview with the Maintenance Director, on 06/22/19 at 11:30 AM, revealed the Administrator directed him to immediately change all entry/exit codes on all of the facility's doors and document the previous code and the new code on a log. Interview with CNA #12, on 06/22/19 at 10:55 AM, revealed she continuously worked at the facility for the past seven (7) years and the entry/exit code to the door located by Resident #11's room had not changed in two years. Interview with CNA #8, on 06/22/19 at 12:15 PM, revealed she worked at the facility for over a year and the entry/exit code by Resident #11's room had never changed. She stated if a previous employee wanted to gain entry into the facility's building, they could enter the facility at any time through the back door. (The back door was approximately 44 feet from the resident's room.) CNA #8 stated after the facilty's annual survey the maintenance department change the front lobby entry/exit code, but approximately two (2) weeks later, the codes were changed back to what they orginally were. Interview by telephone, on 05/10/19 at 10:44 AM, with CNA #9 revealed she was working at the facility when she heard Resident #11 say his/her money was missing and she heard LPN #8 tell the resident to calm down. CNA #9 stated no one asked her any questions about the incident and did not ask her to write a statement. Interview, on 05/09/19 at 3:35 PM, with LPN #2 revealed on 03/26/19, she heard CNA #13 yelling and acting very hostile and upset, and stated CNA #13 threatened harm to Resident #11. She stated she wrote a statement that night and put it in the Administrator's mailbox and spoke to the Administrator the next day and reported everything she had heard CNA #13 say. However, further review of the facility's investigation revealed no written statement by LPN #2 nor a documented interview with LPN #2 in the file. Interview, on 05/10/19 at 2:46 PM and 4:58 PM, with LPN #8 revealed on 03/26/19, she went to Resident #11's room and the resident and CNA #13 were yelling and cursing at each other. She stated she slowly got the CNA to move toward the door of the resident's room and the CNA pulled up her shirt, which made her bra visible, and then turned around and pulled her pants down and exposed her bare buttock toward the resident. She stated the CNA yelling and cursing at the resident was verbal and mental abuse. LPN #8 stated when an abuse allegation was made against staff; staff had to leave the facility pending the investigation, and was not allowed back in the building. However, when she was leaving to go home, she saw CNA #13 had returned to the facility. She did not report to anyone that the CNA had returned and stated she did not know what she should have done when she saw that the CNA had come back. Interview, on 05/10/19 at 10:35 PM, with LPN #9 revealed to enter the facility; staff entered a code into a key pad at the front door to unlock the door, which was available to all employees. She revealed she worked the night Resident #11 alleged a CNA stole money from him/her, and the code to enter the building was not changed after the incident. LPN #9 stated when staff entered the code to the door, there were no alerts, and staff at the nurses' station would not know if someone entered the building. Interview with CNA #10, on 05/10/19 at 10:54 PM, revealed on 03/26/19, when she arrived to work she saw police cars outside. She entered the code in the key pad to unlock the door and got report from CNA #13. She stated CNA #13 was angry regarding Resident #11 allegation CNA #13 stole his/her money. CNA #10 could not recall anyone telling CNA #13 to leave the facility but after CNA #13 left, she returned about 11:00 PM or 12:00 AM, saying she forgot something and went into a resident's room. She stated Resident #11 was at the nurses' station at the time and CNA #13 teased the resident, and stuck her tongue out at the resident when she walked past him/her. CNA #10 stated the facility did not change the code to enter the building after 03/26/19. Interview, on 05/11/19 at 11:15 AM, with the Assistant Director of Nursing (ADON) revealed after Resident #11's allegation of abuse, the facility did not change the code to unlock the front door in order to prevent potential further abuse from CNA #13, as she was able to re-enter the facility. The ADON further stated she did not know what the facility did to prevent CNA #13 from re-entering the building during the investigation. Interview, on 05/11/19 at 12:07 PM, with the interim DON, revealed she participated in Resident #11's abuse investigation. She stated CNA #13 allegedly misappropriated Resident #11's money, was verbally abusive to the resident when she cursed at the resident, and pulled up her shirt and pulled down her pants to prove she did not have the resident's money, which the Interim DON stated could be considered sexual abuse. She further stated she and the Human Resources Coordinator interviewed CNA #13 over the telephone and the CNA admitted to threatening and cursing at the resident and admitted she pulled up her shirt and pulled down her pants in front of the resident. However, this information was not included in the documented interview in the investigation file. The Interim DON stated CNA #13 was told not to come back to the facility to prevent the risk of additional abuse and misappropriation. She stated the facility did not adequately protect the residents from the CNA after the incident occurred, as the CNA was able to re-enter the facility. Interview, on 05/10/19 at 4:04 PM and 05/11/19 at 12:54 PM, with the Regional Director of Operation (RDO) revealed she served as the Interim Administrator during the investigation. The RDO stated she was made aware of Resident #11's abuse allegation the morning of 03/27/19, and started following up on the investigation that afternoon as the former Administrator had done some of the investigation by phone during the night. The RDO stated CNA #13 allegedly took Resident #11's money, cursed at the resident, and raised her shirt up and pulled her pants down in front of the resident. She stated she was not aware the CNA threatened the resident, and when she spoke to the resident, she focused on the resident's money, as the resident was not distressed over the CNA's cursing and exposing herself. She stated the facility did interviews with other residents related to misappropriation but did not interview for other things, such as cursing or staff exposing themselves, or if anything else had upset them that night. The RDO stated she did not thoroughly investigate the verbal and sexual abuse, and unsubstantiated the allegation. She stated she did not ask Resident #11 about inappropriate staff behavior, and she wished she had included questions about verbal abuse. In addition, the RDO stated she did not know a person could come in the front door by entering a code in a key pad. The RDO stated CNA #13 was suspended 03/26/19 and left with the police; however, she came back and the RDO assumed someone had let her in, but the CNA let herself in and could have come back again. The RDO further stated the facility failed to