Every finding on record at Pensacola Nursing & Rehabilitation Center

Based on observations, interviews, record reviews, review of the facility's policy and education, and review of Florida Administrative Code, the facility failed to ensure that residents who required ileostomy services received such care consistent with professional standards of nursing practice for 2 of 2 residents reviewed for ileostomy care (Resident #1 and #2).The findings included:On 06/24/2025 at approximately 8:30 AM, an initial tour of the facility was conducted. Resident #1 and Resident #2 were identified as having ileostomies (a surgical procedure that diverts digestive waste out of the body by connecting the lowest part of the small intestine (the ileum) to an opening in the abdominal wall, by passing the colon).A review of Resident #1 medical record revealed he was first admitted to the facility on [DATE]. His medical history was significant for an ileostomy. Resident #1 had multiple hospitalizations and was last readmitted to the facility on [DATE]. Review of his Minimum Data Set (MDS) revealed Resident #1 had a Brief Interview of Mental Status (MDS) score of 6, which indicates he had significant cognitive impairment and was therefore not appropriate for interview.Review of Resident #1's physician orders revealed an order was written for Ostomy care Q (every) Shift with a start date of 04/30/2026. This order was discontinued on 05/13/2026 (photographic evidence obtained). When Resident #1 was re-admitted on [DATE], no orders were written for ostomy care (photographic evidence obtained).Review of Resident #1's Plan of Care revealed there was a care plan regarding the presence of Resident #1's ileostomy with a goal written for patency and function of the stoma. Interventions included skin barrier around the stoma to protect from excoriation secondary to urine feces, monitor and report for abnormal bleeding in collection bag or continuous bleeding from stoma and/or surrounding skin as a CNA task, and monitor and report to provider if skin around stoma shows increased irritation, ostomy care daily and as needed as nursing task (photographic evidence obtained).Review of the nurse documentation specified the nurse signed off on 06/01/2026 and 06/03/2026 documenting they changed the ileostomy related to a fistula/abscess that was located directly next to the ileostomy. Further review revealed the CNAs colostomy task completed was signed off by CNAs. However, this documentation did not specify change wafer.On 06/24/2026 at approximately 9:40 AM, an interview was conducted with Resident #2. Resident #2 reported having an ileostomy for more than 10 years. He reported that over the past 2 weeks he had used approximately 8 ostomy wafers because they leaked stool due to incorrect wafer size and improper application. Resident #2 further stated that, unlike previous facilities where the nurses performed his ostomy care, Certified Nursing Assistants (CNA) at this facility routinely performed the ostomy care, including the ostomy wafer application. He stated the leakage occurred because the staff were not using the appropriate template to cut the wafer opening, often cutting it too large. He expressed further concern of the staff not allowing his skin to fully dry before applying the wafer to his skin. He expressed concern that most of the facility's CNAs did not appear to be competent or adequately trained to perform the task of ostomy care.A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE]. Review of his MDS revealed he had a BIMS score of 15, which indicates he was cognitively intact.Review of Resident #2's physician orders revealed an order was written on 04/17/2026 for Ostomy site: monitor stoma and surrounding skin for any abnormalities, notify provider if indicated (photographic evidence obtained).On 06/24/2026 at approximately 10:42 AM, an interview was conducted with Staff C, Licensed Practical Nurse (LPN), Unit Manager. Staff C explained that both nurses and CNAs were trained to provide ostomy care, as CNAs were permitted to perform it within their scope of practice.On 06/24/2026 at approximately 11:35 AM, an interview was conducted with Staff D, Registered Nurse (RN) and Unit Manager. Staff D stated he had knowledge of towels being used to manage the stool leakage for Resident #1's ostomy on one to two occasions. He explained the stool leakage occurred because the wafer opening had been cut too large. He further stated some staff were unfamiliar with the proper ostomy care, particularly how to correctly cut the wafer. He stated that there were no physician's orders for ostomy care as it was a CNA task and was documented as such.On 06/25/2026 at approximately 12:44 PM an interview was conducted with Staff E, Advanced Registered Nurse Practitioner (ARNP). She stated that ostomy care orders were generated as part of the facilities standard order set. She further stated she did not personally enter those orders. She confirmed that it was appropriate and expected to have an ostomy care order present in a resident's medical record.On 06/24/2026 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON). He confirmed that Resident #1 did not have any monitoring orders for ostomy care since his last readmission on [DATE], as the facility did not initiate ostomy orders. When asked how the facility monitored an ostomy site, he stated that it was only a CNA task initiated and the CNAs were the only ones that would document on the medical record that care was provided. He explained that CNAs could perform ostomy care including changing the wafer if they were comfortable with the task; otherwise, the nurses would provide the care. He stated that all staff received refresher education and the competency checklist validation was completed during onboarding (Photographic evidence obtained). Staff were expected to ensure that the ostomy bag was applied correctly and appropriately size the wafer opening to prevent leakage. When asked how the facility monitored for complications related to an ostomy, he stated that care is provided since it is documented in the CNAs tasks. He added that if the CNAs had any concerns they would report to the nurse. The DON independently reviewed Resident #1's physician orders and confirmed that an order was in place for the ostomy care prior to the last readmission on [DATE] but had been discontinued (Photographic evidence obtained).On 06/24/2026 at approximately 3:38 PM, an interview was conducted with Staff G, CNA. She explained although CNAs were permitted to provide ostomy care with wafer change, she chose to just empty the bag. She stated that documenting ostomy care on the CNAs task on the electronic health record, referred to emptying the bag, not changing the wafer or bag.On 06/25/2026 at approximately 8:11 AM, an interview was conducted with Staff J, CNA. She explained that both nurses and CNAs could complete ostomy care that consisted of changing all the ostomy supplies, including the wafer. She stated that she attempted to perform the task but experienced leakage each time, resulting in a mess. As a result, she chose to leave the ostomy care to the nurses and just emptied the bag.On 06/25/2026 at approximately 8:15 AM, an interview was conducted with Staff K, CNA. She explained that she provided ostomy care to residents by emptying the ostomy bag and changing the wafer if needed.On 06/25/2026 at approximately 9:21 AM, an interview was conducted with the Administrator. He recalled Staff D had reporting that Resident #1 was having difficulty with ostomy leakage. He explained that both nurses and CNAs performed ostomy care, including changing the wafer. He stated he was unaware that this task may not be permitted under the license or scope of practice of a CNA.On 06/25/2026 at approximately 11:55 AM, an interview was conducted with the Assistant Director of Nursing (ADON). She stated that she was unaware that ostomy care that included changing the wafer, was out of the scope of practice under a CNA's license.A review of the facility Colostomy Skills Competency for CNAs was reviewed. It included assessing the skin around the stoma for irritation, measuring the stoma using a sizing template, cutting the opening, and applying the ring (Photographic evidence obtained).A review of the facility Ostomy Care refresher conducted on 06/03/2026-06/05/2026 by the ADON for all nursing and certified nursing assistants was reviewed. Ostomy care included cutting the supply to fit the stoma opening. (Photographic evidence obtained).Facility policy titled Colostomy Care issued 06/2020 and last revised 11/2023 was reviewed. It stated that ostomy care will be provided per physician orders. Review the resident care plan to assess any special needs of the resident and assemble the equipment and supplies as needed. The date and time the colostomy/ileostomy care was provided, the name and title of the individual who provided the care, how the resident tolerated the procedure. Notify the supervisor if the resident refuses care, any abnormal findings (i.e. breaks in skin, excoriation, signs of infection, etc.), and any information in accordance with facility policy and professional standards of practice.Per review of the Florida Administrative Code R. 59A-18.0081 for Certified Nursing Assistant and Home Health was reviewed. The certified nursing assistant (CNA).: (1) Be limited to assisting a patient in accordance with Section 400.506(6)(b), F.S.(5) Perform other activities as taught and documented by a registered nurse, concerning activities for a specific patient and restricted to the following:(a) Assisting with the placement or removal of a colostomy bag, excluding the removal of the flange or manipulation of the stoma's site.Florida Administrative Code Department of Health Board of Nursing Chapter 64B9-15 - CERTIFIED NURSING ASSISTANTS, Section 64B9-15.002 - Certified Nursing Assistant Authorized Duties further states A certified nursing assistant shall provide care and assist residents with the following tasks related to the activities of daily living under the general supervision of a registered nurse or licensed practical nurse. (d) Tasks associated with elimination. 5. Emptying ostomy bags, or changing bags that do not adhere to the skin.

Based on observations, interviews and record review, the facility failed to follow acceptable nationally accepted infection prevention and control standards including proper use of Personal Protective Equipment (PPE) to prevent the spread of infections for 2 of 2 residents observed for direct resident care (Resident#1, #5).The findings included:On 06/24/2026 at approximately 8:42 AM, an observation was made of Resident #1's room. An Enhanced Barrier Precaution (EBP) sign was posted on the outside of the room door. While touring the room, it was noted that multiple used enteral feeding syringes were present in the room in undated bags (Photographic evidence obtained). During this observation, Staff A, Registered Nurse (RN), entered the room and donned gloves. Staff A refilled the empty hydration bag and used one of the open, undated syringes to flush Resident #1's peg tube (a flexible feeding tube which is surgically placed through the abdominal wall directly into the stomach). Staff A then reconnected the tube feeding tubing to Resident #1's feeding tube and restarted the tube feeding pump. It was noted during this observation that Staff A did not wear the appropriate isolation gown while providing this care to Resident #1. A review of Resident #1 medical record revealed he was last readmitted to the facility on [DATE]. His medical history was significant for an ileostomy (a surgical procedure that diverts digestive waste out of the body by connecting the lowest part of the small intestine (the ileum) to an opening in the abdominal wall, by passing the colon) and a peg tube.Review of Resident #1's medical record revealed the order for EBP was initiated on 05/20/2026 related to his peg tube and wounds. The order did not acknowledge that the EBP was also related to Resident #1 having an ileostomy. Additionally, an order initiated on 05/15/2026 revealed Enteral feeding, change feeding set/bag/syringe every night shift.Further review of the medical record revealed a progress note written by the Medical Director, dated 06/16/2026. This note documented that Resident #1 had a medical history significant for an ileostomy and C-Diff (Clostridioides difficile, a highly contagious bacterium that infects the large intestine, causing severe watery diarrhea and colon inflammation). The note further indicated that Resident #1 had a recent hospitalization on 05/08/2026, during which he tested positive for MRSA associated pneumonia (Methicillin-resistant Staphylococcus aureus, a bacterium that has developed resistance to many common antibiotics). Resident #1 was initially treated with two intravenous antibiotics and was then transitioned to two alternate antibiotics for these infections.Review of Resident #1's Plan of Care revealed a care plan was written regarding Resident #1 requiring EBP during high contact resident care activities related to peg tube and wounds. Interventions for this care plan included require protective measures and the importance of adhering to protocols to prevent the spread of infections during high contact care activities.On 06/24/2026 at approximately 8:45 AM, an interview was conducted with Staff A. Staff A stated that wearing an isolation gown under Enhanced Barrier Precautions (EBP) was not necessary when flushing or connecting a peg tube; isolation gown use was required for changing dressings or providing ostomy care. She acknowledged that the enteral feeding syringes were undated and could not determine when they were last used. She confirmed that they should be dated when first opened.On 06/25/2026 at approximately 11:30 AM, an observation was made of Resident #5's room. An Enhanced Barrier Precaution (EBP) sign and a Protective Personal Equipment (PPE) cart were posted on the outside of Resident #5's door (Photographic Evidence obtained). After knocking on the resident's door with the plan to conduct an interview with the resident, Staff L, Certified Nursing Assistant (CNA) opened the door stating, resident care. Staff L, CNA and Staff M, CNA were observed completing a transfer of Resident #5 using a Hoyer lift. Both staff members were observed wearing gloves but were not wearing isolation gowns during the resident care activity.On 06/25/2026 at approximately 11:35 AM, a combined interview was conducted with Staff L and Staff M. They explained that Resident #5 was on EBP because he had a peg tube. They acknowledged the EBP signage and PPE cart located outside the resident's room. They confirmed they did not wear the required isolation gowns during the resident transfer. They stated they were in a hurry and forgot to put on the isolation gowns before providing care to and transferring Resident #5.On 06/25/2026 at approximately 11:38 AM, an interview was conducted with Resident #5. The resident stated that staff had just finished providing her care and transferred her to her wheelchair using the Hoyer lift. She added that staff did not wear isolation gowns during her care or showers.On 06/25/2026 at approximately 1:00 PM an interview was conducted with the facility's Administrator. He explained that the staff were expected to wear the appropriate PPE while providing care to residents on EBP per facility infection prevention policy.Policy titled EBP issued 03/2024 and last revised 05/28/2024 was reviewed. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of Multi Drug Resistant Organism (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP Are used for residents with indwelling medical device that includes central lines, urinary catheters, feeding tubes, tracheostomy, ostomies. Appropriate Personal Protective Equipment (PPE) would include gowns and gloves. Employees should wear appropriate PPE when performing the following duties for residents: dressing, bathing and showering, transferring, providing hygiene, changing linens, providing peri-care such as changing briefs, toileting, device care and wound care. Employees are not required to wear PPE when answering a call light, delivering a meal tray, conversing with the resident, administrating medications that do not involve high contact with the resident such as oral medications, eye drops, inhalers, nebulizers or injections.

Based on observations, interviews, record reviews, policy review, and a review of the Resident Council minutes, the facility failed to uphold resident rights and dignity by not knocking and announcing staff presence before entering the rooms of two residents (Resident #23 and Resident #37). The findings include:On 04/07/2026 at 12:35 PM during observation and interview with Resident #23, Staff P, Certified Nursing Assistant entered Resident #23's room and passed the partially pulled privacy curtain by Resident #23's bed and turned and walked back out of the room. Staff P re-entered the room within a few seconds and knocked on the door and entered stating I have your lunch. On 04/07/2026 at 9:50 AM, at the suggestion of Resident #23, a telephone interview was performed with the local Long Tem Care Ombudsman. The Ombudsman revealed she visited Resident #23 last week and observed three occurrences of staff members coming into Resident #23's room without knocking or announcing themselves. The Ombudsman stated this was a concern for Resident #23, so she informed the facility's Administrator. On 04/07/2026 at 2:55 PM, an interview with the Administrator was conducted. When the Administrator was informed of Staff P entering Resident #23's room without knocking, the Administrator stated he was aware of the Ombudsman reporting issues of staff members entering Resident #23's room without knocking. On 04/06/2026 at 02:28 PM, during an observation and interview with Resident #37, Staff V, Maintenance Personnel entered Resident #37's room without knocking or announcing himself or what he was there to do. Staff V walked directly over to the window to the air conditioning (AC) unit and began taking the unit out from the wall. After removing the front cover of the AC unit, he left the room and entered back into the room after about 5 minutes without stating his purpose or announcing or knocking on the door. An interview with the Director of Nursing was conducted on 04/06/2026 at 3:30 PM. She stated her expectations of all staff is to knock on a resident's door and announce entry into a resident's room and to always explain what they are there for and explain any procedures to a resident prior to initiating care or any services. Requested policy for Resident privacy. (Policy was not provided by facility per request x 2 to DON). An interview with Staff V was conducted at 12:20 PM on 04/07/2026. He revealed he had been employed with the facility for 2 years working in the maintenance department. He stated, I had to change out the AC unit in the room due to leaking onto the floor where the AC was turned down too low. Upon asking him to explain his process for entering a resident's room to perform job duties, he stated, I already know. I didn't knock on the door; I just came right on in and went to work on the AC unit. I have gotten too comfortable with the residents here. He expressed understanding that knocking respects their privacy and upon asking him how he would feel if someone entered his home or personal space without knocking or announcing themselves before entry, he stated, I would be very upset about it, very, very upset. I will admit I am guilty of doing that, and I cannot promise that it will not happen again, but I will try and do better.