protect residents from further abuse when CNA #13 returned to the facility. Surveyor attempted to interview the previous Maintenance Director, on 06/22/19 at 11:04 AM, but could not leave a voice mail due to voice mail box was full. Observation of the facility's basement door, on 06/22/19 at 11:30 AM, revealed staff utilized an entry/exit code to enter the door in the basement, and from the basement staff could access the residents' rooms. Interview with CNA #18, on 06/22/19 at 11:34 AM, revealed the facility never changed the basement door's entry/exit code in years. She stated the facility changed the code to the main entrance lobby, but not the basement door. Interview with the Environment Services Director, on 06/22/19 at 11:45 AM, revealed on 05/11/19 she assisted the previous Maintenance Director with changing the main entrance door's entry/exit code, but none of the other codes were changed. She stated the main entrance door's entry/exit code was changed back to the original code approximately two (2) weeks after the facility's annual survey, but she could not recall why it was changed or who changed it back to the original code. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she was not aware that some of the doors' entry/exit codes were never changed and she did not know the main entrance door's entry/exit code reverted back to the previous code that would allow previous employees entry into the facility's building. The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the Vice President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The Vice President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), Admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire re

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement care plans for four (4) of forty-four (44) residents, Resident #22, #23, #54, and #97. The facility assessed Resident #22 with a left heel ulcer on 02/04/19. The resident was care planned to have a heel lift boot to the left heel except with ambulating; however, observations on three (3) days during the survey revealed the resident in bed without the heel boot in place. In addition, review of a physician's Wound Evaluation, dated 03/25/19, revealed the resident did not have the heel boot in place and the combination of comorbidities and lack of off-loading led to an increase in the area. In addition, Resident #23 was care planned for falls with an intervention to keep the call light within reach; however, observation revealed the call light was not in reach of the resident. The facility did not implement the care plan for Resident #54 who was at risk of compression fractures in order to maintain level of function, and Resident #97's care plan was not implemented related to monitoring of behaviors and potential side effects of psychoactive medication. The findings include: Review of the facility's policy, Baseline Care Plan Assessment/Comprehensive Care Plans, updated 09/18/18, revealed the Comprehensive Care Plan would expand on the resident's risks, goals and interventions using the Person-Centered plan of care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental, and psychosocial needs. The care plan would promote continuity of care and communication among nursing home staff, increase safety, and safeguard against adverse events. In addition, the facility used interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort, safety, and overall well-being attainable for the resident. 1. Review of the facility's policy, Preventive Skin Care, not dated, revealed the facility provided preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well groomed, and free from pressure sores. Heels would be up or specialty ordered therapeutic boots might be used to protect heels on those residents identified to be high risk. Review of the clinical record for Resident #22 revealed the facility readmitted the resident on 01/12/19, with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS), dated [DATE], revealed Resident #22 had no pressure ulcers and was at risk for developing pressure ulcers. In addition, the facility determined the resident had no arterial or venous ulcers. The facility provided a pressure-reducing device for the chair and bed. Review of the Care Plan for Resident #22, initiated 11/25/18, revealed the resident was at increased risk for alteration in skin integrity related to incontinence of bladder, incontinence of bowel, impaired mobility, status left heel arterial. Interventions included a heel boot to left heel, as resident would comply, dated 03/27/19. The care plan was revised during surveyor observations, on 05/08/19; with a notation that the resident was non-compliant with heel boots; however, there were no interventions for staff on what to do when the resident was non-compliant. Review of the Certified Nursing Assistant (CNA) care plan, not dated, for Resident #22, revealed special instructions included moon boots. Review of a Weekly Skin Check for Resident #22, dated 01/28/19, revealed no skin issues were noted. Review of a Weekly Skin Check, dated 02/04/19, revealed the resident had new loss of skin integrity and the facility was following resident's current skin care interventions. Review of a Significant Change MDS, dated [DATE], revealed the resident had one (1) unstageable pressure ulcer. Review of the Care Area Assessment (CAA) Worksheet revealed Resident #22 had an unstageable pressure ulcer to his/her left heel that originated on 02/04/19, and measured 1.9 centimeters (cm) length by 2.5 cm width. Treatments included elevate on heel boots. Review of Resident #22's Wound Assessment by the wound care physician, dated 03/25/19, revealed the left heel wound measured 2.4 cm by 3 cm. The physician documented the wound was deteriorating. The physician revealed no heel lift boot was in place, and the combination of comorbidities and lack of off-loading led to an increased area. The physician documented he personally applied the heel lift boot after his evaluation, orders were re-provided for use of the heel boot and discussed with the nursing staff. Review of Resident #22's Medication Administration Record [REDACTED]. Observation, on 05/07/19 at 11:45 AM and 12:30 PM, revealed Resident #22 in bed with no boots to his/her feet and the resident's heels laid on the mattress. Heel boots laid on the floor near the foot of the bed. Observation, on 05/09/19 at 10:47 AM, revealed Resident #22 in bed with no boots on the resident and his/her feet on the mattress. Observation, on 05/10/19 at 8:20 AM and 9:00 AM, revealed Resident #22 in bed and his/her bilateral boots were next to the sink. The resident's feet laid on the mattress. Interview with CNA #14, on 05/10/19 at 10:23 AM, revealed she was Resident #22's CNA for today (05/10/19). She stated she had not seen the heel boots on Resident #22, and was not sure when the resident needed to wear the boots. After breakfast (at approximately 8:00 AM) she stated the resident did not have the heel lift boots on, and she did not put them on him/her but she knew Resident #22 wore them. She stated the CNAs received a printout of resident needs for