Based on record reviews and interviews, the facility failed to inform residents of care and treatment prior to the start of care and treatment of psychotic medication for 2 out 5 residents reviewed for general consent to treat (Resident # 12 and #37).The findings include:A record review was conducted for Resident #12. Resident #12 was readmitted to the facility following a hospital stay on 2/12/26 with the diagnoses including major depressive disorder, anxiety, bipolar disorder, and insomnia. Resident #12's medical record revealed they had a brief interview for mental status score of 15, which meant she was cognitively intact. Review of Resident #12's physician orders revealed that Resident #12 was taking Paroxetine Mesylate daily for depression, Trazodone nightly for insomnia (psychotropic), Topiramate twice a day for bipolar disorder, and Hydroxyzine three times a day for anxiety. A review of Resident #12's Minimum Data Set, dated [DATE] indicated the use of antidepressant medications being used. The care plan, with the review date of 2/26/26, indicated that Resident #12 took antidepressant medication related to depression and had a psychiatric consult. Further review of Resident #12's medical record revealed there was no consent for psychotropic medications present in the chart. An interview was conducted on 4/8/26 at approximately 1:30 PM with the Director of Nursing (DON), requesting the consent for Paroxetine, Trazodone, Topiramate and Hydroxyzine as there was no evidence that informed consent specific to the use of psychotropic medications was obtained prior to administration of the medications. On 4/9/26 at approximately 11:45 PM, the DON supplied a consent dated 5/16/25 that was signed by Resident #12 and a Licensed Practical Nurse. Closer review of this document revealed there were no medications listed on the consent form. A record review was completed for Resident #37. Resident #37 was admitted to the facility on [DATE] with the diagnoses of Polyneuropathy, Lupus, Cellulitis of left lower extremity, heart attack, Anxiety, Pulmonary embolism, and Depression. She was receiving the following medications since admission to facility: Zolpidem for sleep, Xanax for anxiety, and Fluoxetine for depression. Resident #37 had plans of care for Insomnia including use of hypnotic medication for sleep initiated on 4/7/26, depression including use of an anti-depressant medication related to depression disorder initiated on 4/8/2026, and for anxiety including use of anti-anxiety medication due to anxiety disorder with date of 04/06/2026. Review of Resident #37's MDS showed use of antianxiety, antidepressant, and hypnotic medications. Further review of Resident #37's medical record revealed there was no consent for psychotropic medications present in the chart. An interview was conducted with the DON on 4/8/2026 at 5:15 PM. She stated that they were unable to locate the admission documents, including consents to treat, consent for advance directives, and psychotropic medication consents. She further explained that treatment should not have been initiated without consent first.

Based on record reviews and staff interviews, the facility failed to maintain required advance directive documentation for 2 of 35 sampled residents (Residents #37 and #114). The findings include: A record review was completed for Resident #37. This review revealed Resident #37 was a full code, but no advance directive education discussion sheet was available in the electronic medical record. Resident #37 had a plan of care, dated 2/10/26, which indicated she requested Full Code status. An interview was conducted with the Director of Nurses (DON) on 4/8/26 at 5:15 PM. She stated, We are unable to locate the admission documents, including [Resident #37's] consent for advance directives. During a record review of Resident #114, the electronic medical record contained no admission consent or advance directive documentation since admission on [DATE]. Requests for these documents were made to the Administrator on 4/7/26 at 10:44 AM and again during an interview with the Social Services Director on 4/7/26 at 12:57 PM. By 3:16 PM on 4/7/26, the facility still could not produce the advance directives documentation to the survey staff. A subsequent request on 4/8/2026 at 12:29 PM also yielded no documentation.

Based on observation, interview, and record review, the facility failed to maintain a clean and comfortable environment for 2 of 29 sampled occupied resident rooms. (Rooms #201 and #206) The findings include: On 4/6/26 at approximately 12:30 PM, during the initial tour, occupied room [ROOM NUMBER]'s shower was observed with black grime on the tile walls and floors. The shower drain was covered with hair and a thick white substance. (Photographic evidence obtained)An interview conducted with room [ROOM NUMBER]'s occupant, who stated he had been using the shower in his room. The resident further stated he had asked the staff multiple times to clean it. On 4/7/26 at approximately 10:30 AM, an additional observation was made. The shower still had black grime on the tile walls and floors. The shower drain was still covered with hair and thick white substance.A follow up interview was conducted with the room's occupant, who stated he wanted to take a shower but wanted it cleaned first.On 4/7/26 at approximately 12:45 PM, an interview conducted with Staff B, Housekeeping, who stated the rooms, bathrooms, and showers get cleaned daily.On 4/7/26 at approximately 12:55 PM, an interview conducted with Staff C, Housekeeping Manager (HM), who stated his expectations were for staff to clean bedrooms, bathrooms, and showers daily and deep cleans are conducted monthly. The HM stated there were logs for the deep cleaning schedule and rooms were assigned per month. A tour was conducted with the HM, who observed room [ROOM NUMBER]'s shower and stated he would not want to use the shower with grime and hair in the drain. The HM went on to state the shower did not look like it had been cleaned. The HM reviewed the monthly deep cleaning schedule, which revealed room [ROOM NUMBER] was not cleaned by the staff.Review of Facility's Deep Clean Verification form for room [ROOM NUMBER] (dated 3/20/26) page 1 of 1 revealed: unsatisfactory for resident bathroom shower sanitized & shower curtain checked. (Photographic evidence obtained.) On 4/6/26 at approximately 9:00 AM, during the initial tour, room [ROOM NUMBER]'s bathroom was observed. An observation of the toilet revealed a thick brown and black substance around the base of toilet. There was also approximately a half inch gap where the toilet was pulled away from the floor. (Photographic evidence obtained) On 4/8/26 at approximately 12:05 PM, a tour was conducted with the Administrator and Maintenance Director. They both observed the base of the toilet with the black substance and that the toilet was pulled away from the floor. An interview was conducted with the Maintenance Director. He stated the staff should report repairs by writing a ticket, calling, or entering in the facility's Secura System. They both stated the toilet would be repaired. A review of Facility's Maintenance Service policy (dated 12/2009) page #1 of 2 revealed: The maintenance department is responsible for maintaining the buildings, ground, and equipment in a safe and operable manner. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. (Photographic evidence obtained.)

Based upon interview and record review, the facility failed to follow up on a grievance for 1 of 3 residents reviewed (Resident #40)The findings include: On 04/06/2026 at 12:13pm, an interview with Resident #40's sister was conducted. Resident #40's sister stated clothing items went missing in March and, when she reported it, she was informed a grievance would be completed and the facility would resolve the issue. She stated it had been about three weeks, and she has not heard the resolution.On 04/08/2026 at 2:07pm, an interview with the Social Services Assistant and the Director of Social Work was conducted. A review of the facility grievance logs from 01/28/2026 through 03/31/2026 was also conducted. There were no entries in the grievances logs regarding Resident #40. The Social Services Assistant stated she was not aware of a grievance filed by the sister of Resident #40. There was no grievance log for April 2026. The Social Services Assistant stated she still needs to make the April log. The Director of Social Work stated they could not locate a grievance form regarding Resident #40.On 04/09/2026 at 9:36am, an interview was conducted with the Director of Admissions. She stated Resident #40's sister informed her of missing clothing items, and she completed the grievance form and turned it into the Social Services office. The Director of Admissions stated she did not know the exact date but stated it was not long after Resident #40 was admitted to the facility. She also stated she is unsure of the specific person she handed the grievance form to, but she stated it was one of the two people who work in Social Services. On 04/09/2026 at 11:50am a review of the facility procedure titled, Standards and Guidelines: Grievance - Resident Rights was conducted. The procedure revealed in Step #8, upon receipt of a grievance and/or complaint, the Grievance officer will review and investigate the allegations and submit a report of such findings to the Administrator within five (5) working days and Step #12 reveals, The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and/or in writing as per request) of the findings of the investigation and the actions that will be taken to correct any identified problems, and Step 12a., The Administrator, or his or her designee, will make such reports orally within ten (10) working days of the filings of the grievance or complaint with the facility.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 2 of 2 residents sampled for indwelling urinary catheters (Residents #10 and #122) and 1 of 2 residents reviewed for falls (Resident #11).The findings include: On 4/6/26 at approximately 1:14 PM observations were made of the indwelling urinary catheters for Resident #10 and Resident #122. A review of Resident #10's clinical record revealed they were admitted to the facility on [DATE]. Further review revealed Resident #10 had an active physician's order for a Foley catheter. The Comprehensive Care Plan failed to include a care plan focus area for the indwelling urinary catheter or catheter care interventions. Review of Resident #122's clinical record revealed they were admitted to the facility on [DATE]. Further review revealed Resident #122 had an active physician's order for a Foley catheter. The Comprehensive Care Plan failed to include a care plan focus area for the indwelling urinary catheter or catheter care interventions. On 4/8/26 at approximately 1:10 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated the indwelling urinary catheter care plan for Resident #10 and Resident #122 should have been developed within 48 hours of their admission and admitted that it had been omitted for both residents. Observations were conducted of Resident #11 on 4/6/26 at 11:57 AM, 4/7/26 at 10:02 AM, 12:25 PM, 3:26 PM and 4/8/26 at 9:11 AM. During each of these observations, Resident #11 was seen lying and moving around in their bed. During each of these observations, it was noted that there was no fall mats present at the bedside. A review of Resident #11's physician's orders revealed an active order for fall mats to be placed at the bedside due to Resident #11 having a history of falls. A review of the care plan revealed Resident #11 was identified as being at risk for falls related to weakness and involuntary movements and included the use of fall mats as an intervention. Despite the physician order and care plan interventions, fall mats were not in place for Resident #11. On 4/8/26 at approximately 9:00 AM, an interview with Staff X, Certified Nursing Assistant (CNA) confirmed Resident #11 had not had any fall mats in place since they were moved into their current room. On 4/8/26 at approximately 1:49 PM, an interview with Staff E, Unit Manager (UM) revealed Resident #11 was recently moved to their current room and the fall mats were not transferred with the resident but that they should have been.

Based on observations, interviews, and record reviews, the facility failed to carry out physician orders for 2 of 20 residents reviewed. (Resident #69 and #108)Observations of Resident #69 were conducted on 04/06/2026 at 12:30 PM and 4:30 PM, 04/07/2026 at 11:30 AM, 2:30 PM, and 4:30 PM, 04/08/2026 at 8:38 AM. During each of these observations, it was noted that Resident #69 had contractures to bilateral hands. Closer observation revealed no splints or braces were in place during these observations. A record review revealed a physician order for Splint/Brace application, Encourage and assist resident to participate with donning and doffing of Bilateral palm protectors' splint/brace. Bilateral Palm protectors to be used at all times except for ADLs and skin assessment. Monitor skin surfaces under device and notify physician of abnormal findings This order was initiated on 3/31/2026. Resident #69 also had a plan of care in place for skin impairment to left palm with the goal that she will be free from any skin impairment through review date and skin will show signs of healing without complications initiated on 2/3/26. One goal is to apply palm guard due to debility / weakness, decrease in strength, decreased cognition, presence of contractures initiated on 03/25/2026. The care plan went on to document that Resident #69 is to wear bilateral palm guards during the day, date initiated 05/31/2024, revised 03/24/26. An interview was conducted with the Director of Nursing (DON) on 04/09/2026 at 10:19 AM, who revealed that the restorative nurse was out and the restorative aide only worked every other week. The DON revealed that she was aware the restorative process was broken, and the residents who were on the restorative program were not receiving consistent care to meet their needs. During an interview on 04/06/2026 at 2:45 PM, Resident #108 reported that her incontinence briefs were too small and tight and stated she had been experiencing burning with urination for several days. On 04/06/2026 at 4:12 PM, Staff T, Certified Nursing Assistant (CNA), reported to Staff E, Nurse Manager that Resident #108 continued to complain of burning during urination while Staff T was providing care. A record review for Resident #108 showed that a urinalysis was ordered on 03/31/2026 at 5:00 PM. The record also showed that Resident #108 had a history of urinary tract infections (UTI). The care plan, updated on 02/09/2026, indicated Resident #108 was at risk for UTIs and that labs should be monitored as ordered. During an interview on 04/08/2026 at 2:40 PM, Staff G, Licensed Practical Nurse (LPN), reviewed the outgoing lab binder and confirmed that no laboratory specimens had been sent for Resident #108 since the urinalysis order was written on 03/31/2026. Staff E was notified and stated another order would be entered for a straight catheter urinalysis due to reported resident refusal to provide a sample. However, a review of the resident's record contained no documentation indicating Resident #108 had refused to provide a sample.

Based upon interviews and record reviews, the facility failed to provide treatment and services to 1 of 1 residents reviewed for pressure ulcers. (Resident #125) The findings include:A record review was conducted for Resident #125. Resident #125 was admitted to the facility on [DATE] with diagnoses including Sepsis due to EColi, Peripheral vascular disease, acquired absence of foot, and wound to right hip. Physician orders included Wound care to cleanse the right great toe with wound cleanser, paint with betadine every day shift (start date 3/13/26); Sacrum, cleanse with wound cleanser, apply barrier ointment and nystatin powder to wound bed every day shift (start date of 3/13/26); Wound Vac -apply wound care vac to right hip at 125mmhg. Cleanse area with normal saline, pat dry, apply wound vac 3 times a week and prn. every day shift on Monday, Wednesday, and Friday to right hip (start date of 3/11/26); Apply skin prep to bilateral heels as tolerated every shift for 14 days (start date of 3/7/26). A plan of care was initiated on 3/10/26 for Resident #125 which stated she had a pressure ulcer to hip with a goal that wound will show signs of healing as evidenced by decrease in size, improved appearance, and be free from infections. A wound care nursing evaluation was completed on 3/10/26 revealing a wound care assessment for a surgical wound to the Right trochanter hip wound that measured 6cm x 2cm x 1cm which was identified on 3/10/26. Wound vac orders were in place, treatment initiated on 3/10/26. A wound care evaluation dated 3/12/26 revealed: right great toe wound that measured 2cm x 1.9cm x 0.1cm which was identified on 3/12/26, wound color black, date treatment ordered 3/12/26.An interview was conducted with Staff X, Wound Care Nurse on 4/9/26 at 9:00 AM. Staff X revealed Resident #125 had a wound vac at home with home health services providing care. Resident #125 went to the hospital then was admitted to facility on 3/7/26 (which was a Saturday). Staff X completed a wound assessment on 3/10/26 and initiated the wound vac to Resident #125's right hip. Staff X confirmed it was a surgical wound, but the wound care physician who came to the facility every week did not address surgical wounds. Upon asking Staff X if she was aware that the wound was a pressure area to the right hip and that it was surgically debrided while at the hospital, she stated she was not aware. When asked to explain why the wound vac did not get placed on Resident #125 on admission, she stated that she didn't work weekends, so no one else at the facility would have been able to place the wound vac. She stated she saw Resident #125 when she returned to work on 3/10/26 (which was a Tuesday) and that's when she initiated the wound vac for Resident #125. An interview was conducted with the facility's Admissions Coordinator on 4/9/26 at 9:35 AM. She stated that any equipment usually is delivered to the facility within 24 hours of being ordered. She stated she ordered the wound vac on 3/4/26 and it was present in the facility prior to Resident 125 being admitted on [DATE]. A copy of the requisition order was made available and indicates a wound vac order was placed on 3/4/26 along with wound vac supplies. An interview was conducted with the facility's Director of Nursing (DON) on 4/9/26 at 10:19 AM. The DON revealed that facility's staff nurses are all knowledgeable in applying wound vacs as well as the wound care nurse. The DON stated it was her expectation that, if the wound vac was present and the nurses were aware of the need for a wound vac to be administered to a resident, then it should be completed the day the resident is admitted to facility. She confirmed the wound vac should have been placed on Resident #125 the day she was admitted -on 3/7/26.

Based on record reviews and interviews, the facility failed to monitor weights for 1 of 3 residents reviewed for weights (Resident #9).The findings include:During an interview conducted with Resident #9 on 4/6/26 at approximately 2:06 PM, he stated he had lost some weight since being admitted to the facility.A review of Resident #9's clinical record revealed an active physician's order, dated 2/6/26, for weights 3 times a week every Monday, Wednesday, and Friday. The Comprehensive Care Plan included a care plan focus area for at risk for alteration nutrition/hydration related to history of weight loss/weight fluctuations due to Congestive Heart Failure (a chronic condition where the heart does not pump blood efficiently enough to meet the body's needs) and Edema (swelling caused by excess fluid trapped in the body's tissues) with interventions for weights as ordered. (Photographic evidence obtained.)Review of the facility's list for obtaining regular weights (dated 3/30/26) revealed Resident #9's name was omitted. (Photographic evidence obtained.)On 4/7/26 at approximately 12:30 PM, Staff A, Licensed Practical Nurse (LPN) independently reviewed Resident #9's weight input on the Medication Administration Record and stated Resident #9 did have an active order to obtain weights 3 times a week on Mondays, Wednesdays, and Fridays. Staff A stated she was unaware why the weights were not documented in the computer. On 4/7/26 at approximately 1:15 PM an interview conducted with Staff E, Unit Manager (UM). She stated the restorative aide was responsible for obtaining weights on residents and the assigned nurse would follow up if no weights were obtained. Staff E reviewed the clinical record for Resident #9 and stated she did not know why the weights were not obtained per the physician order.