each shift but she did not carry the printout, as she knew what the residents needed. She did not ask the nurse any information regarding the moon boots, also known as the heel lift boots. She stated the purpose of the boots were to protect the resident's heels from rubbing on the bed. Interview with Registered Nurse (RN) #1, on 05/10/19 at 10:50 AM, revealed she provided some supervision of the CNAs and she tried to make sure each resident was provided the needed care. She stated the purpose of the lift heel boots were to help give support to Resident #22's heels and prevent further skin breakdown. She stated she was not aware the boots were not put on Resident #22 this morning and remained off. She stated it was important to utilize the boots, and to protect the heels, as the boots were to keep the heels lifted off the bed. Interview with the Director of Nursing (DON), on 05/10/19 at 11:07 AM, revealed she was not aware the resident did not have his/her heel boots on. She stated the resident was non-compliant at times and was care planned for that; however, the resident's non-compliance was not added to the care plan until 05/08/19, during the survey. The DON revealed she developed pocket sheets for the CNAs so they would know the care plan needs of each resident and staff should follow resident care plans. 2. Review of the clinical record revealed the facility admitted Resident #54 on 09/17/15, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The resident used a walker and a wheelchair for mobility and required extensive assistance of one (1) staff to walk in his/her room and corridor. Review of a Physical Therapy Discharge Summary, dated 01/24/19, revealed Resident #54 reached maximum functional potential and was able to ambulate 350 feet using a walker with stand-by assistance. Review of a Physician Order, dated (MONTH) 2019, revealed Resident #54 could participate in the restorative nursing program. Review of the Care Plan, initiated 01/09/19, revealed Resident #54 was at risk for compression fractures related to [MEDICAL CONDITION] with a goal to maintain the highest level of function. Interventions included encouraging exercise as tolerated to maintain movement. Interview with Resident #54, on 05/07/19 at 10:18 AM, revealed the CNAs had walked him/her once in the past four (4) weeks. Interview with CNA #1, on 05/09/19 at 11:24 AM, revealed Resident #54 was supposed to be walked daily and stated it was important to ensure residents were walked to maintain function. Interview with CNA #6, on 05/10/19 at 9:47 AM, revealed CNAs were responsible for ambulating residents; however, she never had enough time to ambulate her assigned residents. CNA #6 revealed residents could lose their ability to walk or get pressure ulcers if they were not ambulated daily. Interview with LPN #1, on 05/09/19 at 2:59 PM, revealed residents sometimes reported they were not ambulated when the unit was short a CN[NAME] LPN #1 revealed residents could lose function if they were not ambulated according to restorative orders. Interview with LPN #5, on 05/10/19 at 11:32 AM, revealed the CNAs were responsible for ambulating residents; however, it could be overwhelming because CNAs had a lot to do. Interview with Physical Therapist (PT) #1, on 05/09/19 at 10:55 AM, revealed the Restorative Program was pretty limited because of staff turnover. The PT revealed she evaluated Resident #54 for therapy services on 05/08/19, and stated the resident ambulated 50 feet using a walker with contact/guard assistance. The PT stated the resident had a decline in mobility since his/her discharge from therapy. Interview with the ADON, on 05/10/19 at 1:35 PM, revealed she observed care and reviewed CNA documentation daily to ensure restorative tasks were completed. Interview with the DON, on 05/11/19 at 2:07 PM, revealed she had no concerns with the ability of staff to complete assigned tasks. 3. Review of the clinical record revealed the facility admitted Resident #97 on 07/25/17, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #97 exhibited no behavioral symptoms. Review of Resident #97's Physician Order, dated 02/15/19, revealed to increase [MEDICATION NAME] ([MEDICATION NAME]-antipsychotic medication) to 1 milligram (mg) twice a day for behaviors. Review of Resident #97's Nursing Progress Notes revealed no behaviors or clinical rationale for the increased dose of [MEDICATION NAME]. Review of the Care Plan for Resident #97, last reviewed 02/14/19, revealed [MEDICAL CONDITION] medication was prescribed to manage the resident's appetite. Interventions included assuring the [DIAGNOSES REDACTED]. The care plan did not include target behavior(s) or non-pharmacological interventions for management of the behavior(s). The facility did not provide Behavior Tracking Forms for Resident #97. Review of Resident #97's Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed no monitoring for potential side effects of the medication, as stated in the care plan. Interview with LPN #1, on 05/09/19 at 2:59 PM, revealed Resident #97's care plan for [MEDICAL CONDITION] medication should include a [DIAGNOSES REDACTED]. He stated behaviors should be documented in the clinical record to justify the need for [MEDICAL CONDITION] medication. LPN #1 revealed the facility assessed residents quarterly for Extrapyramidal Symptoms (EPS-side effects, such as involuntary body movements, from antipsychotic drug use); however, he was not sure if EPS were associated with [MEDICATION NAME] use. He further revealed he was not familiar with the side effects of [MEDICATION NAME] and would have to google it. Interview with LPN #5, on 05/10/19 at 11:32 AM, revealed the purpose of the care plan was to ensure resident centered care and to communicate resident needs. She revealed medication was not a primary intervention to manage behavior(s) and the care plan should include non-pharmacological interventions, such as offering a snack or walking the resident. Interview with the ADON, on 05/10/19 at 1:35 PM, revealed the care plan should detail behavior(s) and include interventions to address the behavior(s). The ADON revealed the facility's system for tracking behaviors was broken and stated there was no tool in place to monitor for side effects of [MEDICAL CONDITION] medication. Interview with the DON, on 05/11/19 at 2:07 PM, revealed it was important to ensure behaviors and side effects were monitored to provide rationale for the increased dose of [MEDICATION NAME]. The DON revealed Resident #97's care plan for psychoactive medication was not implemented. 