Based on observations and record reviews, the facility failed to ensure ongoing communication and collaboration was maintained with the dialysis facility for 1 of 1 resident reviewed for dialysis services (Resident #52).The findings include:On 4/7/26 at 9:31 AM, Resident #52 was out of the facility for dialysis treatment. Resident #52 returned to the facility after lunch, around 2:00 PM. An observation was conducted at 4:15 PM with Resident #52. He voiced being tired due to his treatment but was okay. On 4/8/26 at 11:30 AM, during an interview with Resident #52, he stated, I don't always get the paperwork to take with me to the dialysis center.A record review revealed that Resident #52 was initially admitted to the facility on [DATE] and re-admitted to facility on 8/7/25 post hospitalization with diagnoses including end stage renal disease (ESRD), arteriovenous fistula, and dependence of dialysis. He was ordered for dialysis every Tuesday, Thursday and Saturday for his ESRD. Resident #52 had a plan of care for being at risk for fluid imbalance related to kidney failure, fluid restrictions. Resident #52 was at risk for complications related to hemodialysis with goal that he will be compliant with dialysis appointments, nursing interventions and physician orders.The dialysis communication binder with instruction sheet present in front of binder revealed contains tabs of patients who has dialysis for your unit, dialysis sheets will need to be filled out by our nurse prior to dialysis clinic nurse, and then vital signs once patient arrives at facility, if patient does not have sheet filled out and back to facility, contact the dialysis clinic to retrieve the portion where the dialysis clinic.A review of the Long-term care facility outpatient dialysis services care coordination agreement: section B information sharing: for the purposes of care coordination, in advance of each resident's dialysis treatment, long term care facility shall furnish all information and documentation necessary for dialysis facility to provide safe and appropriate care, including any and all information reasonably requested by dialysis facility. Further review of hemodialysis communication records dated 3/2/24, 2/5/26, and 3/14/26 revealed no documentation of collaboration of care is observed in the medical chart or in dialysis communication binders on the unit.

Based on observations, staff interviews, and record reviews, the facility failed to acquire pain medication from the pharmacy in a timely manner to ensure proper continuity of care for 1 of 1 resident reviewed for pain (Resident #103).The findings include: On 4/6/26 at approximately 12:00 PM, an interview was conducted with Resident #103. Resident #103 stated he received Tramadol twice a day, but did not receive any pain medication on 4/3/26, 4/4/26 or 4/5/26. He further stated he worked out every morning despite not having his pain medication and was not going to let the pain stop him from participating in activities he enjoyed. A review of Resident #103's medical record was conducted. A review of Resident #103's diagnoses include fractured tibia, cervicalgia, and chronic pain. Further review revealed an order for Tramadol 50 mg by mouth every day at 9:00 AM and 11:00 PM. A review of the medication administration record (MAR) for April 2026 confirmed Resident #103 did not receive Tramadol on 4/3/26, 4/4/26, and 4/5/26. The documented reason indicated the medication was not available. On 4/8/26, at approximately 8:30 AM, an interview was conducted with Staff N, Licensed Practical Nurse (LPN). Staff N stated if a medication was empty in the medication cart and not available from the Pyxis machine (an automated medication dispensing system used in healthcare for secure, efficient, and traceable medication management), the nurse should notify the Physician or Advanced Registered Nurse Practitioner (ARNP) for further guidance. On 4/9/26 at approximately 8:25 AM, an interview was conducted with Staff L, LPN. Staff L confirmed that on 4/3/26, the night shift nurse had informed him Resident #103 did not have Tramadol in the medication cart or in the Pyxis machine. He stated he had contacted the ARNP regarding this and she informed him that she was taking care of reordering Resident #103's Tramadol. Staff L, LPN stated the medication never arrived from the pharmacy. He further stated he was not aware he needed to call the pharmacy and if the medication was not available to give to the patient, he should notify the physician or ARNP.On 4/9/26 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). She stated her expectation if a medication is not available in the medication cart or Pyxis, the nurse should contact the pharmacy. If the pharmacy is unable to deliver or complete the order, the nurse should notify the doctor or ARNP for an alternative medication. Review of the facility policy, Standards and Guidelines: Medication Administration, (issued 10/2020 and revised 1/2024) stated, If a Drug is withheld, refuse, or given at a time other than the scheduled time, The individual administering the medication shall document the rationale in the residence medical record and notify the physician. And responsible party if indicated. Medications will be reordered as needed with practitioner approval unless otherwise indicated. (ie auto-refill from pharmacy, emergency medication supply use, etc)

Based on observations, interviews, and record review, the facility failed to ensure appropriate infection control practices were followed for 3 of 3 residents reviewed for infection control (Residents #1, #10, #122). The findings include:On 4/6/26 at 1:50 PM, an observation was made of Resident #1 eating lunch. During this observation, it was noted that red biohazard bags were on the floor of Resident #1's room. An interview was conducted at the time of the observation with Staff J, Certified Nursing Assistant. Staff J stated that Resident #1 did not have a roommate because Resident #1 was on Transmission Based Precautions (TBP) for Methicillin resistant Staphylococcus aureus (MRSA) in a wound (MRSA is a drug-resistant bacteria). It was noted that no TBP signage was posted on the door of Resident #1's room. An additional observation of Resident #1's room was conducted on 4/7/26 revealed that no TBP sign was present. A review of the medical record showed that TBP had been ordered on 4/6/26. On 4/8/26, it was observed that an Enhanced Barrier Precaution (EBP) sign was posted on the outside of Resident #1's room. On 4/8/26, an interview with the Director of Nursing was performed. She acknowledged these signs had not been present until that day. On 4/6/26 at approximately 1:14 PM, observations were made of indwelling urinary catheters for Resident #10 and Resident #122. During these observations, it was noted that there was no signage posted for Enhanced Barrier Precautions (an infection control measure requiring staff to wear gowns and gloves during high-contact care) on the doors of either resident. A review of Resident #10's clinical record, admitted [DATE], revealed an active physician's order for Enhanced Barrier Precautions. The Comprehensive Care Plan, reviewed on 4/7/26, included a care plan focus area for Enhanced Barrier Precautions with interventions. (Photographic evidence obtained.) Review of Resident #122's clinical record, admitted [DATE], revealed an active physician's order for Enhanced Barrier Precautions. The Comprehensive Care Plan, reviewed on 4/7/26, included a care plan focus area for Enhanced Barrier Precautions with interventions. (Photographic evidence obtained.) On 4/7/26 at approximately 9:00 AM a follow up observation was conducted with Staff A, Licensed Practical Nurse (LPN), who acknowledged signage for Enhanced Barrier Precautions needed to be posted for Resident #10 and Resident #122. Staff A stated a sign would be posted. On 4/7/26 at approximately 12:55 PM, an interview was conducted with Staff E, Unit Manager (UM). Staff E confirmed that an Enhanced Barrier Precautions sign should have been placed on the door of the resident's rooms for the staff to know what Personal Protective Equipment (PPE) to wear. On 4/7/26 at approximately 1:30 PM, an interview was conducted with Staff F, Certified Nursing Assistant (CNA). Staff F stated she was unaware of what appropriate PPE to wear for Resident's #10 and #122.

Based on observation, interview, and policy review, the facility failed to maintain handrails in a safe, secure, and functional condition for the 200 hallway.The findings include:On 4/6/26 at approximately 11:35 AM during an initial tour, the handrail on the 200 hall outside of room [ROOM NUMBER] was noted to be broken. When pressure was applied to the handrail, the handrail displaced approximately 3 inches vertically. (Photographic evidence obtained)On 4/8/26 at approximately 12:05 PM, a follow-up observation on the broken handrail was conducted with facility's Administrator and Maintenance Director. They both confirmed handrails should be secure to the wall and they confirmed this handrail needed to be repaired. A review of Facility's Maintenance Service policy (dated 12/2009) page #1 of 2 revealed: The maintenance department is responsible for maintaining the buildings, ground, and equipment in a safe and operable manner. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. (Photographic evidence obtained.)

Based on observation, interview, and record review, the facility failed to implement care plan interventions for supervision during meals for 1 of 4 residents sampled. (Resident #6)The findings include: On 2/19/26 at approximately 9:00 AM, an observation made in Resident #6's room revealed signage above the head of bed that reads, 1. Supervised All meals. (Photographic evidence obtained).On 2/19/26 at approximately 11:10 AM, an interview was conducted with Staff A, Unit Manager (UM), who stated if a resident requires assistance or supervision with meals there is usually an order, or it will be listed on the resident's care plan. Staff A went on to state the certified nursing assistants and staff are made aware during daily shift reports.On 2/19/26 at approximately 11:45 AM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA), who stated if a resident requires assistance or supervision with meals, it will be located on the meal ticket for that resident. On 2/19/26 at approximately 12:45 PM, an observation was made of Resident #6's room. The door was open with the privacy curtain pulled. Resident #6 was observed sitting up in bed feeding himself with no staff present. On 2/19/26 at approximately 12:47 PM, an interview was conducted with Staff B (CNA) who stated she was unaware that Resident #6 required supervision with all meals. Staff B went on to state the sign in Resident #6's room means staff are to be with the resident while he eats and she will stay with him.On 2/19/26 at approximately 12:55 PM, an interview was conducted with the Speech Pathologist, who stated Resident #6 has a history with difficulty swallowing and he recommended supervision with all meals on 02/01/26. The Speech Pathologist stated supervision with meals means staff are to be in sight of the resident during the entire meal and staff should not leave a meal tray with Resident #6 alone.On 2/19/26 at approximately 1:00 PM, an interview was conducted with the Regional Nurse Consultant (who is currently acting as the Director of Nursing). She stated her expectations for staff when a resident requires supervision during meals is, when the staff delivers the tray to the resident, that staff is to stay with the resident during the entire meal.A record review of Resident #6' revealed the following: An order dated 2/1/26 reading, Supervised all meals, monitor oral holding. A Diet Order and Communication by the Speech Pathologist dated 2/1/26 reading, Supervised all meals, monitor oral holding. A Speech Therapy Evaluation, with certification period dates 2/1/26 through 3/2/26, stating, Patient requires supervision at mealtime prior to onset. Resident #6's care plan date initiated 2/4/26 states, Supervise for all meals. (Photographic evidence obtained).

Based on observation, interview, and record review, the facility failed to provide an ordered therapeutic diet for 1 of 4 residents sampled. (Resident #6)The findings include: On 2/19/26 at approximately 9:00 AM, an observation made in Resident #6's room revealed signage above the head of bed that read, 3. Mech soft, chopped meats, thin liquids. (Photographic evidence obtained)On 2/19/26 at approximately 12:45 PM, an observation was made of Resident #6 feeding himself with no staff present. The meal tray was observed to have approximately 7 potato chips and approximately 2 saltine crackers with his meal. The meal ticket read, Regular-DYS ADV (DYS ADV is short for Dysphagia Advanced, which means a regular diet, but avoiding hard, sticky, or crunchy foods. Foods should be bite-size). (Photographic evidence obtained).On 2/19/26 at approximately 12:47 PM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA), who stated chips and crackers are not part of a mechanical soft texture diet. Staff B entered Resident #6's room and removed the chips and crackers from his meal tray. Staff B stated the Regular-DYS ADV on the meal ticket means the diet is regular with mechanical soft texture.On 2/19/26 at approximately 12:50 PM, an interview was conducted with Staff A, Unit Manager (UM), who stated chips and crackers are not part of a mechanical soft texture diet and would notify dietary.On 2/19/26 at approximately 12:55 PM, an interview was conducted with the Speech Pathologist, who stated a resident with a mechanical soft and chopped meat diet would not have chips and crackers on a meal tray.On 2/19/26 at approximately 1:00 PM, an interview was conducted with the Regional Nurse Consultant (who is acting Director of Nursing). She stated her expectations are for staff to follow therapeutic diets according to the meal tickets and physician orders.On 2/19/26 at approximately 1:05 PM, an interview was conducted with the Administrator, who stated his expectation for the dietary department is to accurately place meals on trays according to the meal tickets.On 2/19/26 at approximately 1:10 PM, an interview was conducted with the Certified Dietary Manager (CDM), who stated dietary staff are to read each meal ticket and place food on the meal tray according to the therapeutic diet on the ticket. The CDM stated the chips and saltine crackers should not have been placed on Resident #6's tray.Resident #6's diet order dated 2/1/26 reads, Regular diet, mechanical soft texture, thin consistency. Resident #6's Speech encounter date of service 2/1/26 reads, Dysphagia Precautions: aspiration, malnutrition, voice, cognition, exercises to improve mastication with solids, reduce oral holding, swallow strategy, staff education. Mechanical soft/chopped textures.A review of the facility's Diet Consistency policy (revised: 7/2024) reveals, Texture modified diets will be prepared to the appropriate consistency for ease of chewing/swallowing. Follow the diet manual instructions for texture modified diets. Texture modified diets are: Mechanical/Ground Soft Diet and Puree Diet. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: The Diet order should have: Diet Type, Texture, and fluid consistency.

Based on record review, staff interview, and policy review, the facility failed to offer the 2024 influenza vaccine to 1 of 5 sampled residents (Resident #3) and failed to document the provision of education regarding the benefits and potential side effects of the 2024 influenza vaccine and pneumonia vaccine for 5 of 5 sampled residents. (Residents #3, #37, #46, #54, and #73) The findings include: A review of Resident #3's medical record revealed the resident had not been offered an influenza vaccine since 11/10/23. No education had been documented as provided for Resident #3 regarding the influenza vaccine since 2022. A review of Resident #37's medical record revealed no education regarding the pneumonia vaccine had ever been documented. A review of Resident #46's medical record revealed no education regarding the influenza vaccine had been documented since 2021. A review of Resident #54's medical record revealed no education regarding the pneumonia vaccine had ever been documented. A review of Resident #73's medical record revealed no influenza education had been documented since 2022 and no pneumonia education had ever been documented. An interview was conducted with the Assistant Director of Nursing (ADON) on 1/9/25 at 11:59 AM. She stated she had no evidence of education for the 5 sampled residents and confirmed that Resident #3 had not been offered the influenza vaccine in 2024. Review of the facility policy for Immunizations- Influenza and Pneumonia (revised 2/2024) revealed residents who have no medical contraindications to the influenza vaccine will be offered the vaccine annually. Prior to vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccines. Such education shall be documented in the resident's medical record.

Based on record review, staff interview, and policy review, the facility failed to offer the 2024 COVID-19 vaccine to 4 of 5 sampled residents. (Residents #37, #46, #54, and #73) The findings include: A review of Residents #37, #46, #54, and #73's medical records revealed the residents had not been offered the COVID-19 vaccine in 2024. An interview was conducted with the Assistant Director of Nursing (ADON) on 1/9/25 at 10:53 AM. The ADON stated the last time the facility offered the COVID-19 vaccine to residents was in November 2023. She stated it should be offered annually and they just have not done so. Review of the facility policy for COVID-19 (revised 6/24/24) revealed COVID-19 vaccines are offered to residents and staff in accordance with CDC guidance. Review of the current CDC (Centers for Disease Control) recommendations for COVID-19 vaccines in the long term care setting was accessed at https://www.cdc.gov/covid/vaccines/long-term-care-residents.html on 1/10/25 at 11:10 AM. The CDC recommendations were: *Everyone ages 6 months and older should get a 2024-2025 COVID-19 vaccine. *Children ages 6 months-4 years may need more than 1 updated COVID-19 vaccine dose to be up to date. *CDC recommends everyone ages 5-[AGE] years, including people who live and work in long-term care (LTC) settings, get 1 dose of a 2024-2025 COVID-19 vaccine. *CDC recommends everyone ages [AGE] years and older, including people who live and work in LTC settings, get 2 doses of a 2024-2025 COVID-19 vaccine 6 months apart. *People who are moderately or severely immunocompromised should get at least 2 doses of 2024-2025 COVID-19 vaccine 6 months apart. They may also get more age-appropriate doses, beyond two doses at least 2 months apart, after talking to a healthcare provider.