4. Review of Resident #23's clinical record revealed the facility admitted the resident on 02/12/19, with [DIAGNOSES REDACTED]. Review of Resident #23's Admission MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance to complete transfers and for locomotion. The facility conducted a BIMS exam with a score of four (4) out of fifteen (15) and determined the resident was not interviewable. Review of Resident #23's Care Plan, dated 02/12/19, revealed the resident was at risk for falls related to weakness, Dementia, history of falls, and psychoactive medications. Interventions included all staff was to be sure the resident's call light was within reach and encourage the resident to use it for assistance. However, observation of Resident #23, on 05/08/19 at 3:03 PM, revealed the resident was in his/her room in a wheelchair with the wheels locked, positioned between the bed and the door, and the call light was on the resident's bed, out of reach of the resident. Resident #23 leaned over the side of the wheelchair toward bed, was unable to reach the call light, and was unable to unlock his /her wheelchair in order to access the call light. Interview with CNA #11, on 05/08/19 at 3:07 PM, revealed the resident's call light should be within reach of the resident so the resident could ask for help from staff. Interview, on 05/08/19 at 3:12 PM, with Physical Therapy Assistant (PTA) #1 revealed Resident #23 had attempted previously to transfer himself/herself, was not able to do it safely, and required staff assistance. PTA #1 further stated he assisted Resident #23 with getting a drink, and when he left the resident, he/she was in the wheelchair between the bed and the door and he left the call light out of the resident's reach. Interview, on 05/10/19 at 1:28 PM, with LPN #7 revealed on 05/08/19, Resident #23 was in his/her room in a wheelchair with the call light out of the resident's reach. The LPN stated call lights needed to be in reach of the residents so they could request staff assistance and prevent an unsafe transfer and fall. LPN #7 revealed the facility had not followed Resident #23's care plan and the purpose of the plan was to communicate the resident's care needs to each staff. Interview, on 05/10/19 at 2:35 PM, with LPN #8 revealed on 05/08/19, Resident #23 could not reach his/her call light from where he/she was positioned in the wheelchair in the resident's room. The LPN stated the call light should have been within the resident's reach so if the resident needed something or wanted to go to the toilet, he/she could ask for assistance. LPN #8 stated staff did not follow the care plan for keeping the call light in reach. Interview, on 05/11/19 at 10:22 AM, with the DON revealed call lights should be within reach of the residents so residents could get the needed help from staff. The DON stated staff did not follow Resident #23's care plan when they left the resident with his/her call out of reach. Interview, on 05/11/19 at 10:50 AM, with the Interim Administrator revealed call lights should be in reach of the residents. He stated if staff did not place the call light in the resident's reach, per the care plan, then staff did not follow the care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to prevent the development of a pressure ulcer and promote healing for one (1) of forty-four (44) residents, Resident #22. The facility readmitted Resident #22 on 01/12/19 with no pressure ulcers and assessed the resident to be at risk for skin breakdown. On 02/04/19, the resident developed a pressure ulcer to the left heel and the facility put treatments in place, which included elevating the heel with a heel lift boot. However, multiple observations during survey revealed the resident in bed without the heel boot on and his/her heels in contact with the mattress. In addition, review of a physician Wound Evaluation, dated 03/25/19, revealed the resident did not have the heel boot in place and the combination of comorbidities and lack of off-loading led to an increase in the area. The findings include: Review of the facility's policy, Preventive Skin Care, not dated, revealed the facility provided preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well groomed, and free from pressure sores. Heels would be up or specialty ordered therapeutic boots might be used to protect heels on those residents identified to be high risk. Review of the clinical record for Resident #22 revealed the facility readmitted the resident on 01/12/19, with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS), dated [DATE], revealed Resident #22 had no unhealed pressure ulcers and was at risk for developing pressure ulcers. In addition, the facility determined the resident had no arterial or venous ulcers. The facility provided a pressure-reducing device for the chair and bed. Review of Physician order [REDACTED]. Review of the Care Plan for Resident #22, initiated 11/25/18, revealed the resident was at increased risk for alteration in skin integrity related to incontinence of bladder and bowel, impaired mobility, and status left heel arterial. Interventions included heel boot to left heel, as resident would comply, dated 03/27/19. Review of Resident #22's Medication Administration Record [REDACTED]. Review of the Certified Nursing Assistant (CNA) care plan, not dated, for Resident #22, revealed special instructions included moon boots. Review of a Weekly Skin Check for Resident #22, dated 01/28/19, revealed no skin issues were noted. Review of the Weekly Skin Check, dated 02/04/19, revealed the resident had new loss of skin integrity and the facility was following resident's current skin care interventions. Review of a Significant Change MDS, dated [DATE], revealed the resident had one (1) unstageable pressure ulcer. Review of the Care Area Assessment (CAA) Worksheet revealed Resident #22 had an unstageable pressure ulcer to his/her left heel that originated on 02/04/19, and measured 1.9 centimeters (cm) length by 2.5 cm width, and light serous exudate with 75-100% slough covering the wound bed. Treatments included cleansing with normal saline, apply Iodosorb to the wound bed, cover with an ABD (abdominal) pad, secure with Kerlix, elevate on heel boots, and no shoes-nonskid socks only. Review of the Resident #22's Wound Assessment by the wound care Physician, dated 03/11/19, revealed the left heel wound measured 2.5 cm by 2.6 cm. The physician documented the wound was an unstageable pressure injury with obscured full-thickness skin and tissue loss. The wound margins were well defined with necrotic (dead) tissue. Review of the Resident #22's Wound Assessment by the wound care physician, dated 03/18/19, revealed the left heel wound measured 2 cm by 2.5 cm. Review of the Resident #22's Wound Assessment by the wound care physician, dated 03/25/19, revealed the left heel wound measured 2.4 cm by 3 cm. The physician documented the wound was deteriorating. The physician revealed no heel lift boot was in place, and the combination of comorbidities and lack of off-loading led to an increased area. The physician documented he personally applied the heel lift boot after his evaluation, orders were re-provided for use of the heel boot and discussed with nursing staff. Review of the facility's Weekly Wound Evaluation for Resident #22, dated 04/08/19, revealed left heel pressure ulcer was unstageable and measured 2 cm by 2.3 cm by 0 cm depth. Treatments included cleansing with normal saline, apply Iodosorb to the wound bed, cover with an ABD pad, and secure with Kerlix. Heel boots, no shoes, nonskid socks only. Review of the facility's Weekly Wound Evaluation, dated 05/06/19, revealed the left heel pressure ulcer was unstageable and measured 1.5 cm by 2.2 cm by 0 cm depth. Treatments included wearing heel boot at all times when in bed. Observation of Resident #22, on 05/07/19 at 11:45 AM and 12:30 PM, revealed the resident in bed with no boots to his/her feet and the resident's heels were not off-loaded, as they laid on the mattress. Two (2) boots laid on the floor near the foot of his/her bed. Observation of Resident #22, on 05/09/19 at 10:47 AM, revealed the resident in bed with no boots on the resident and his/her feet laid on the mattress. Observation of Resident #22, on 05/10/19 at 8:20 AM and 9:00 AM, revealed the resident in bed and his/her bilateral boots were next to the sink in the resident's room. The resident's feet laid on the mattress. Interview with CNA #14, on 05/10/19 at 10:23 AM, revealed the CNAs had a printout of what the residents' needs were for each shift but she did not carry one because she knew the residents. She stated Resident #22 turned himself/herself and did not require any cues, or reminders, but was confused at times. She stated she had not seen boots on Resident #22 and was not sure when the resident needed to wear the boots. CNA #14 revealed Resident #22 did not have the heel lift boots on this morning and she did not put them on him/her. She stated the purpose of the boots was to protect the resident's heels from rubbing on the bed. Interview with Registered Nurse (RN) #1, on 05/10/19 at 10:50 AM, revealed she ensured the CNAs turned the residents and got the residents up when she made rounds. She stated the CNAs made rounds about every two (2) hours. RN #1 stated the purpose of heel boots was to keep Resident #22's heels off the bed to prevent further breakdown; however, she stated she was not aware the boots were not on Resident #22 this morning and remained off the resident. Per interview, Resident #22 had vascular disease problems and it was important to utilize the boots to protect the heels. Review of the Arterial Bilateral Lower Extremity, Ankle-Brachial Index (ABI) Study, for Resident #22, date of service 02/11/19, revealed no evidence of significant lower extremity arterial stenotic or occlusive disease. Interview with the Director of Nursing (DON), on 05/10/19 at 11:07 AM, revealed not all pressure ulcers could be prevented. She stated Resident #22 had bouts of non-compliance, which was care planned; however, further review of the care plan revealed the resident's non-compliance was added to the plan 05/08/19, during the survey.

Based on observation, interview, record review and facility policy for care plans, it was determined the facility failed to provide care in accordance with the written plan of care for three (3) of five (5) sampled residents. 1. The Care Plan for Resident #1 detailed an intervention to 'perform treatment to opened area as ordered,' to address skin breakdown. Wound care to the pressure ulcer was not initialed as completed on the Treatment Administration Record (TAR). 2. The Care Plan for Resident #2 detailed an intervention to 'treat open area as ordered,' to address skin breakdown to coccyx and detailed an intervention to provide a Roho seat cushion when up in the geri-chair. Daily wound care for Resident #2 was initialed as completed on two occasions, but it was found the wound care was not provided. 3. The Care Plan for Resident #4 detailed an intervention to 'treat open area as ordered,' to address skin breakdown of the right buttock, wound care was not performed for Resident #4 on two days. Wound care was not documented for Resident #4 for two shifts after a physician order increased it to twice daily. The findings include: Record review of the facility policy for Care Plans revealed the facility had a list of recommendations with no date, rather than an a policy for developing a Care Plan. The recommendations suggested the use of the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS), review by the Interdisciplinary team, observations available in the Matrix (computerized program utilized by the facility), and care conferences to complete the resident assessment and care planning process. 1. Closed record review for Resident #1 revealed the TAR and Nurse's Notes indicated a Weekly Skin Assessment was completed on 10/14/10; however, no other Weekly Skin Assessments were completed until the stage IV pressure ulcer was documented on 01/28/11. A physician order dated 01/18/11 revealed daily wound care to a stage IV pressure ulcer. The Care Plan for Resident #1 detailed an intervention to 'observe skin daily with care; skin assessment by licensed nurse, dated 12/02/10 and an intervention to 'perform treatment to opened area as ordered,' to address skin breakdown and was dated 01/28/11. Review of the Treatment Administration Record (TAR) revealed wound care was not documented as completed, and review of Nurse's Notes did not reveal wound care was performed on 01/29/11, 02/05/11, or 02/13/11. Interview, on 04/26/11 at 1:25pm, with the MDS Coordinator revealed that the Unit Managers are responsible for initiating Care Plans, then the MDS Coordinator reviews the Care Plan for accuracy. Interview, on 04/26/11 at 3:25pm, with LPN #5 revealed she did not recall how often she refers to the Care Plan when providing resident care and said she was confused about the purpose of the Care Plan. Interview, on 04/26/11 at 3:50pm, with LPN #6 revealed that when a CNA informed her on 01/28/11 of an open area on the coccyx of Resident #1, she looked for the Weekly Skin Assessment which was due to be completed on the day before and could not find it in the chart. LPN #6 stated that she did not often review Care Plans for the residents because she relied on physician orders and shift report to obtain the most current information. Interview on 04/27/11 at 1:40pm with the DON revealed there are no facility guidelines to suggest how often staff should review the care plan, and said all staff are responsible for initiating and updating the Care Plans. The DON said she audits the TAR to ensure the treatments are completed as ordered as part of the Quality Assessment and Assurance Program. The DON stated she thought some of the missing documentation of wound care treatments for Resident #1 were the result of nurses who neglected to initial the treatment as completed, rather than the treatment having not been completed. 