Based on record review and interview, the facility failed to act promptly to resolve and properly investigate grievances submitted for 2 out 2 residents sampled. (Resident #54 and #21) The findings include: On 11/17/24 Resident #54 filed a grievance. The form stated that she was only getting grits, a slice of toast and a glass of tea. She included the meal card to show what she should be getting. Resident #54's meal card for 11/17/24 stated she should receive: a double protein at breakfast, bacon, hot cereal, biscuit, jelly, margarine, juice of choice, orange juice, coffee, creamer, sausage patty, English muffin, jelly, margarine, toast, jelly, margarine. This complaint was verbally communicated to the administrator and dietary. This section was signed by the business office manager (BOM) on 11/17/24. This investigation was assigned to dietary staff and the Kitchen Manager on 11/18/24. On the Findings portion of the form, all that was written was, On the menu we have a lot of no meat days. The Plan to Resolve Complaint/Grievance section was left blank. The Expected Results of Actions Taken section only stated, We are just following the menu. This section was not signed or dated. The third section was left blank. This section includes: Was the complaint/grievance resolved?, Is complainant satisfied?, and Who were the investigation findings reported to and how were the results communicated?. The signature and name of who completed that section are blank but Resident # 54 signed it on 11/22/24. Resident #21 filed a grievance on 11/18/24 with the Social Services Director (SSD) stating he has not received meat with his breakfast in the last 2 weeks. The grievance form stated it was assigned to dietary but no name was included. The findings of the investigation were, On the menu we have a lot of no meat days but we do have meat days to we are just following the menu. The Expected Results of Actions Taken section stated, We are just following the menu. The 3rd section was left blank and Resident #21 signed it on 11/22/24. During an interview held on 01/15/25 at 10:59 AM, Resident #54 stated she no longer gets meat with breakfast. When asked if she had filed a grievance, she stated, Not anymore, it does not make a difference. On 01/09/25 at 09:59 AM, an interview was held with the Regional Dietitian. When she was shown the grievances for Residents #54 and #21, she stated that those forms are not filled out correctly because it is unclear what staff did the investigation. She also stated, There is no actual investigation, saying the menu is being followed is not a resolution to a problem, this looks like they never even spoke to the residents. In my opinion those grievances are not acceptable. On 01/09/25 at 12:35 PM, during a meeting with the Facility Administrator (FA), she stated the grievances are not filled out properly and she is aware of the issue. She stated she created a performance improvement plan on 1/2/25 but has not implemented it. Per the facilities Policy/Procedure named Resident Rights, section 9 e, The facility is to ensure grievances have a written decision that includes the steps taken to investigate, a summary of pertinent findings or conclusions, corrective action taken or to be taken.

Based on observation, record reviews, staff interviews, resident interviews, and facility policy review, the facility failed to honor resident rights to be free from or the likelihood of physical and sexual abuse for 6 of 20 sampled residents. (Resident #1, #8, #9, #10, #16, #17). This failure allowed Resident #2, with known sexual behavior and cognitive impairment, to expose his genitals to Resident #1, have a physical altercation with Resident #8, enter the room of Resident #9 and #10 and get into the occupied bed of Resident #9 while unclothed, and wander in the rooms of Resident #16 and Resident #17. The situation resulted in a finding of Immediate Jeopardy. The facility's Regional Administrator was notified of the findings of Immediate Jeopardy on 4/19/23 at approximately 1:30 PM. The Administrator was unavailable and did not return until 4/20/23. On 4/20/23, Immediate Jeopardy deficiencies was reduced from a K level to an E, pattern no actual harm with potential for no more than minimal harm level. Immediate Jeopardy was removed on 4/20/23 at approximately 3:15 PM when the facility provided evidence of the removal of immediacy actions which included placing Resident #2 on one to one constant staff supervision, immediate training of staff on abuse policies, auditing of resident records for abuse concerns, interviewing residents for abuse concerns, immediate federal reports were filed with the state agency, and developing a new system to audit and review notes daily for immediate response to any allegations or concerns. Cross reference F607, F609, F610, F835, and F867. The findings include: Resident #2 An observation and attempted interview was conducted with Resident #2 on 4/18/23 at 3:23 PM. The resident was in his bed covered with a sheet. The surveyor knocked on the door and asked to enter. The resident did not respond but only looked at the surveyor. The surveyor remained at the doorway. The resident was observed to be moving his hand under the sheet. The resident then pulled back the sheet and exposed his penis and began fondling himself. The observation was terminated. A review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses of Wernicke's encephalopathy (degenerative brain disorder caused by the lack of vitamin B-1), restlessness and agitation, psychosis, dementia, and generalized anxiety disorder. The quarterly minimum data set with an assessment reference date of 2/1/23 revealed Resident #2 was rarely or never understood, required supervision to ambulate, had moderately impaired cognitive skills, inattention and disorganized thinking was present, and no limitation was present in range of motion. Resident #2's current care plan was initiated 11/30/2020 for a behavior problem related to frequently masturbating, throwing himself on the floor, kicking staff, and refusing medications. The interventions included educating the resident on successful coping and interaction strategies; if reasonable, discuss the resident's behavior; explain/reinforce why certain behaviors are inappropriate; and provide a program of activities that is of interest. A review of the progress notes for Resident #2 revealed on 11/3/22 at 7:22 PM, the nurse was notified that the resident was displaying sexually inappropriate behavior towards the certified nursing assistant (CNA) by swinging his genitalia towards the CNA during check and change rounds. On 2/20/23 at 5:39 PM, the progress note read resident's behavior has changed today of being more aggressive, he went into another resident's room, threatened and pushed her, he went into a room and sat on the bed and demanded for that resident to get out of the room, he was redirected back to his room and the unit manager was notified. On 3/6/23 at 9:52 PM the progress note stated, he was eating food from roommate's side of the room, went across the hall and sat on another resident's bed and was eating her food and drink, then after having a bowel movement removed brief and chased another nurse with the brief in the halls. On 4/4/23 at 10:45 AM, the progress note read, CNA reported resident is self-pleasuring during bath time and brief changes, resident continued behavior even after being asked to stop, reported to nurse practitioner, social services, and psychiatry. On 4/14/23 at 10:55 PM, the progress noted read, resident wandered into another resident's room thinking it was his bedroom, he took his shirt and pants off and left brief intact, then climbed into bed, he was redirected to his room and clothing replaced, physician contacted for agitation and new order received for one time dose of Seroquel 50 mg. A review of the psychiatric progress note dated 11/21/22 indicated the provider's review of the progress notes over the past 30 days revealed 1 episode of sexually inappropriate behavior towards staff. The record included a room change notice dated 2/24/23 indicating the resident was moved to a different hall due to roommate incompatibility. The facility provided point of care task records indicating the resident was placed on every 15-minute safety checks from 4/5/23 through the survey date. Resident #1 A review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses to include encephalopathy and aphasia. The quarterly minimum data set, with an assessment reference date of 1/13/23, revealed the resident had a BIMS (Brief Interview of Mental Status) of 8, indicating moderate cognitive impairment, had hallucinations, and could ambulate with supervision. A medication administration note documented by Employee D (licensed practical nurse (LPN)) dated 2/16/23 at 10:45 PM stated the resident #1 was found by the CNA (Employee E) on the edge of their roommate's bed with his penis aroused sitting next to his roommate (Resident #2). The record revealed a room change notice dated 2/17/23 indicating Resident #1 was moved due to bed management. An interview was conducted with Employee G (LPN) on 4/17/23 at 2:44 PM. She stated about 1- 1.5 months ago she heard a CNA walked in and Resident #2 had his penis out and Resident #1 was sitting on the foot of Resident #2's bed watching Resident #1 with an erect penis. An interview was conducted with Employee K (CNA) on 4/18/23 at 8:54 AM. She stated about 3 months ago she observed Resident #2 pulling on his penis and Resident #1 sitting on the foot of Resident #2's bed at the time. She reported the incident to Employee G (LPN) and had Resident #1 return to his side of the room. A telephone interview was conducted with Employee E (CNA) on 4/18/23 at 12:25 PM. Employee E stated she found Resident #1 sitting on Resident #2's bed with his penis aroused. It looked like Resident #1 had gone to the bathroom and took his brief off but he had on shorts. She did not recall if Resident #1's shorts were pulled down. She stated she did not recall which nurse she informed. An interview was conducted with the Regional Administrator on 4/18/23 at 12:48 PM. She stated she was the Administrator of record for the facility from 1/10/23 through 2/14/23 and she then oriented the new Administrator through 2/16/23. She had no knowledge of Resident #2 being found on his roommate's bed (Resident #1) with his penis aroused. She stated she would expect staff to report this to Administration. An interview was conducted with the Administrator on 4/18/23 at 3:48 PM. She stated she had no knowledge of the incident between Resident #1 and #2 and she was not aware of the incident on 2/20/23 when Resident #2 allegedly pushed a female resident. The staff would be expected to report those allegations to the Administrator and DON, complete a full investigation, and follow the facility policy and procedure for abuse. A telephone interview was conducted with Employee D (LPN) on 4/19/23 at 11:59 PM. She recalled the incident she documented on 2/16/23 regarding Resident #1 and #2 and she reported the incident to the nurse practitioner, director of social services, and the unit manager. An interview was conducted with the ADON on 4/19/23 at 2:04 PM. She stated she recalled hearing in a morning meeting about the incident involving Resident #1 and #2. She heard one of the residents was on the other resident's bed and the other resident had his own penis in his own hand. She was not aware of any investigation into the incident. Resident #2 was then moved to a different room. The ADON could not remember if the incident was discussed in a Quality Assurance meeting. Resident #8 An interview was conducted with Resident #8 on 4/19/23 at 10:28 AM. Resident #8 stated that Resident #2 came into her room toward the end of February in the afternoon. She asked him to get out of her room. She then grabbed his arm to try to get him to leave her room and he threw his arm at her throat. She stated she felt threatened by Resident #2 and did not always feel safe in the facility. Resident #8 revealed staff were aware because they came into her room and assisted removing Resident #2 from her room. An interview was conducted with Employee P (Registered Nurse (RN)) on 4/19/23 at 11:01 AM. She stated the incident involving Resident #2 going into Resident #8's room was discussed in the morning meeting the Tuesday following the 2/20/23 incident (2/21/23). The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were present in the meeting. Resident #2 was subsequently moved to the other side of the facility. The incident on 4/14/23 regarding Resident #2 getting in bed with Resident #9 was discussed in the morning meeting on 4/17/23 and the DON and ADON were present. Employee P (RN) stated she has had no specific training regarding how to handle resident sexual behaviors. An interview was conducted with Employee Q (unit manager) on 4/19/23 at 11:29 AM. Employee Q stated she was notified of the incident between Resident #2 and #8 the following day on 2/21/23. The staff notified her Resident #2 had entered Resident #8's room. Resident #8 then pushed Resident #2 out of the room and Resident #2 swung his hands in the air at Resident #8 but did not make physical contact. Employee Q stated she reported the incident to administration during the stand down meeting. She was not aware of any specific training regarding resident sexual behaviors. Employee Q stated Resident #2 often masturbated in his room, and he was able to ambulate unassisted. An interview was conducted with Employee O (CNA) on 4/19/23 at 12:54 PM. Employee O stated, [Resident #2] plays with his genitals, he takes out his privates and wiggles it around. The last time she cared for Resident #2, he asked her to get in bed with him. An interview was conducted with the Social Services Director (SSD) on 4/19/23 at 2:15 PM. He stated he was made aware of Resident #2 attempting to go into Resident #8's room in February 2023. He believes the facility investigated the incident. He interviewed the unit manager (Employee Q) and Resident #8 regarding the incident. A further interview was conducted with the SSD on 4/19/23 at 2:36 PM. He provided documented interviews with Employee D regarding the incident between Resident #1 and #2 on 2/16/23 and Resident #2 and #8 on 2/20/23. He stated he did not interview the CNA that observed Resident #1 and #2 on 2/16/23. It did not occur to him that he needed to complete a full investigation because the nurse did not state the resident's penis was out. He stated, I am in crisis management in the facility, meaning I have residents that are always coming to the office, and I'm constantly putting out fires. Regarding the incident on 2/20/23, he stated he did not review the progress notes in the record. He reported his findings to the current Administrator. An interview was conducted with the DON on 4/19/23 at 2:26 PM. She stated there was a good possibility she had been notified of some of the allegations regarding Resident #2 during a meeting. An additional interview was conducted with the DON on 4/20/23 at 9:35 AM. She stated she did not feel the incidents on 2/16/23 and 2/20/23 were thoroughly investigated. The DON stated, she usually came in on Mondays and would go over anything that happened over the weekend and that did not occur for this incident. A follow-up interview was conducted with the Administrator on 4/20/23 at 9:35 AM. She stated the staff are expected to report allegations of abuse, neglect, and exploitation to the supervisor, Administrator, or DON. The facility reports the allegations of abuse to the regional staff, state agency, and Department of Children and Families. The SSD did complete an investigation for the incidents on 2/16/23 and 2/20/23. The Administrator was asked if she felt the investigations were thorough, she stated she could not answer the question. She stated it was hard to investigate when you do not know what is going on and, in her absence, the DON would be in charge of the facility. 46833 Resident #9 & Resident #10 A record review was conducted on 04/18/2023 at approximately 8:30 AM for Resident #9. Resident #9 has diagnoses to include: chronic obstructive pulmonary disease with acute exacerbation, asthma, acute respiratory failure with hypoxia, pneumonia, mobility, assistance with personal care, difficulty walking, repeated falls, muscle weakness, systolic and diastolic heart failure, chronic atrial fibrillation, malignant neoplasm of temporal lobe, anemia, and abdominal aortic aneurysm. The record revealed no documentation in Resident #9's chart regarding the incident with Resident #2 entering her room and getting into bed with her. An interview was conducted on 04/17/2023 at approximately 12:00 PM with Resident #9. Resident #9 stated, About four or five days ago, a man came into my room, took his clothes off and got into bed with me. I was in my bed, and he got into bed with me. That poor guy didn't have a chance. I started beating his back and telling him to get out. I'm not sure where he touched me at because I was hitting him so much. The staff finally came and got him out of my bed. It took a bunch of them to get him out of here. An interview was conducted on 04/17/2023 at approximately 12:15 PM with Resident # 10. Resident #10 stated, We have some people who wander around and come into our room. But they have dementia. This was a completely different situation. It was very scary. He had his hands on her. I don't know what part of her body exactly. But I did see him touching her. I went to the door and screamed so loudly. I have a pretty big mouth. I was screaming for help. He was going to do something to her. It took a few of them to get him out of here. (Resident #10's account of the incident in which Resident #2 got into the bed with Resident #9) An interview was conducted on 04/17/2023 at approximately 2:00 PM with the Director of Nursing (DON). The DON stated she did get a message regarding Resident #2 going into Resident #9's room on Friday, 04/14/2023. The DON stated that Resident #2 does get confused and does wander around the facility. The DON stated, We did call the Administrator and our Corporate team to report it to them. The DON stated, We haven't had any other reports of similar situations with Resident #2. He was moved from one side of the building to the other side because of complaints from other residents of snoring from this resident. So, we moved him. The DON stated the facility corporate team consisted of the [NAME] President of Clinical Operations, Clinical Regional Administrator, and [NAME] President of Operations. An interview was conducted on 04/18/2023 at approximately 9:30 AM with Staff A (LPN). Staff A stated, I was at the nurses' station, and we heard [Resident # 9's] roommate, [Resident # 10] at her door yelling down the hallway. We all ran down there, and we saw his shirt, pants, and shoes on the floor beside Resident #9's bed. [Resident #2] had gotten in bed with her and woke her up. Then the roommate yelled out for help. We had to redirect [Resident #2] out of the room. We called and got medication ordered for him to calm him down. He didn't touch her that we know of. [Resident #2] does have behavioral issues. He does walk in and out of people's rooms. He must be constantly redirected. He has been pacing and fidgeting. He throws his feces around. He has had increased agitation lately. And he does get aggressive. Staff A reported recently having an abuse in-service and additional in-services in the future. Staff A stated, But I am not sure of the whole process to report anything or what I am supposed to report. An interview was conducted on 04/18/2023 at approximately 12:45 PM with the DON. The DON stated, If I know of an issue with any type of abuse, I will report it to my corporate team and start an investigation. I did not start an investigation this past Friday because I didn't think it was really anything. But I would start my investigation within an hour or two of finding out and then report it. An interview was conducted on 04/18/2023 at approximately 2:50 PM with Staff B (CNA). Staff B stated, [Resident #2] wanders sometimes. He went into [Resident #9's] room and got in bed with her while she was sleeping. We escorted him out and took him back to his room. [Resident #2] didn't do anything sexual with her. He took off his clothes with his brief on and got onto the bed with her. Staff B reported that Resident #2 has wandered in other rooms before. But we keep an eye on him and try and redirect him. An interview was conducted on 04/19/2023 at approximately 10:45 AM with the Administrator. The Administrator stated, I am not aware of any instances of abuse being reported to me. I was in orientation that first week (this Administrator started at the facility on 02/14/2023). I was not in all the morning meetings. The first four days were me acclimating to the facility and being oriented. I do know that both residents (Residents #1 and #2) have had behaviors since I have been there. I don't remember the behaviors that were being talked about. But I do know they have had some behaviors. Additional Incidents of Wandering Into Residents Rooms Unsupervised An interview was conducted on 04/19/2023 at approximately 9:30 AM with Resident #16. Resident #16 stated, [Resident #2] used to come into my room. But I don't think he meant any harm. I would just tell him to get out. Resident #16 stated Resident # 2 never tried anything with me or sat on my bed or anything. An interview was conducted on 04/19/2023 at approximately 9:45 AM with Resident #17. Resident #17 stated, Yes. [Resident #2] has been in our room twice. It was a couple of months ago. [Resident #2] was naked when he came into our room. They moved him to another area of the building. [Resident #2] has never sat on my bed or done anything in front of me. Review of the facility policy for Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property (8/22/22) revealed, It is the policy of this Center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation, and misappropriation of property. In addition, each resident will be protected from those practices and omissions, which if left unchecked, could lead to abuse. Further, each resident will be treated with respect and dignity at all times. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care. Residents will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, contract staff, family members, friends, or others. On 4/19/2023, the facility submitted a removal plan for F600 with immediate corrective actions to further prevent residents from further sexual abuse. The facility's removal plan included: 1. Resident #2 placed on one-on-one supervision 4/19/2023. 2. All current residents in the facility audited for concerns of abuse in the resident records completed 4/19/2023. 3. Administrator and Director of Nursing (DON) and department heads educated by Director of Clinical Services on facility policy and procedures of sexual abuse, investigations, and reporting into allegations of abuse with consultation with Regional Administrator on 4/19/2023. 4. Residents #8, #9, #10 to be evaluated 4/20/2023 and followed by psych APRN to provide psychosocial support from exposure to sexual abuse. 5. 100% of interviewable residents were interviewed for concerns with care or abuse 4/19/23. 6. In-services and competencies completed on abuse policy and procedure, inservices completed on the following dates: a. 4/19/2023 - 90% of all staff complete. b. 4/20/2023 - 100% of all staff complete. c. No staff members were permitted to work until all topic education and post in-service competency test for abuse policy and procedure, investigation and report was completed. 7. Upon hire and annually, all staff will complete abuse in servicing by staff developer or designee. 8. Immediate federal reporting for abuse completed for resident #2 on 4/17/2023 for 4/14/2023. 9. Immediate federal reporting for abuse completed for resident #2 on 4/18/2023 for 2/16/2023 and 2/20/2023. 10. DON or designee to audit progress notes and EMAR notes for any note with areas of concern to be investigated starting 4/20/2023. 11. This issue was resolved on 4/20/23 as evidenced by resident #2 was placed on one-on-one supervision, APS notification 4/17/2023 and 4/18/2023, federal immediate reporting completed for all occurrences, staff education completed for all areas, system developed and implemented for auditing the residents' records daily to be aware of concerns not reported. 12. This issue was taken to Quality Assurance Performance Improvement (QAPI) at an ad-hoc meeting on 4/18/2023 with Medical Director, Administrator, Director of Nursing, Social Services Director, MDS Director, and Unit Managers for both Units to discuss the concerns with sexual abuse, investigations, reporting and adequate follow up with PIP with new system to audit and review notes daily for immediate response in any allegations or concerns. On 4/20/23 at approximately 3:15PM, Immediate Jeopardy deficiencies was reduced from a K level to an E, pattern no actual harm with potential for no more than minimal harm level. As evidenced by the following: On 4/20/23 at 11:04PM, Resident #2 was observed to in bed while his 1:1 supervision staff was seated at the resident's open bedroom door. This started on 4/19/23 according to documentation reviewed. Evidence of the resident record audits was provided to surveyors and dated 4/20/23. Upon review all residents were audited and no additional concerns were identified. Staff education in-services for the Administrator, DON, and other Department Heads, related to sexual abuse reporting, sexual abuse, investigative processes, and investigations was reviewed. Training dated for 4/19/23. The facility provided a sign-in sheet with 18 staff signatures. Interviews with Administrator, DON, and at least 3 other Department Heads validating reeducation. One Hundred percent of staff received staff education on abuse policy and procedures, inservices verified to have been completed on 4/19-4/20/23. Staff interviews conducted with at least 10 staff(non-administrative) from various shifts and departments which indicated training was received. Staff were able to verbally recite abuse policies and procedures they recently received in re-education related to abuse. Review of staff files for verification of abuse training upon hire. Education provided included but not limited to an explanation of abuse, signs and symptoms of abuse, and reporting. 3 recently hired staff records reviewed verifying training had been completed. Review of records for Residents #8, #9, and #10 revealed orders dated 4/20/23 for Psych eval and treat for psychosocial support status post resident interaction in her room. Observed Psychiatric Provider seeing Resident #10 on 4/20/23 at approximately 11:47AM. The Facility developed and conducted a Questionnaire for interviewable residents on 4/18-4/19/23. Interviewed a total of 6 residents and all confirmed that facility staff had interviewed them about abuse and staff concerns. No additional concerns identified. Review of the facility's federal reporting for abuse was completed for resident #2 for all incidents that were discovered. Documentation provided confirm all three incidents had been reported to the abuse hotline. Review of audits completed of progress notes and EMAR (Electronic Medication Administration Records). No additional concerns noted. Review of Meeting Notes and Interview with the Administrator verified adhoc QAPI meeting on 4/18/223 to discuss supervision for Resident #2 and concerns with sexual abuse, investigations, reporting and an update to the facility's action plan started on 4/17/23.

Based on observation, record reviews, staff interviews, resident interviews, and facility policy review, the facility failed to implement their policies regarding sexual and physical abuse for 4 of 4 sampled residents. (Resident #1, #2, #8, and #9) This failure allowed Resident #2, with known sexual behavior and cognitive impairment, to expose his genitals to Resident #1, have a physical altercation with Resident #8, and enter the occupied bed of Resident #9 unclothed. The allegations of physical and sexual abuse were not reported to the State Survey Agency or abuse hotline, or thoroughly investigated. The facility failed to implement effective interventions to protect vulnerable residents. The situation resulted in a finding of Immediate Jeopardy. The facility's Regional Administrator was notified of the findings of Immediate Jeopardy on 4/19/23 at approximately 1:30 PM. The Administrator was unavailable and did not return until 4/20/23. Immediate Jeopardy was removed on 4/20/23 at approximately 3:15 PM when the facility provided evidence of the removal of immediacy actions which included placing Resident #2 on one to one constant staff supervision, immediate training of staff on abuse policies, auditing of resident records for abuse concerns, interviewing residents for abuse concerns, immediate federal reports were filed with the state agency, and developing a new system to audit and review notes daily for immediate response to any allegations or concerns. Cross reference F600, F609, F610, F835, and F867. The findings include: Review of the facility policy for Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property (dated 8/22/22) revealed, It is the policy of this Center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation, and misappropriation of property. In addition, each resident will be protected from those practices and omissions, which if left unchecked, could lead to abuse. Further, each resident will be treated with respect and dignity at all times. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care. Residents will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, contract staff, family members, friends, or others. Prevention of abuse will be accomplished by the timely reporting of the suspected abuse and a thorough investigation of these instances. Those reporting abuse should not be subjected to any disciplinary action for the correct reporting of abuse or suspected abuse. The Center will post steps on abuse and abuse reporting for staff, residents, and family members in designated areas of the Center. The material will advise the parties on how to report and to whom to report. The Center will ensure that the call will be confidential. Resident Behavior- our residents have the right to be free from resident-to-resident abuse. All altercations, including those that may represent resident to resident abuse shall be investigated and reported in accordance with established reporting procedures. If two residents are involved in an altercation, staff will separate the residents, identify what happened, assess both residents for any clinical, psychological and/or psychosocial changes that may have led to the incident, and notify the attending physician, each resident's respective representative and the appropriate State agency as required by State law. Investigation- all suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee. The findings should be reported to the appropriate governing agencies. Reporting/Documentation Requirements- ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the center and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care Centers) in accordance with State law through established procedures in these timeframes: * If the events that cause the allegation involve abuse or result in serious bodily injury, the event must be reported immediately, but not later than 2 hours after the allegation is made. * If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the event must be reported no later than 24 hours after the allegation is made. Resident #2's Behavioral History A review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses of Wernicke's encephalopathy (degenerative brain disorder caused by the lack of vitamin B-1), restlessness and agitation, psychosis, dementia, and generalized anxiety disorder. The quarterly minimum data set with an assessment reference date of 2/1/23 revealed Resident #2 was rarely or never understood, required supervision to ambulate, had moderately impaired cognitive skills, inattention and disorganized thinking was present, and no limitation was present in range of motion. Resident #2's current care plan was initiated 11/30/2020 for a behavior problem related to frequently masturbating, throwing himself on the floor, kicking staff, and refusing medications. The interventions included educating the resident on successful coping and interaction strategies; if reasonable, discuss the resident's behavior; explain/reinforce why certain behaviors are inappropriate; and provide a program of activities that is of interest. A review of the progress notes for Resident #2 revealed on 11/3/22 at 7:22 PM, the nurse was notified that the resident was displaying sexually inappropriate behavior towards the certified nursing assistant (CNA) by swinging his genitalia towards the CNA during check and change rounds. On 2/20/23 at 5:39 PM, the progress note read resident's behavior has changed today of being more aggressive, he went into another resident's room, threatened and pushed her, he went into a room and sat on the bed and demanded for that resident to get out of the room, he was redirected back to his room and the unit manager was notified. On 3/6/23 at 9:52 PM the progress note stated, he was eating food from roommate's side of the room, went across the hall and sat on another resident's bed and was eating her food and drink, then after having a bowel movement removed brief and chased another nurse with the brief in the halls. On 4/4/23 at 10:45 AM, the progress note read, CNA reported resident is self-pleasuring during bath time and brief changes, resident continued behavior even after being asked to stop, reported to nurse practitioner, social services, and psychiatry. On 4/14/23 at 10:55 PM, the progress noted read, resident wandered into another resident's room thinking it was his bedroom, he took his shirt and pants off and left brief intact, then climbed into bed, he was redirected to his room and clothing replaced, physician contacted for agitation and new order received for one time dose of Seroquel 50 mg. A review of the psychiatric progress note dated 11/21/22 indicated the provider's review of the progress notes over the past 30 days revealed 1 episode of sexually inappropriate behavior towards staff. The record included a room change notice dated 2/24/23 indicating the resident was moved to a different hallway due to roommate incompatibility. The facility provided point of care task records indicating the resident was placed on every 15-minute safety checks from 4/5/23 through the survey date. During the survey, an attempt was made by this surveyor to interview resident #2. On 4/18/23 at 3:23 PM, Resident #2 was observed to be in bed covered with a sheet. The surveyor knocked on the door and asked to enter. The resident did not respond but only looked at the surveyor. The surveyor remained at the doorway. The resident was observed to be moving his hand under the sheet. Then the resident pulled back the sheet and exposed his penis and began fondling himself. The surveyor terminated the observation. Incident #1 (between Resident #1 and Resident #2 on 2/16/23) According to record reviews and staff interviews for Resident #2, this resident was observed with his penis out and erected while Resident #1 was sitting on Resident #2's bed with an erection on 2/16/23. The quarterly minimum data set, with an assessment reference date of 1/13/23, revealed resident #1 had a BIMS (Brief Interview of Mental Status) of 8, which indicated resident #1 to have moderately impaired Cognition (A person's decisions are consistently poor or unsafe; the person requires reminders, cues, or supervision at all times to plan, organize, and conduct daily routines). An interview was conducted with the Regional Administrator on 4/18/23 at 12:48 PM. She stated she was the Administrator of record for the facility from 1/10/23 through 2/14/23 and she then oriented the new Administrator through 2/16/23. She had no knowledge of Resident #1 being found on his roommate's bed with his penis aroused. She stated she would expect staff to report this to Administration. An interview was conducted with the Administrator on 4/18/23 at 3:48 PM. She stated she had no knowledge of the incident between Resident #1 and #2. She stated the staff would be expected to report such allegations to the Administrator and Director of Nursing (DON), complete a full investigation, and follow the facility policy and procedure for abuse. An interview was conducted with the ADON on 4/19/23 at 2:04 PM. She stated she recalled hearing in a morning meeting about the incident involving Resident #1 and #2. She heard one of the residents was on the other resident's bed and the other resident had his own penis in his own hand. She was not aware of any investigation into the incident. She stated Resident #2 was then moved to a different room. She stated the incident was not discussed in a Quality Assurance meeting. Incident #2 (between Resident #2 and Resident #8 on 2/20/23) An interview was conducted with the Administrator on 4/18/23 at 3:48 PM. She was not aware of the incident on 2/20/23 when Resident #2 allegedly pushed a female resident. She stated the staff would be expected to report those allegations to the Administrator and DON, complete a full investigation, and follow the facility policy and procedure for abuse. An interview was conducted with Resident #8 on 4/19/23 at 10:28 AM. Resident #8 stated that Resident #2 came into her room toward the end of February in the afternoon. She asked him to get out of her room. She then grabbed his arm to try to get him to leave her room and he threw his arm at her throat. She stated she felt threatened by Resident #2 and did not always feel safe in the facility. Resident #8 revealed staff were aware because they came into her room and assisted removing Resident #2 from her room. An interview was conducted with Employee P (Registered Nurse (RN)) on 4/19/23 at 11:01 AM. She stated the incident involving Resident #2 going into Resident #8's room was discussed in the morning meeting the Tuesday following the 2/20/23 incident (2/21/23). The DON and Assistant Director of Nursing (ADON) were present in the meeting. Resident #2 was subsequently moved to the other side of the facility. An interview was conducted with Employee Q (unit manager) on 4/19/23 at 11:29 AM. Employee Q stated she was notified of the incident between Resident #2 and #8 the following day on 2/21/23. The staff notified her Resident #2 had entered Resident #8's room. Resident #8 then pushed Resident #2 out of the room and Resident #2 swung his hands in the air at Resident #8 but did not make physical contact. Employee Q stated she reported the incident to administration during the stand down meeting. She was not aware of any specific training regarding resident sexual behaviors. Incident #3 (between Resident #2 and Resident #9 on 4/14/23) An interview was conducted on 04/17/2023 at approximately 12:00 PM with Resident #9. Resident #9 stated, About four or five days ago, a man came into my room, took his clothes off and got into bed with me. I was in my bed, and he got into bed with me. That poor guy didn't have a chance. I started beating his back and telling him to get out. I'm not sure where he touched me at because I was hitting him so much. The staff finally came and got him out of my bed. It took a bunch of them to get him out of here. The record revealed no documentation in Resident #9's chart regarding the incident with Resident #2 entering her room and getting into bed with her. Additional Interview with the Administrator on 4/18/23 at 3:48 PM, revealed she was not aware of the incident on 2/20/23 when Resident #2 allegedly pushed a female resident. She stated the staff would be expected to report those allegations to the Administrator and DON, complete a full investigation, and follow the facility policy and procedure for abuse. An interview was conducted on 04/17/2023 at approximately 12:15 PM with Resident # 10. Resident #10 stated, We have some people who wander around and come into our room. But they have dementia. This was a completely different situation. It was very scary. He had his hands on her. I don't know what part of her body exactly. But I did see him touching her. I went to the door and screamed so loudly. I have a pretty big mouth. I was screaming for help. He was going to do something to her. It took a few of them to get him out of here. (Resident #10's account of the incident in which Resident #2 got into the bed with Resident #9) An interview was conducted with Employee P (Registered Nurse (RN)) on 4/19/23 at 11:01 AM. The incident on 4/14/23 regarding Resident #2 getting in bed with Resident #9 was discussed in the morning meeting on 4/17/23 and the DON and ADON were present. Employee P (RN) stated she has had no specific training regarding how to handle resident sexual behaviors. An additional interview was conducted with the Regional Administrator on 4/19/23 at 9:55 AM. She stated none of the allegations had been reported to the abuse hotline prior to the state survey. An interview was conducted with the Social Services Director (SSD) on 4/19/23 at 2:15 PM. He stated he was made aware of Resident #2 attempting to go into Resident #8's room in February 2023. He believes the facility investigated the incident. He stated he interviewed the unit manager and Resident #8. Further interview was conducted with the SSD on 4/19/23 at 2:36 PM when he provided documented interviews regarding the incident between Resident #1 and #2 on 2/16/23 and Resident #2 and #8 on 2/20/23. He stated he did not interview the CNA that observed Resident #1 and #2 on 2/16/23. He stated he did not realize a full investigation was necessary. Regarding the incident on 2/20/23, he stated he did not review the progress notes in the record. He stated he reported his findings to the current Administrator. An interview was conducted with the DON on 4/19/23 at 2:26 PM. She stated there was a good possibility she had been notified of some of the allegations regarding Resident #2 during a meeting. An additional interview was conducted with the DON on 4/20/23 at 9:35 AM. She stated she did not feel the incidents on 2/16/23 and 2/20/23 were thoroughly investigated. She stated she did not believe a thorough review of the incident on 4/14/23 occurred. An interview was conducted with the Administrator on 4/20/23 at 9:35 AM. She stated the staff are expected to report allegations of abuse, neglect, and exploitation to the supervisor, Administrator, or DON. The facility reports the allegations of abuse to the regional staff, state agency, and Department of Children and Families. She stated SSD did complete some investigation. The Administrator was asked if she felt the investigations were thorough, she stated she could not answer the question. She stated it was hard to investigate when you do not know what is going on and in her absence the DON would be in charge of the facility. On 4/19/2023, the facility submitted a removal plan for F607 with immediate corrective actions to further prevent residents from further sexual abuse. The facility's removal plan included: 1. Resident #2 placed on one-on-one supervision 4/19/2023. 2. All current residents in the facility audited for concerns of abuse in the resident records completed 4/19/2023. Any identified instances were investigated with no new concerns noted. 3. Administrator and Director of Nursing (DON) and department heads educated by Director of Clinical Services on facility policy and procedures of sexual abuse, investigations, and reporting into allegations of abuse with consultation with Regional Administrator on 4/19/2023. 4. Residents #8, #9, #10 to be evaluated 4/20/2023 and followed by psych APRN to provide psychosocial support from exposure to sexual abuse. 5. 100% of interviewable residents were interviewed for concerns with care or abuse 4/19/2023. 6. In-services and competencies completed on abuse policy and procedure, inservices completed on the following dates: a. 4/19/2023 - 90% of all staff complete. b. 4/20/2023 - 100% of all staff complete. c. No staff members were permitted to work until all topic education and post in-service competency test for abuse policy and procedure, investigation and report was completed. 7. Upon hire and annually, all staff will complete abuse in servicing by staff developer or designee. 8. Immediate federal reporting for abuse completed for resident #2 on 4/17/2023 for 4/14/2023. 9. Immediate federal reporting for abuse completed for resident #2 on 4/18/2023 for 2/16/2023 and 2/20/2023. 10. DON or designee to audit progress notes and EMAR notes for any note with areas of concern to be investigated starting 4/20/2023. 11. The immediate jeopardy was removed on 4/20/23 as evidenced by resident #2 was placed on one-on-one supervision, Adult Protective Services state abuse agency notification 4/17/2023 and 4/18/2023, federal immediate reporting completed for all occurrences dates, staff education completed for all areas, system developed and implemented for auditing the residents' records daily to be aware of concerns not reported. 12. This issue was taken to Quality Assurance Performance Improvement at an ad-hoc meeting on 4/18/2023 with Medical Director, Administrator, Director of Nursing, Social Services Director, MDS Director, and Unit Managers for both Units to discuss the concerns with sexual abuse, investigations, reporting and adequate follow up with PIP with new system to audit and review notes daily for immediate response in any allegations or concerns. Abuse Policy reviewed for meeting requirements of regulation. No changes indicated. On 4/20/23 at approximately 3:15PM, Immediate Jeopardy deficiencies was reduced from a K level to an E, pattern no actual harm with potential for no more than minimal harm level. As evidenced by the following: On 4/20/23 at 11:04PM, Resident #2 was observed to in bed while his 1:1 supervision staff was seated at the resident's open bedroom door. This started on 4/19/23 according to documentation reviewed. Evidence of the resident record audits was provided to surveyors and dated 4/20/23. Upon review all residents were audited and no additional concerns were identified. Staff education in-services for the Administrator, DON, and other Department Heads, related to sexual abuse reporting, sexual abuse, investigative processes, and investigations was reviewed. Training dated for 4/19/23. The facility provided a sign-in sheet with 18 staff signatures. Interviews with Administrator, DON, and at least 3 other Department Heads validating reeducation. One Hundred percent of staff received staff education on abuse policy and procedures, inservices verified to have been completed on 4/19-4/20/23. Staff interviews conducted with at least 10 staff(non-administrative) from various shifts and departments which indicated training was received. Staff were able to verbally recite abuse policies and procedures they recently received in re-education related to abuse. Review of staff files for verification of abuse training upon hire. Education provided included but not limited to an explanation of abuse, signs and symptoms of abuse, and reporting. 3 recently hired staff records reviewed verifying training had been completed. Review of records for Residents #8, #9, and #10 revealed orders dated 4/20/23 for Psych eval and treat for psychosocial support status post resident interaction in her room. Observed Psychiatric Provider seeing Resident #10 on 4/20/23 at approximately 11:47AM. The Facility developed and conducted a Questionnaire for interviewable residents on 4/18-4/19/23. Interviewed a total of 6 residents and all confirmed that facility staff had interviewed them about abuse and staff concerns. No additional concerns identified. Review of the facility's federal reporting for abuse was completed for resident #2 for all incidents that were discovered. Documentation provided confirm all three incidents had been reported to the abuse hotline. Review of audits completed of progress notes and EMAR (Electronic Medication Administration Records). No additional concerns noted. Review of Meeting Notes and Interview with the Administrator verified adhoc QAPI meeting on 4/18/223 to discuss supervision for Resident #2 and concerns with sexual abuse, investigations, reporting and an update to the facility's action plan started on 4/17/23.