2. Review of the record for Resident #2 revealed the Care Plan for Resident #2 detailed an intervention to 'treat open area as ordered,' to address skin breakdown to coccyx with a start date of 03/02/10. The Care Plan also detailed an intervention to provide a Roho seat cushion when the resident sat in the geri-chair, with a start date of 06/07/10. A physician order dated 08/13/10 indicated daily wound care of a stage IV pressure ulcer on the coccyx. Review of the TAR revealed that daily wound care for Resident #2 was initialed as completed by LPN #4 on 04/08/11 and LPN #5 on 04/07/11. Review of the treatment record revealed LPN #5 initialed that the wound care to the coccyx was completed on 04/07/11 and LPN #4 had initialed wound care completion for 04/08/11. However, on 04/08/11 at 10:20am, wound care observation performed by the WCN, revealed the coccyx dressing was intact and dated 04/06/11. The WCN said she performed the wound care and dressing change on 04/06/11, and acknowledged the dressing wasn't changed on 04/07/11. Interview on 04/26/11 at 3:25pm with LPN #5 revealed that the TAR was initialed on 04/07/11 before the treatment was completed. LPN #5 became busy near the end of the shift on that date, and forgot to complete the treatment. LPN #5 said she did not remember being told during orientation to initial the TAR only after the treatment is completed. LPN #5 stated it could become confusing when treatments are initialed before being performed, as it would be difficult to determine which treatments remain to be completed. Interview on 04/08/11 at 10:55am with LPN #4 revealed that she didn't know the WCN was going to do wound care for Resident #2, and she had already initialed the treatment as completed. LPN #4 stated she was trained to initial the treatments after the care is provided, but sometimes she signs them off early to ensure all treatments are signed. She avoids confusion by keeping a handwritten note of treatments to be completed during the shift, but admits it could become confusing when her note does not correspond with the initialed treatments on the TAR. Observation, on 04/06/11 at 3:15pm, revealed Resident #2 sitting in a geri-chair with no Roho cushion in place. Interview, on 04/06/11 at 3:30pm, with the Wound Care Nurse (WCN) revealed that the WCN was not aware Resident #2 had an order for [REDACTED].#2 and stated the cushion would be found in the resident room. The WCN was unable to locate the Roho seat cushion. Interview, on 04/06/11 at 3:45pm, with the House Manager revealed that she was unaware Resident #2 had an order for [REDACTED]. Interview, on 04/06/11 at 3:45pm, with the House Manager revealed that she was unaware Resident #2 had an order for [REDACTED]. Interview, on 04/27/11 at 9:15am, with CNA #7 revealed that she was aware of a Care Plan Intervention to use a Roho seat cushion when Resident #2 was seated in a geri-chair, and said the Roho seat cushion had not been used for the last month. Interview on 04/27/11 at 1:40pm with the DON revealed that staff was unable to find the Roho seat cushion for Resident #2 on 04/06/11 and a new seat cushion was ordered. The DON said staff was aware of the Care Plan Intervention for use of the Roho seat cushion, but did not know how long the seat cushion had been missing. 3. Review of the record for Resident #4, revealed a physician order dated 03/21/11 for once daily wound care of a stage IV pressure ulcer. Review of the Care Plan for Resident #4 detailed an intervention to 'treat open area as ordered,' to address skin breakdown of the right buttock, with a start date of 03/21/11. A physician order dated 04/04/11 instructed the nursing staff to increase the wound care to twice daily. Review of the TAR revealed the wound care treatment was not initialed as completed on 03/31/11, 04/01/11, 04/15/11 (first shift), and 04/19/11 (second shift). Interview, on 04/08/11 at 2:40pm, with LPN #3 revealed she told the second shift nurse in shift report that the treatment needed to be completed for Resident #4 on 03/31/11 and 04/01/11 during second shift. LPN #3 said she did not document in the Nurse's Notes that she reported to the second shift nurse the wound care had not been completed for Resident #4 on 03/31/11 and 04/01/11. Facility staff were not able to provide documentation to confirm that the wound care was completed on second shift. Interview, on 04/08/11 at 2:20pm, with the DON revealed that it would not be appropriate to neglect a dressing change due to a resident's busy therapy schedule. The DON said when a resident is not available for a wound care treatment during first shift, it is the facility's expectation that the treatment would be completed during a later shift. The DON was not aware that the wound treatment to a stage IV ulcer for Resident #4 was not completed for two (2) consecutive days (03/31/11 and 04/01/11). Neglected wound care treatments would have a negative effect on wound healing. Continued interview on 04/27/11 at 1:40pm with the DON revealed she was unaware that wound care was not provided on 04/15/11 and 04/19/11.

Based on observation, interview, review of the record and the Skin Care Assessment Policy it was determined the facility failed to follow the skin care assessment policy, failed to complete physician ordered wound care treatments, failed to accurately document in the medical record pressure/skin assessments and completion of treatments for three (3) of five (5) sampled residents (Resident's #1, #2, and #4). On 01/28/11, the facility identified Resident #1 as having a stage IV pressure ulcer. The facility failed to conduct weekly skin assessments since 10/14/10. The facility failed to accurately document wound treatments on the Treatment Administration Record (TAR) for Resident #2. The facility failed to document wound treatments for two days for Resident #4's stage IV pressure area in the Nurse's Notes or on the TAR and failed to document wound treatments in the Nurse's Notes or on the TAR for two shifts after the physician ordered it increased to twice a day. The findings include: Record review of the Skin Care Assessment Policy (undated), detailed that upon admission, a head-to-toe skin assessment should be completed by a licensed professional nurse, then weekly as needed. The Pressure Ulcer Risk Assessment should be done upon admission, then quarterly to coincide with the Minimum Data Set (MDS) assessment. Interview, on 04/08/11 at 2:20pm, with the DON revealed that staff are trained to perform a treatment and then initial the treatment as completed on the TAR. The DON said when a resident is not available for a wound care treatment during first shift, it is the facility's expectation that the treatment would be completed during a later shift. 1. Closed record review revealed the facility admitted Resident #1 on 03/26/07 with [DIAGNOSES REDACTED]. The facility completed a Pressure Ulcer Risk Assessment on 03/26/07 which detailed Resident #1 was at high risk for developing a pressure ulcer. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was admitted with no wounds, was totally dependent on staff for transfers and mobility, required a two person assist to transfer, and demonstrated a cognitive ability as moderately impaired. Review of the treatment record and Nurse's notes revealed on 10/14/10 weekly skin assessment documentation detailed, "no new skin issues." The Pressure Ulcer Risk assessment dated [DATE] indicated Resident #1 was at high risk for pressure ulcer, with a score of twelve (12) on a scale of twenty-four (24). The MDS admission assessment dated [DATE], revealed Resident #1 was at risk to develop pressure ulcers, and did not have any unhealed pressure ulcers. Interview, on 04/27/11 at 10:30am, with LPN #2 revealed that she completed Weekly Skin Assessments for Resident #1, and verified that she initialed the assessments as completed on the TAR for 12/02/10, 12/09/10, and 12/23/10. LPN #2 stated it was her practice to document Weekly Skin Assessments on the TAR Treatment Notes Sheet. LPN #2 said she remembered performing the Weekly Skin Assessments for Resident #1; however, review of the (TAR) Treatment Notes Sheets were not completed during the month of December, 2010, and review of the Weekly Skin Assessments for 12/02/10, 12/09/10, and 12/23/10 were not documented in the Nurse's Notes. Interview, on 04/26/11 at 2:55pm, with CNA #5 revealed that she observed a red area on the coccyx and reported the redness to a LPN in mid-December. CNA #5 could not remember the LPN she reported to, but was told by that LPN that the redness had been previously discovered and documented. CNA #5 said she continued to observe the red area on the coccyx through December and into the month of January until she saw a dressing on the coccyx. Interview, on 04/26/11 at 2:45pm, with CNA #4 revealed he was responsible for providing showers and incontinent care for Resident #1. CNA #4 said while providing care for Resident #1, he found a red-purple area on the coccyx which he said "looked like a bruise." CNA #4 said he thought this could lead to a skin ulcer, and reported the finding to the LPN, but was unable to remember the exact date the wound was located or which LPN he advised. CNA #4 said he did not notice any change in treatment for [REDACTED].#1 was receiving wound care to the area. There was no evidence the facility had identified through CNA report or skin assessment that Resident #1 had developed an area to the coccyx. However, interview with LPN #6, on 04/26/11 at 3:50pm, revealed a CNA told her Resident #1 had an open wound of the coccyx on 01/28/11 at 5:00am. LPN #6 said she was surprised to find an open wound, and said, "I couldn't believe this wasn't found earlier." LPN #6 said after observing the wound, she left a message for the WCN on the 24 hour report, and then looked for the last Weekly Skin Assessment which she could not find. Review of the Nurse's Notes for Resident #1, revealed the Wound Care Nurse (WCN) documented a stage IV pressure ulcer of the coccyx on 01/28/11. The stage IV pressure ulcer was described in the Nurse's Notes as, "coccyx to left buttock-stage IV-3.9cm long x 8.4cm wide with area of black eschar 2.5cm long x 3.8cm wide, rest of wound bed is dark red in color with small amount of S/A drainage and slight odor," which was documented on 01/28/11. Review of the WCN wound assessment dated [DATE] revealed, "coccyx-stage IV-6cm long x 9cm wide-thick softening brown/dark yellow eschar covered," with large amount of brown drainage and foul odor, wound culture results were reported to MD, awaiting an order for [REDACTED]. Interview with the Wound Care Nurse (WCN) on 04/07/11 at 10:45am, revealed Resident #1 was identified by the facility to be at risk for pressure ulcers. The WCN said Resident #1 was on a low air-loss mattress, and was difficult to keep positioned off of the back. The WCN said on 01/28/11, she was notified by a LPN that Resident #1 had a wound on the coccyx. The WCN assessed the wound and documented the wound in the Nurse's Notes on 01/28/11. The WCN said her next day of work was 02/02/11, when she completed the wound assessment, she found the wound "much worse" with the presence of slough and odor. The WCN stated on the weekly wound assessments she performed, the pressure ulcer developed a foul odor and had more drainage, and that the wound was cultured, and an IV antibiotic was ordered for Resident #1. The WCN stated that Resident #1 was transferred to the hospital in February, and did not return to the nursing facility. The WCN was not aware that weekly skin assessments had not been performed since 10/14/10, prior to identification of the stage IV ulcer, and said the assessment should have been completed as Resident #1 was determined by the facility to be at risk for pressure ulcer. The WCN stated, she didn't know how the nursing staff could have missed the pressure ulcer in an earlier stage and said, "maybe they didn't know what they were looking at." The WCN said if the pressure ulcer was identified earlier, a better outcome could have been possible. Continued interview on, 04/07/11 at 2:30pm, with the WCN revealed she completed the Unavoidable Pressure Ulcer form on 01/18/11 which was signed by the physician on 02/04/11. The WCN said Resident #1 had other pressure ulcers since admission, which were deemed unavoidable due to the resident condition and were signed by the physician and placed on the chart. Interview, on 04/07/11 at 11:30am, with the House Manager (HM) revealed that weekly skin assessments can be documented on the TAR/Ulcer Documentation Form, or in the Nurse's Notes. The HM was not aware the weekly skin assessments for Resident #1 were not documented since 10/14/10, until a stage IV pressure ulcer was documented by the WCN on 01/28/11. The HM said the pressure ulcer should have been identified by staff prior to the wound reaching stage IV. Interview, on 04/07/11 at 11:55am, with the Director of Nursing (DON) revealed the facility identified Resident #1 was at risk for pressure ulcers. The DON described Resident #1 as difficult to turn and position, and said the resident was provided a specialty mattress for pressure reduction. The DON was not aware the weekly skin assessments were not completed for Resident #1 since 10/14/10. The DON said it was possible that Resident #1 developed a stage IV pressure ulcer on 01/28/11 which was not present on the shift before, and did not think it was unusual that the pressure ulcer was classified as a stage IV ulcer on the day the pressure ulcer was identified. The DON stated, "There has to be a first day a wound is found, and we would like to think we found it as soon as possible." Interview, on 04/27/11 at 1:40pm, with the DON revealed that she was surprised that no Weekly Skin Assessments were completed for Resident #1 since 10/14/10. The DON said LPN #2 did a good job and did not know why the Weekly Skin Assessments were not completed. The DON did not know why the Weekly Skin Assessments had not been completed since 10/14/10. The DON said if a CNA reported an area of pressure concern on Resident #1, the nursing staff would have documented it and initiated measures to promote skin integrity. The DON stated the two (2) CNA reports of a red or purple area on the coccyx may have been mistaken for scar tissue, as Resident #1 had a history of [REDACTED].#1 frequently, and was familiar with the skin condition, and stated, "I know he didn't open until January." The DON did not believe it would have been possible to identify the pressure wound prior to documentation as a stage IV pressure ulcer on 01/28/11. Interview, on 04/08/11 at 1:50pm, with the Physician revealed the facility staff complete the Unavoidable Skin Ulcer form and during rounds the form is reviewed, and the physician consults the chart and considers the resident's condition prior to signing the form. The Physician signed the form indicating it was unavoidable. The Physician said there were too many factors to consider in determining if the wound could have been identified in an earlier stage, before the pressure ulcer was staged as a stage IV ulcer. When the Physician was asked if Resident #1 could have experienced a better outcome and healing of the pressure ulcer if it was identified earlier, the Physician replied, "Yes, in theory." Interview, on 04/27/11 at 9:40am, with the Director of Medical Records revealed she was unable to locate Weekly Skin Assessments for the months of December, 2010 and January, 2011 after reviewing the closed record for Resident #1. Interview, on 04/27/11 at 10:30am, with LPN #2 revealed that she completed Weekly Skin Assessments for Resident #1, and verified that she initialed the assessments as completed on the TAR for 12/02/10, 12/09/10, and 12/23/10. LPN #2 stated it was her practice to document Weekly Skin Assessments on the TAR Treatment Notes Sheet. LPN #2 said she remembered performing the Weekly Skin Assessments for Resident #1, however the TAR Treatment Notes Sheets were not completed during the month of December, 2010, and Weekly Skin Assessments for 12/02/10, 12/09/10, and 12/23/10 were not documented in the Nurse's Notes. 2. Record review revealed the facility admitted Resident #2 on 08/08/08 with [DIAGNOSES REDACTED]. The Care Plan detailed an intervention to provide a Roho seat cushion when the resident sat in the geri-chair, with a start date of 06/07/10. Review of the resident record detailed a physician order [REDACTED]. Review of Nurse's Notes dated 04/06/11 detailed a wound assessment documented by WCN which stated, "coccyx stage IV .5cm long x .5 cm wide x .4cm deep-red wound bed with no drainage and no odor." Review of the MDS assessment dated [DATE], revealed the facility assessed Resident #2 as totally dependent and required an assist of one to transfer and had a stage IV pressure ulcer of the coccyx that measured 1.4 cm in length by 1 cm in width with undermining. Review of the treatment record revealed LPN #5 initialed that the wound care to the coccyx was completed on 04/07/11 and LPN #4 had initialed wound care completion for 04/08/11. However, on 04/08/11 at 10:20am, wound care observation performed by the WCN, revealed the coccyx dressing was intact and dated 04/06/11. The WCN said she performed the wound care and dressing change on 04/06/11, and acknowledged the dressing wasn't changed on 04/07/11. Interview, on 04/26/11 at 3:25pm, with LPN #5 revealed that the TAR was initialed on 04/07/11 before the treatment was completed. LPN #5 became busy near the end of the shift on that date, and forgot to complete the treatment. LPN #5 said she did not remember being told during orientation to initial the TAR only after the treatment is completed. LPN #5 stated it could become confusing when treatments are initialed before being performed, as it would be difficult to determine which treatments remain to be completed. Interview, on 04/08/11 at 10:55am, with LPN #4 revealed that she didn't know the WCN was going to do wound care for Resident #2, and she had already initialed the treatment as completed. LPN #4 stated she was trained to initial the treatments after the care is provided, but sometimes she signs them off early to ensure all treatments are signed. She avoids confusion by keeping a handwritten note of treatments to be completed during the shift, but admits it could become confusing when her note does not correspond with the initialed treatments on the TAR. Continued interview, on 04/08/11 at 2:20pm, with the DON revealed she spoke with LPN #5 about the wound care not provided for Resident #2 on 04/07/11 and was told that LPN #5 signed the treatment of [REDACTED].#5 didn't get to the wound care. Interview, on 04/08/11 at 11:15am, with the HM revealed the wound care for Resident #2 was not performed on 04/07/11. The HM was surprised that the treatments were initialed before completion as staff are trained to perform treatments, then initial the treatment as completed. Observation, on 04/06/11 at 3:15pm, revealed Resident #2 was sitting in a geri-chair in a common area near the South Nurse's Station. No Roho-cushion was on the seat of the geri-chair. Interview, on 04/06/11 at 3:30pm, with the Wound Care Nurse (WCN) revealed that the WCN was not aware Resident #2 had an order for [REDACTED]. Interview, on 04/06/11 at 3:45pm, with the House Manager revealed that she was unaware Resident #2 had an order for [REDACTED]. Interview, on 04/27/11 at 9:15am, with CNA #7 revealed that she was aware of the use a Roho seat cushion when Resident #2 was seated in a geri-chair, and said the Roho seat cushion had not been used for the last month. Interview, on 04/27/11 at 1:40pm, with the DON revealed that staff was unable to find the Roho seat cushion for Resident #2 on 04/06/11 and a new seat cushion was ordered. 3. Record review revealed the facility admitted Resident #4 on 03/21/11 from another nursing facility with [DIAGNOSES REDACTED]. Record review of Nurse's Notes dated 03/21/11, detailed a wound assessment by the WCN that stated, "Right buttock stage IV, .9 cm long x 1.4 cm wide, white slough with small amount of s/a drainage and no odor." Review of Physician orders [REDACTED]. Review of the Nurse's Notes and TAR revealed on 03/31/11 and 04/01/11, the daily wound care for Resident #4 was initialed and circled with a note, "PT." Record review of Nurse's Notes for 03/31/11 reveal no details of wound care, and Nurse's Notes dated 04/01/11 revealed LPN #3 noted, "dressing change not done due to resident being up in chair and in therapy all day," with no mention of the wound care. Interview, on 04/08/11 at 2:40pm, with LPN #3 revealed Resident #4 spent most of first shift in Physical Therapy; therefore, she told the second shift nurse in shift report that the treatment needed to be completed on 03/31/11 and 04/01/11 during second shift. LPN #3 said she did not document in the Nurse's Notes that she advised the second shift nurse the wound care had not been completed for Resident #4 on 03/31/11 and 04/01/11, and facility staff was not able to provide documentation to confirm that the wound care was completed on second shift. Review of the MDS dated [DATE], detailed documentation of a Stage III pressure ulcer which measured .9cm in length, 1.4cm in width, with slough. Record review of Nurse's Notes dated 04/04/11, detailed a wound assessment by the WCN that stated, "Right Buttock unstageable 1.3 cm long x 2.4 cm wide, area covered with grayish slough. Small amount of brownish drainage and no odor. Area with decline since last evaluation. Will notify MD." A Physician order [REDACTED]. Further review of the Nurse's Notes and TAR revealed wound care was not provided on 04/15/11 and 04/19/11. Interview, on 04/08/11 at 2:20pm, with the DON revealed that it would not be appropriate to neglect a dressing change due to a busy resident therapy schedule. The DON was not aware that the wound treatment to a stage IV ulcer for Resident #4 was not completed for two (2) consecutive days (03/31/11 and 04/01/11), and stated neglected wound care treatments would have a negative effect on wound healing. Continued interview on 04/27/11 at 1:40pm with the DON revealed she was unaware that wound care was not provided on 04/15/11 and 04/19/11.