Based on observation, record reviews, staff interviews, resident interviews, and facility policy review, the facility failed to report immediately all allegations of abuse to the State Survey Agency and adult protective services in accordance with facility policy, involving 4 of 4 sampled residents. (Resident #1, #2, #8, and #9). Failure to report allegations of abuse to the appropriate authorities placed residents at risk for further abuse. The situation resulted in a finding of Immediate Jeopardy. The facility's Regional Administrator was notified of the findings of Immediate Jeopardy on 4/19/23 at approximately 1:30 PM. The Administrator was unavailable and did not return until 4/20/23. Immediate Jeopardy was removed on 4/20/23 at approximately 3:15 PM, when the facility provided evidence of immediate corrective actions which included placing Resident #2 on one to one constant staff supervision, immediate training of staff on abuse policies, auditing of resident records for abuse concerns, interviewing residents for abuse concerns, immediate federal reports were filed with the state agency, and the facility developed a new system to audit and review notes daily for immediate response to any allegations or concerns. Cross reference F600, F607, F610, F835, and F867. The findings include: Resident #2 had a history of behaviors that included but not limited to frequently masturbating, throwing himself on the floor, kicking staff, and refusing medications. There were multiple documented incidents in Resident #2's medical record that revealed incidents of the resident displaying sexually inappropriate and/or physical behaviors toward staff and residents dating back to 11/30/20 (date of behavior problems initiated on resident's care plan). According to record reviews, staff interviews, and resident interviews, Resident # 2 was observed with his penis out and erected while Resident #1 was sitting on Resident #2's bed with an erection on 2/16/23. The quarterly minimum data set, with an assessment reference date of 1/13/23, revealed resident #1 had a BIMS (Brief Interview of Mental Status) of 8, which indicated resident #1 to have moderately impaired Cognition (A person's decisions are consistently poor or unsafe; the person requires reminders, cues, or supervision at all times to plan, organize, and conduct daily routines). On 4/19/23 at 10:28 AM, Resident #8 reported that on 2/20/23, Resident #2 entered her room and would not leave. Resident #8 stated that in her attempt to guide the resident from her room by grabbing his arm and walking toward the door, Resident #2 swung his arm at her throat. Resident #8 reports that staff had to come into her room to assist in removing resident #2 from her room. Resident #8 reports she felt threatened by resident #2 and did not always feel safe in the facility. Staff interviews and record reviewed collaborated these allegations. On 4/14/23, staff documented in resident #2's chart that [Resident #2] wandered into another resident's room thinking it was his bedroom, he took his shirt and pants off and left brief intact, then climbed into bed, he was redirected to his room and clothing replaced, physician contacted for agitation and new order received for one time dose of Seroquel 50 mg. Interview with Resident #9 and her roommate (#10) collaborated the documented incident on 4/14/23. An interview was conducted on 04/17/2023 at approximately 12:00 PM with Resident #9. Resident #9 stated, About four or five days ago, a man came into my room, took his clothes off and got into bed with me. I was in my bed, and he got into bed with me. That poor guy didn't have a chance. I started beating his back and telling him to get out. I'm not sure where he touched me at because I was hitting him so much. The staff finally came and got him out of my bed. It took a bunch of them to get him out of here. On 4/17/23 at approximately 12:15PM, Resident #10 reported to this surveyor, We have some people who wander around and come into our room. But they have dementia. This was a completely different situation. It was very scary. He (referring to Resident #2) had his hands on her. I don't know what part of her body exactly. But I did see him touching her. I went to the door and screamed so loudly. I have a pretty big mouth. I was screaming for help. He was going to do something to her. It took a few of them to get him out of here. (Resident #10's account of the incident in which Resident #2 got into the bed with Resident #9) The medical record revealed no documentation in Resident #9's chart regarding the incident with Resident #2 entering her room and getting into bed with her. However, staff interviews during the survey collaborated Resident #9's allegations toward Resident #2. An interview was conducted with Employee P (Registered Nurse (RN)) on 4/19/23 at 11:01 AM. She stated the incident involving Resident #2 going into Resident #8's room was discussed in the morning meeting the Tuesday following the 2/20/23 incident (2/21/23). The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were present in the meeting. Resident #2 was subsequently moved to the other side of the facility. The incident on 4/14/23 regarding Resident #2 getting in bed with Resident #9 was discussed in the morning meeting on 4/17/23 and the DON and ADON were present. Employee P (RN) stated she has had no specific training regarding how to handle resident sexual behaviors. An interview was conducted with Employee Q (unit manager) on 4/19/23 at 11:29 AM. Employee Q stated she was notified of the incident between Resident #2 and #9 the following day on 2/21/23. The staff notified her Resident #2 had entered Resident #8's room. Resident #8 then pushed Resident #2 out of the room and Resident #2 swung his hands in the air at Resident #8 but did not make physical contact. Employee Q stated she reported the incident to administration during the stand down meeting. She was not aware of any specific training regarding resident sexual behaviors. An interview was conducted with the Regional Administrator on 4/18/23 at 12:48 PM. She stated she was the Administrator of record for the facility from 1/10/23 through 2/14/23 and she then oriented the new Administrator through 2/16/23. She had no knowledge of Resident #1 being found on his roommate's bed with his penis aroused. She stated she would expect staff to report this to Administration. An interview was conducted with the Administrator on 4/18/23 at 3:48 PM. She stated she had no knowledge of the incident between Resident #1 and #2 and she was not aware of the incident on 2/20/23 when Resident #2 allegedly pushed a female resident. She stated the staff would be expected to report those allegations to the Administrator and DON, complete a full investigation, and follow the facility policy and procedure for abuse. An additional interview was conducted with the Regional Administrator on 4/19/23 at 9:55 AM. She stated none of the allegations had been reported to the abuse hotline prior to the state survey. An interview was conducted with the Social Services Director (SSD) on 4/19/23 at 2:15 PM. He stated he was made aware of Resident #2 attempting to go into Resident #8's room in February 2023. He believes the facility investigated the incident. He stated he interviewed the unit manager and Resident #8. Further interview was conducted with the SSD on 4/19/23 at 2:36 PM when he provided documented interviews regarding the incident between Resident #1 and #2 on 2/16/23 and Resident #2 and #8 on 2/20/23. He stated he did not interview the CNA that observed Resident #1 and #2 on 2/16/23. He stated he did not realize a full investigation was necessary. Regarding the incident on 2/20/23, he stated he did not review the progress notes in the record. He stated he reported his findings to the current Administrator. An interview was conducted with the DON on 4/19/23 at 2:26 PM. She stated there was a good possibility she had been notified of some of the allegations regarding Resident #2 during a meeting. An interview was conducted with the Administrator on 4/20/23 at 9:35 AM. She stated the staff are expected to report allegations of abuse, neglect, and exploitation to the supervisor, Administrator, or DON. The facility reports the allegations of abuse to the regional staff, state agency, and Department of Children and Families. She stated SSD did complete some investigation. The Administrator was asked if she felt the investigations were thorough, she stated she could not answer the question. She stated it was hard to investigate when you do not know what is going on and in her absence the DON would be in charge of the facility. Despite the facility staff and management having knowledge of the reported allegations of abuse by Resident #2 toward resident #1, #8, and #9, there was no evidence that either of the above-mentioned incidents were reported to the State Survey Agency nor adult protective services. Review of the facility policy for Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property (dated 8/22/22) revealed, It is the policy of this Center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation, and misappropriation of property. In addition, each resident will be protected from those practices and omissions, which if left unchecked, could lead to abuse. Further, each resident will be treated with respect and dignity at all times. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care. Residents will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, contract staff, family members, friends, or others. Prevention of abuse will be accomplished by the timely reporting of the suspected abuse and a thorough investigation of these instances. Those reporting abuse should not be subjected to any disciplinary action for the correct reporting of abuse or suspected abuse. The Center will post steps on abuse and abuse reporting for staff, residents, and family members in designated areas of the Center. The material will advise the parties on how to report and to whom to report. The Center will ensure that the call will be confidential. Resident Behavior- our residents have the right to be free from resident-to-resident abuse. All altercations, including those that may represent resident to resident abuse shall be investigated and reported in accordance with established reporting procedures. If two residents are involved in an altercation, staff will separate the residents, identify what happened, assess both residents for any clinical, psychological and/or psychosocial changes that may have led to the incident, and notify the attending physician, each resident's respective representative and the appropriate State agency as required by State law. Investigation- all suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee. The findings should be reported to the appropriate governing agencies. Reporting/Documentation Requirements- ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the center and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care Centers) in accordance with State law through established procedures in these timeframes: * If the events that cause the allegation involve abuse or result in serious bodily injury, the event must be reported immediately, but not later than 2 hours after the allegation is made. * If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the event must be reported no later than 24 hours after the allegation is made. A review of the facility's policy titled Reporting Reasonable Suspicion of Crime dated 08/22/2022 revealed it is the center's policy to comply with the Elder Justice Act (EJA) about reporting reasonable suspicion of a crime to the State Survey Agency (SSA) and local law enforcement. Associates must report the suspicion of an incident to the Administrator or Director of Nursing. When an associate suspects a crime has occurred against a resident at the center, they must report the incident to SSA and local law enforcement. If the reportable event does not result in serious bodily injury, the associate shall report the suspicion not later than 24 hours after forming the suspicion. On 4/19/2023, the facility submitted a removal plan for F600 with immediate corrective actions to further prevent residents from further sexual abuse. The facility's removal plan included:1. All current residents in the facility audited for concerns of abuse in the resident records completed 4/19/2023. No additional concerns which required abuse reporting found. 2. Administrator and Director of Nursing (DON) and department heads educated by Director of Clinical Services on facility policy and procedures of sexual abuse, investigations, and reporting into allegations of abuse with consultation with Regional Administrator on 4/19/2023. 3. In-services and competencies completed on abuse policy and procedure, including when and how to report, mandatory reporters, and Elder Justice Act, inservices completed on the following dates: a. 4/19/2023 - 90% of all staff complete. b. 4/20/2023 - 100% of all staff complete. c. No staff members were permitted to work until all topic education and post in-service competency test for abuse policy and procedure, investigation and report was completed. 4. Responsible parties were previously notified of concerns. 5. Upon hire and annually, all staff will complete abuse training including when and how to report, mandatory reporters, and the Elder Justice Act by staff developer or designee. 6. Immediate federal reporting for abuse completed for resident #2 on 4/17/2023 for 4/14/2023. 7. Immediate federal reporting for abuse completed for resident #2 on 4/18/2023 for 2/16/2023 and 2/20/2023. 8. DON or designee to audit progress notes and EMAR notes for any note with areas of concern to be investigated starting 4/20/2023. 9. The immediate jeopardy was removed on 4/20/23 as evidenced by resident #2 was placed on one-on-one supervision, Adult Protective Services state abuse agency notification 4/17/2023 and 4/18/2023, federal immediate reporting completed for all occurrences dates, staff education completed for all areas, system developed and implemented for auditing the residents' records daily to be aware of concerns not reported. 13. This issue was taken to Quality Assurance Performance Improvement at an ad-hoc meeting on 4/18/2023 with Medical Director, Administrator, Director of Nursing, Social Services Director, MDS Director, and Unit Managers for both Units to discuss the concerns with sexual abuse, investigations, reporting requirements and adequate follow up with PIP with new system to audit and review notes daily for immediate response in any allegations or concerns. Abuse Policy reviewed for meeting requirements of regulation. No changes indicated. 14. Administrator and Director of Nursing have submitted for access to federal reporting system access. Regional Administrator has current access to assist until access granted. On 4/20/23 at approximately 3:15PM, Immediate Jeopardy deficiencies was reduced from a K level to an E, pattern no actual harm with potential for no more than minimal harm level. As evidenced by the following: On 4/20/23 at 11:04PM, Resident #2 was observed to in bed while his 1:1 supervision staff was seated at the resident's open bedroom door. This started on 4/19/23 according to documentation reviewed. Evidence of the resident record audits was provided to surveyors and dated 4/20/23. Responsible parties were notified. Upon review all residents were audited and no additional concerns were identified. Staff education in-services for the Administrator, DON, and other Department Heads, related to sexual abuse reporting, sexual abuse, investigative processes, and investigations was reviewed. Training dated for 4/19/23. The facility provided a sign-in sheet with 18 staff signatures. Interviews with Administrator, DON, and at least 3 other Department Heads validating reeducation. One Hundred percent of staff received staff education on abuse policy and procedures, inservices verified to have been completed on 4/19-4/20/23. Staff interviews conducted with at least 10 staff(non-administrative) from various shifts and departments which indicated training was received. Staff were able to verbally recite abuse policies and procedures they recently received in re-education related to abuse. Review of staff files for verification of abuse training upon hire. Education provided included but not limited to an explanation of abuse, signs and symptoms of abuse, and reporting. 3 recently hired staff records reviewed verifying training had been completed. Review of records for Residents #8, #9, and #10 revealed orders dated 4/20/23 for Psych eval and treat for psychosocial support status post resident interaction in her room. Observed Psychiatric Provider seeing Resident #10 on 4/20/23 at approximately 11:47AM. The Facility developed and conducted a Questionnaire for interviewable residents on 4/18-4/19/23. Interviewed a total of 6 residents and all confirmed that facility staff had interviewed them about abuse and staff concerns. No additional concerns identified. Review of the facility's federal reporting for abuse was completed for resident #2 for all incidents that were discovered. Documentation provided confirm all three incidents had been reported to the abuse hotline. Evidence of additional designees being granted access to the federal reporting system. Review of audits completed of progress notes and EMAR (Electronic Medication Administration Records). No additional concerns noted. Review of Meeting Notes and Interview with the Administrator verified adhoc QAPI meeting on 4/18/223 to discuss supervision for Resident #2 and concerns with sexual abuse, investigations, reporting and an update to the facility's action plan started on 4/17/23.

Based on observation, record reviews, staff interviews, resident interviews, and facility policy review, the facility failed to thoroughly investigate and report the results of investigations of all sexual and physical abuse allegations to the state survey agency within 5 working days of the alleged violations involving 4 of 4 sampled residents (Resident #1, #2, #8, and #9). The failure to thoroughly investigate, report allegations of abuse to the authorities, and implement effective interventions placed residents in the facility at risk for physical and/or sexual abuse. The situation resulted in a finding of Immediate Jeopardy. The facility's Regional Administrator was notified of the findings of Immediate Jeopardy on 4/19/23 at approximately 1:30 PM. The Administrator was unavailable and did not return until 4/20/23. Immediate Jeopardy was removed on 4/20/23 at approximately 3:15 PM when the facility provided evidence of immediate corrective actions which included placing resident number 2 on one to one constant staff supervision, immediate training of staff on abuse policies, resident records were audited for abuse concerns, residents were interviewed for abuse concerns, immediate federal reports were filed with the state agency, and the facility developed a new system to audit and review notes daily for immediate response to any allegations or concerns. The scope and severity of the Immediate Jeopardy deficiencies was reduced from a K level to a E level. Cross reference F600, F607, F609, F835, and F867. The findings include: Incident #1 (between Resident #1 and Resident #2 on 2/16/23) According to record reviews and staff interviews for Resident #2, this resident was observed with his penis out and erected while Resident #1 was sitting on Resident #2's bed with an erection on 2/16/23. The quarterly minimum data set, with an assessment reference date of 1/13/23, revealed resident #1 had a BIMS (Brief Interview of Mental Status) of 8, which indicated resident #1 to have moderately impaired Cognition (A person's decisions are consistently poor or unsafe; the person requires reminders, cues, or supervision at all times to plan, organize, and conduct daily routines). An interview was conducted with Employee K (CNA) on 4/18/23 at 8:54 AM. She stated about 3 months ago she observed Resident #2 pulling on his penis and Resident #1 sitting on the foot of Resident #2's bed at the time. She reported the incident to Employee G (LPN) and had Resident #1 return to his side of the room. A telephone interview was conducted with Employee E (CNA) on 4/18/23 at 12:25 PM. Employee E stated she found Resident #1 sitting on Resident #2's bed with his penis aroused. It looked like Resident #1 had gone to the bathroom and took his brief off, but he had on shorts. She did not recall if Resident #1's shorts were pulled down. She stated she did not recall which nurse she informed. Incident #2 (between Resident #2 and Resident #8 on 2/20/23) An interview was conducted with Resident #8 on 4/19/23 at 10:28 AM. Resident #8 stated that Resident #2 came into her room toward the end of February in the afternoon. She asked him to get out of her room. She then grabbed his arm to try to get him to leave her room and he threw his arm at her throat. She stated she felt threatened by Resident #2 and did not always feel safe in the facility. Resident #8 revealed staff were aware because they came into her room and assisted removing Resident #2 from her room. An interview was conducted with Employee P (Registered Nurse (RN)) on 4/19/23 at 11:01 AM. She stated the incident involving Resident #2 going into Resident #8's room was discussed in the morning meeting the Tuesday following the 2/20/23 incident (2/21/23). The DON and Assistant Director of Nursing (ADON) were present in the meeting. Resident #2 was subsequently moved to the other side of the facility. An interview was conducted with Employee Q (unit manager) on 4/19/23 at 11:29 AM. Employee Q stated she was notified of the incident between Resident #2 and #8 the following day on 2/21/23. The staff notified her Resident #2 had entered Resident #8's room. Resident #8 then pushed Resident #2 out of the room and Resident #2 swung his hands in the air at Resident #8 but did not make physical contact. Employee Q stated she reported the incident to administration during the stand down meeting. She was not aware of any specific training regarding resident sexual behaviors. Incident #3 (between Resident #2 and Resident #9 on 4/14/23) An interview was conducted on 04/17/2023 at approximately 12:00 PM with Resident #9. Resident #9 stated, About four or five days ago, a man came into my room, took his clothes off and got into bed with me. I was in my bed, and he got into bed with me. That poor guy didn't have a chance. I started beating his back and telling him to get out. I'm not sure where he touched me at because I was hitting him so much. The staff finally came and got him out of my bed. It took a bunch of them to get him out of here. The record revealed no documentation in Resident #9's chart regarding the incident with Resident #2 entering her room and getting into bed with her. An interview was conducted on 04/17/2023 at approximately 12:15 PM with Resident # 10. Resident #10 stated, We have some people who wander around and come into our room. But they have dementia. This was a completely different situation. It was very scary. He had his hands on her. I don't know what part of her body exactly. But I did see him touching her. I went to the door and screamed so loudly. I have a pretty big mouth. I was screaming for help. He was going to do something to her. It took a few of them to get him out of here. (Resident #10's account of the incident in which Resident #2 got into the bed with Resident #9) An interview was conducted with the Administrator on 4/18/23 at 3:48 PM. She stated she had no knowledge of the incident between Resident #1 and #2 and she was not aware of the incident on 2/20/23 when Resident #2 allegedly pushed a female resident. She stated the staff would be expected to report those allegations to the Administrator and DON, complete a full investigation, and follow the facility policy and procedure for abuse. An interview was conducted with the ADON on 4/19/23 at 2:04 PM. She stated she recalled hearing in a morning meeting about the incident involving Resident #1 and #2. She heard one of the residents was on the other resident's bed and the other resident had his own penis in his own hand. She was not aware of any investigation into the incident. She stated Resident #2 was then moved to a different room. She stated the incident was not discussed in a Quality Assurance meeting. An interview was conducted with the Social Services Director (SSD) on 4/19/23 at 2:15 PM. He stated he was made aware of Resident #2 attempting to go into Resident #8's room in February 2023. He believes the facility investigated the incident. He stated he interviewed the unit manager and Resident #8. Further interview was conducted with the SSD on 4/19/23 at 2:36 PM when he provided documented interviews regarding the incident between Resident #1 and #2 on 2/16/23 and Resident #2 and #8 on 2/20/23. He stated he did not interview the CNA that observed Resident #1 and #2 on 2/16/23. He stated he did not realize a full investigation was necessary. Regarding the incident on 2/20/23, he stated he did not review the progress notes in the record. He stated he reported his findings to the current Administrator. An additional interview was conducted with the DON on 4/20/23 at 9:35 AM. She stated she did not feel the incidents on 2/16/23 and 2/20/23 were thoroughly investigated. She stated she did not believe a thorough review of the incident on 4/14/23 occurred. An interview was conducted with the Administrator on 4/20/23 at 9:35 AM. She stated the staff are expected to report allegations of abuse, neglect, and exploitation to the supervisor, Administrator, or DON. The facility reports the allegations of abuse to the regional staff, state agency, and Department of Children and Families. She stated SSD did complete some investigation. The Administrator was asked if she felt the investigations were thorough, she stated she could not answer the question. She stated it was hard to investigate when you do not know what is going on and in her absence the DON would be in charge of the facility. Review of the facility policy for Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property (dated 8/22/22) revealed, It is the policy of this Center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation, and misappropriation of property. In addition, each resident will be protected from those practices and omissions, which if left unchecked, could lead to abuse. Further, each resident will be treated with respect and dignity at all times. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care. Residents will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, contract staff, family members, friends, or others. Prevention of abuse will be accomplished by the timely reporting of the suspected abuse and a thorough investigation of these instances. Those reporting abuse should not be subjected to any disciplinary action for the correct reporting of abuse or suspected abuse. The Center will post steps on abuse and abuse reporting for staff, residents, and family members in designated areas of the Center. The material will advise the parties on how to report and to whom to report. The Center will ensure that the call will be confidential. Resident Behavior- our residents have the right to be free from resident-to-resident abuse. All altercations, including those that may represent resident to resident abuse shall be investigated and reported in accordance with established reporting procedures. If two residents are involved in an altercation, staff will separate the residents, identify what happened, assess both residents for any clinical, psychological and/or psychosocial changes that may have led to the incident, and notify the attending physician, each resident's respective representative and the appropriate State agency as required by State law. Investigation- all suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee. The findings should be reported to the appropriate governing agencies. Reporting/Documentation Requirements- ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the center and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care Centers) in accordance with State law through established procedures in these timeframes: * If the events that cause the allegation involve abuse or result in serious bodily injury, the event must be reported immediately, but not later than 2 hours after the allegation is made. * If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the event must be reported no later than 24 hours after the allegation is made. On 4/19/2023, the facility submitted a removal plan for F600 with immediate corrective actions to further prevent residents from further sexual abuse. The facility's removal plan included: 1. All current residents in the facility audited for concerns of abuse in the resident records completed 4/19/2023 no further investigations required. 2. Administrator and Director of Nursing (DON) and department heads educated by Director of Clinical Services on facility policy and procedures of sexual abuse, investigations with focus on the interviewing staff involved any resident witnesses, assessing the scene, record review, mitigating factors and root cause analysis, and reporting into allegations of abuse with consultation with Regional Administrator on 4/19/2023. 3. 100% of interviewable residents were interviewed for concerns with care or abuse 4/19/2023. No further investigations required. 4. Investigation for abuse completed for resident #2 on 4/17/2023 for 4/14/2023. 5. Investigation for abuse completed for resident #2 on 4/18/2023 for 2/16/2023 and 2/20/2023. 6. In-services and competencies completed on abuse policy and procedure with investigations with focus on the charge nurses interviewing staff involved, any resident witnesses, assessing the scene, documentation of findings to give to the Administrator and DON, inservices completed on the following dates: a. 4/19/2023 - 90% of all staff complete. b. 4/20/2023 - 100% of all staff complete. c. No staff members were permitted to work until all topic education and post in-service competency test for abuse policy and procedure, investigation and report was completed. 7. DON or designee to audit progress notes and EMAR notes for any note with areas of concern to be investigated starting 4/20/2023. 8. The immediate jeopardy was removed on 4/20/23 as evidenced by resident #2 was placed on one-on-one supervision, Adult Protective Services state abuse agency notification 4/17/2023 and 4/18/2023, federal immediate reporting completed for all occurrences dates with full investigations, staff education completed for all areas, system developed and implemented for auditing the residents' records daily to be aware of concerns not reported. 9. This issue was taken to Quality Assurance Performance Improvement at an ad-hoc meeting on 4/18/2023 with Medical Director, Administrator, Director of Nursing, Social Services Director, MDS Director, and Unit Managers for both Units to discuss the concerns with sexual abuse, investigations, reporting and adequate follow up with PIP with new system to audit and review notes daily for immediate response in any allegations or concerns. Risk Policy reviewed for meeting requirements of regulation. No changes indicated. Investigation process review with focus on the interviewing staff involved any resident witnesses, assessing the scene, record review, mitigating factors and root cause analysis. On 4/20/23 at approximately 3:15PM, Immediate Jeopardy deficiencies was reduced from a K level to an E, pattern no actual harm with potential for no more than minimal harm level. As evidenced by the following: On 4/20/23 at 11:04PM, Resident #2 was observed to in bed while his 1:1 supervision staff was seated at the resident's open bedroom door. This started on 4/19/23 according to documentation reviewed. Evidence of the resident record audits was provided to surveyors and dated 4/20/23. Responsible parties were notified. Upon review all residents were audited and no additional concerns were identified. Staff education in-services for the Administrator, DON, and other Department Heads, related to sexual abuse reporting, sexual abuse, investigative processes, and investigations was reviewed. Training dated for 4/19/23. The facility provided a sign-in sheet with 18 staff signatures. Interviews with Administrator, DON, and at least 3 other Department Heads validating reeducation. One Hundred percent of staff received staff education on abuse policy and procedures, inservices verified to have been completed on 4/19-4/20/23. Staff interviews conducted with at least 10 staff(non-administrative) from various shifts and departments which indicated training was received. Staff were able to verbally recite abuse policies and procedures they recently received in re-education related to abuse. Review of staff files for verification of abuse training upon hire. Education provided included but not limited to an explanation of abuse, signs and symptoms of abuse, and reporting. 3 recently hired staff records reviewed verifying training had been completed. Review of records for Residents #8, #9, and #10 revealed orders dated 4/20/23 for Psych eval and treat for psychosocial support status post resident interaction in her room. Observed Psychiatric Provider seeing Resident #10 on 4/20/23 at approximately 11:47AM. The Facility developed and conducted a Questionnaire for interviewable residents on 4/18-4/19/23. Interviewed a total of 6 residents and all confirmed that facility staff had interviewed them about abuse and staff concerns. No additional concerns identified. Review of the facility's federal reporting for abuse was completed for resident #2 for all incidents that were discovered. Documentation provided verified all three incidents had been reported to the abuse hotline. Evidence of additional designees being granted access to the federal reporting system. Review of audits completed of progress notes and EMAR (Electronic Medication Administration Records). No additional concerns noted. Review of Meeting Notes and Interview with the Administrator verified adhoc QAPI meeting on 4/18/223 to discuss supervision for Resident #2 and concerns with sexual abuse, investigations, reporting and an update to the facility's action plan started on 4/17/23.

Based on observations, record review, staff interviews, Administrator job description review, and policy review, the facility failed to utilize its resources effectively, provide adequate training, report findings to state and federal agencies as required by law and implement facility policies to ensure residents within the facility are properly assessed and treated when exhibiting signs and symptoms of sexual tendencies. The facility further failed to ensure other residents in the facility were free from any form of physical or sexual abuse from Resident #2 and to ensure that staff are aware of the resident's behaviors and followed facility policy for reporting. This has the potential to affect all residents in the facility who encounter the resident. The situation resulted in a finding of Immediate Jeopardy. The facility's Regional Administrator was notified of the findings of Immediate Jeopardy on 4/19/23 at approximately 1:30 PM. The Administrator was unavailable and did not return until 4/20/23. Immediate Jeopardy was removed on 4/20/23 at approximately 3:15 PM when the facility provided evidence of immediate corrective actions which included placing resident #2 on one to one constant staff supervision, immediate training of staff on abuse policies, resident records were audited for abuse concerns, residents were interviewed for abuse concerns, immediate federal reports were filed, and the facility developed a new system to audit and review notes daily for immediate response in any allegations or concerns. The scope and severity of the Immediate Jeopardy deficiencies was reduced from a K level to a E level. Cross reference F607, F609, F610, F835, and F867. The findings include: According to record reviews, staff interviews, and resident interviews during the survey conducted on 4/17/23 through 4/20/23, it was revealed that Resident #2 had inappropriate sexual incidents with at least 3 residents within the facility. Resident #2 was observed by staff to be sitting on his roommate's bed (#1) with his penis out and erected while Resident #1 was sitting on Resident #2's bed with an erection on 2/16/23. Resident #8 reported that on 2/20/23, Resident #2 came into her room toward the end of February in the afternoon. She asked him to get out of her room. She then grabbed his arm to try to get him to leave her room and he threw his arm at her throat. She stated she felt threatened by Resident #2 and did not always feel safe in the facility. Resident #8 revealed staff were aware because they came into her room and assisted removing Resident #2 from her room. Resident #9 reported that approximately 4/14/23, a man(#2) came into her room took clothes off and got into bed with me. I was in bed, and he got into bed with me. Staff failed to immediately report the allegations to facility administration. The allegations of physical and sexual abuse were not reported to the State Survey Agency or abuse hotline, thoroughly investigated, nor were additional effective interventions implemented to protect vulnerable residents. An interview was conducted with the Regional Administrator on 4/18/23 at 12:48 PM. She stated she was the Administrator of record for the facility from 1/10/23 through 2/14/23 and she then oriented the new Administrator through 2/16/23. She had no knowledge of resident #1 being found on his roommate's bed with his penis aroused. She stated she would expect staff to report this to Administration. An interview was conducted with the Administrator on 4/18/23 at 3:48 PM. She stated she had no knowledge of the incident between resident # 1 and 2 and she was not aware of the incident on 2/20/23 when resident # 2 allegedly pushed a female resident. The staff would be expected to report those allegations to the Administrator and DON, complete a full investigation, and follow the facility policy and procedure for abuse. An interview was conducted with the ADON on 4/19/23 at 2:04 PM. She stated she recalled hearing in a morning meeting about the incident involving resident #s 1 and 2. She heard one of the residents was on the other resident's bed and the other resident had his own penis in his own hand. She was not aware of any investigation into the incident. Resident # 2 was then moved to a different room. The incident was not discussed in a Quality Assurance meeting. An interview was conducted with the Social Services Director (SSD) on 4/19/23 at 2:15 PM. He stated he was made aware of resident # 2 attempting to go into resident # 8's room in February 2023. He believes the facility investigated the incident. He interviewed the unit manager and resident # 8. Further interview was conducted with the SSD on 4/19/23 at 2:36 PM when he provided documented interviews with employee D regarding the incident between resident # 1 and 2 on 2/16/23 and resident # 2 and 8 on 2/20/23. He stated he did not interview the CNA that observed resident #s 1 and #2 on 2/16/23. It did not hit him that he needed to complete a full investigation because the nurse did not state the resident's penis was out. He stated he was in crisis management in the facility meaning he has residents that are always coming to the office, and he was putting out fires. Regarding the incident on 2/20/23 he stated he did not review the progress notes in the record. He reported his findings to the current Administrator. An interview was conducted with the DON on 4/19/23 at 2:26 PM. She stated there was a good possibility she had been notified of some of the allegations regarding resident # 2 during a meeting. An additional interview was conducted with the DON on 4/20/23 at 9:35 AM. She stated she did not feel the incidents on 2/16/23 and 2/20/23 were thoroughly investigated. She would come in on Monday and go over anything that happened over the weekend to review the incident on 4/14/23 and that did not occur. An interview was conducted with the Administrator on 4/20/23 at 9:35 AM. She stated the staff are expected to report allegations of abuse, neglect, and exploitation to the supervisor, Administrator, or DON. The facility reports the allegations of abuse to the regional staff, state agency, and Department of Children and Families. SSD did complete some investigation. The Administrator was asked if she felt the investigations were thorough, she stated she could not answer the question. She stated it was hard to investigate when you do not know what is going on and in her absence the DON would be in charge of the facility. 46833 An interview was conducted by this writer on 04/17/2023 at approximately 2:00 PM with the DON. The DON stated she had not had any abuse allegations reported to her regarding Resident #2 or #9. The DON stated she did get a message regarding Resident #2 going into Resident # 9's room on Friday, 04/14/2023. The DON stated, We did call the Administrator and our Corporate team to report it to them. The DON stated, We haven't had any other reports of similar situations with Resident # 2. He was moved from one side of the building to the other because of arguments of snoring. So, we moved him. The DON stated the facility corporate team consisted of the [NAME] President of Clinical Operations, Clinical Regional Administrator, and [NAME] President of Operations Another interview was conducted on 04/18/2023 at approximately 12:45 PM with the DON. The DON stated, If I know of an issue with any type of abuse, I will report it to my corporate team and start an investigation. I did not start an investigation this past Friday because I didn't think it was really anything. But I would start my investigation within an hour or two of finding out and then report it. An interview was conducted on 04/19/2023 at approximately 10:45 AM with the Administrator. The Administrator stated, I am not aware of any instances of abuse being reported to me. I was in orientation that first week (started at facility on 02/14/2023). I was not in all the morning meetings. The first four days were me acclimating to the facility and being orientated. I do know that both residents (Resident's 1 and 2) have had behaviors since I have been there. I don't remember the behaviors that were being talked about. But I do know they have had some behaviors. An interview was conducted on 04/20/2023 at approximately 10:00 AM with the DON. The DON stated she does call the Administrator with any problems. The DON stated if the Administrator is not available, she would call her corporate team for director and provide them with the situation needing guidance. The DON stated she has educated the staff regularly to place an incident report if something happens. The DON stated she does not currently have access to the reporting system for mandated state reporting problems. The DON reported the Administrator did not have access to the system either. The DON stated any reports of abuse goes to the Regional Administrator or to the [NAME] President of Clinical Operations. The DON stated the only current leadership member that has access to the state reporting system is the ADON of the facility. The DON stated she began as the Interim DON at the end of February. She stated she accepted the formal position as DON approximately a week after these two incidents happened. The DON stated, I'm just frustrated. We had a corporate nurse every week. She would come in and she was on the phone with us. Corporate did a realignment. They got rid of her. We walk in and we are off just putting out fires every day. We are constantly just trying to play catch up. We're just trying to put the immediate fires out. I'm going to say I don't feel like I've had any formal training. The Administrator has tried to help me. I still talk to the corporate nurse that we had even though she's no longer with them for guidance. We have the corporate Administrator. She has been great. But the corporate Administrator is not a nurse and not sure of the clinical side. The [NAME] President of Clinical Services checks in and all that. But there's so many little things that we're just trying to keep our head above water in the building. I can't always stop and reach out to her. I don't how she can help me from South Carolina. The DON stated she has not had formal training for her position. The DON stated, It's trying to take everything on and figure out what's the most important. And, keeping the people safe. That is my most important. A review of the Administrator job description dated 04/2022 revealed the Administrator is to lead and direct the overall operation of the facility in accordance with resident needs, government regulations, and company policies as to maintain excellent care for the resident s while achieving the facility's business objectives. The job description further states the Administrator will work with the facility management staff and consultants in planning all aspects of facility operations. The administrator will maintain a working knowledge of and ensure compliance with all governmental regulations. The Administrator will supervise, conduct, and participate in departmental and facility education activities and staff meetings. The Administrator will understand, comply with, and promote rules regarding residents' rights. A review of the Director of Nursing (DON) job description (no date) revealed the DON executes the goals and objectives of the nursing department regarding patient/resident rights, patient/resident care and reflects the mission statement of the facility. The DON provides leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. The DON will review all incident and accident reports before submitting to the Administration and the Medical Director Plan and maintain a Master Staffing Plan. The DON will actively participate in committees such as Quality Assurance Performance Improvement (QAPl), Infection Control, Safety, Ethics, Leadership, and others. The DON will investigate reports of resident abuse and report their findings to the Administrator. The DON will participate in mandatory in-service and job training programs. A review of the Assistant Director of Nursing (ADON) job description (no date) revealed the ADON supports the Director of Nursing in executing the goals and objectives of the nursing department in regard to patient/resident rights, patient/resident care and reflects the mission statement of the facility. The ADON provides leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. The ADON will review all incident and accident reports before submitting to the DON. The ADON will actively participate in committees such as Quality Assurance Performance Improvement (QAPl), Infection Control, Safety, Ethics, Leadership, and others. The ADON will investigate reports of resident abuse and report their findings to the Administrator. The ADON will participate in mandatory in-service and job training programs. The ADON is responsible for New Hire Training of required mandatory training; Works directly with Department Heads to assure that department specific requirements are conducted for new hires and ensures that annual mandatory training are conducted for all staff. A review of the Social Worker (SSD)job description (no date) revealed the social worker will work with the residents in the nursing home by identifying their psychosocial, mental, and emotional needs. The nursing home social worker is responsible for fostering a climate, policies, and routines the enable residents to maximize their individuality, independence, and dignity. The social worker will review facility policies and procedures to assure compliance in state and federal regulations. The social worker will participate in QAPI meetings. The social worker will understand and meet the government requirements for social services documentation. The social worker will work with the interdisciplinary team and administration to promote and protect resident rights and the psychological well -being of each resident. Prevent and address resident abuse as mandated by law and professional licensure. Educate staff regarding residents' rights and how to recognize and prevent abuse, neglect, and mistreatment. The social services director must always review any documents given to governmental bodies or third parties with the Administrator prior to submittal to said agencies. On 4/19/2023, the facility submitted a removal plan for F600 with immediate corrective actions to further prevent residents from further sexual abuse. The facility's removal plan included: 1. Administrator and Director of Nursing (DON) and department heads educated by Director of Clinical Services on facility policy and procedures of sexual abuse, investigations, and reporting into allegations of abuse with consultation with Regional Administrator on 4/19/2023. 2. In-services and competencies completed on abuse policy and procedure, inservices completed on the following dates by DON, Unit Managers, Housekeeping Director, Dietary Manager, Admission Director after being Trained by Director of Clinical Services: a. 4/19/2023 - 90% of all staff complete. b. 4/20/2023 - 100% of all staff complete. c. No staff members were permitted to work until all topic education and post in-service competency test for abuse policy and procedure, investigation and report was completed. 3. Immediate federal reporting for abuse completed for resident #2 on 4/17/2023 for 4/14/2023. 4. Immediate federal reporting for abuse completed for resident #2 on 4/18/2023 for 2/16/2023 and 2/20/2023. 5. DON or designee to audit progress notes and EMAR notes for any note with areas of concern to be investigated starting 4/20/2023. 6. The immediate jeopardy was removed on 4/20/23 as evidenced by resident #2 was placed on one-on-one supervision, Adult Protective Services state abuse agency notification 4/17/2023 and 4/18/2023, federal immediate reporting completed for all occurrences dates, staff education completed for all areas, system developed and implemented for auditing the residents' records daily to be aware of concerns not reported. 7. This issue was taken to Quality Assurance Performance Improvement at an ad-hoc meeting on 4/18/2023 with Medical Director, Administrator, Director of Nursing, Social Services Director, MDS Director, and Unit Managers for both Units to discuss the concerns with sexual abuse, investigations, reporting and adequate follow up with PIP with new system to audit and review notes daily for immediate response in any allegations or concerns. Abuse Policy reviewed for meeting requirements of regulation. No changes indicated. Corporate Compliance program reviewed for inclusion of Elder Justice Act reporting, Federal and State abuse reporting requirements, resident safety intervention guidelines and mandatory reporting requirements. No changes required. 8. Administrator and Director of Nursing have submitted for access to federal reporting system access. Regional Administrator has current access to assist until access granted. On 4/20/23 at approximately 3:15PM, Immediate Jeopardy deficiencies was reduced from a K level to an E, pattern no actual harm with potential for no more than minimal harm level. As evidenced by the following: On 4/20/23 at 11:04PM, Resident #2 was observed to in bed while his 1:1 supervision staff was seated at the resident's open bedroom door. This started on 4/19/23 according to documentation reviewed. Evidence of the resident record audits was provided to surveyors and dated 4/20/23. Upon review all residents were audited and no additional concerns were identified. Staff education in-services for the Administrator, DON, and other Department Heads, related to sexual abuse reporting, sexual abuse, investigative processes, and investigations was reviewed. Training dated for 4/19/23. The facility provided a sign-in sheet with 18 staff signatures. Interviews with Administrator, DON, and at least 3 other Department Heads validating reeducation. One Hundred percent of staff received staff education on abuse policy and procedures, inservices verified to have been completed on 4/19-4/20/23. Staff interviews conducted with at least 10 staff(non-administrative) from various shifts and departments which indicated training was received. Staff were able to verbally recite abuse policies and procedures they recently received in re-education related to abuse. Review of staff files for verification of abuse training upon hire. Education provided included but not limited to an explanation of abuse, signs and symptoms of abuse, and reporting. 3 recently hired staff records reviewed verifying training had been completed. Review of records for Residents #8, #9, and #10 revealed orders dated 4/20/23 for Psych eval and treat for psychosocial support status post resident interaction in her room. Observed Psychiatric Provider seeing Resident #10 on 4/20/23 at approximately 11:47AM. The Facility developed and conducted a Questionnaire for interviewable residents on 4/18-4/19/23. Interviewed a total of 6 residents and all confirmed that facility staff had interviewed them about abuse and staff concerns. No additional concerns identified. Review of the facility's federal reporting for abuse was completed for resident #2 for all incidents that were discovered. Documentation provided confirm all three incidents had been reported to the abuse hotline. Review of audits completed of progress notes and EMAR (Electronic Medication Administration Records). No additional concerns noted. Review of Meeting Notes and Interview with the Administrator verified adhoc QAPI meeting on 4/18/223 to discuss supervision for Resident #2 and concerns with sexual abuse, investigations, reporting and an update to the facility's action plan started on 4/17/23.

Based on record review, staff interviews, quality assurance performance improvement plan review, and policy review the facility failed to develop and implement appropriate plans of action to correctly identify quality deficiencies related to the supervision of a resident (Resident #2) who was exhibiting sexual tendencies including wandering into other resident rooms and to report findings to state and federal agencies as required by law. The facility further failed to develop a Performance Improvement Plan to ensure other residents in the facility were free from any form of physical or sexual abuse and that Resident #2 had appropriate interventions in place. The situation resulted in a finding of Immediate Jeopardy. The facility's Regional Administrator was notified of the findings of Immediate Jeopardy on 4/19/23 at approximately 1:30 PM. The Administrator was unavailable and did not return until 4/20/23. Immediate Jeopardy was removed on 4/20/23 at approximately 3:15 PM when the facility provided evidence of immediate corrective actions which included placing resident number 2 on one to one constant staff supervision, immediate training of staff on abuse policies, resident records were audited for abuse concerns, residents were interviewed for abuse concerns, immediate federal reports were filed, and the facility developed a new system to audit and review notes daily for immediate response in any allegations or concerns. The scope and severity of the Immediate Jeopardy deficiencies was reduced from a K level to a E level. Cross reference F607, F609, F610, and F835. The findings include: According to record reviews, staff interviews, and resident interviews during this survey, it was revealed that Resident #2 had inappropriate sexual incidents with at least 3 residents within the facility. Resident #2 was observed by staff to be sitting on his roommate's bed (#1) with his penis out and erected while Resident #1 was sitting on Resident #2's bed with an erection on 2/16/23. Resident #8 reported that on 2/20/23, Resident #2 came into her room toward the end of February in the afternoon. She asked him to get out of her room. She then grabbed his arm to try to get him to leave her room and he threw his arm at her throat. She stated she felt threatened by Resident #2 and did not always feel safe in the facility. Resident #8 revealed staff were aware because they came into her room and assisted removing Resident #2 from her room. Resident #9 reported that approximately 4/14/23, a man(#2) came into her room took clothes off and got into bed with me. I was in bed, and he got into bed with me. Reference F600, F607, F609, and F610. An interview was conducted on 04/20/2023 at approximately 10:10 AM with the Administrator. The Administrator stated a Quality Assurance Performance Improvement (QAPI) was done in February 2023 and in March 2023. The Administrator stated she did not have any previous notes regarding Resident #2 and any type of behaviors. The Administrator stated she has no recollection of these behaviors or abuse reports being reported in the QAPI meeting. The Administrator stated that any type of abuse reporting should be completed at the daily stand-up meetings. The Administrator stated that during the facility QAPI meetings the QAPI committee would, Normally, we focus on each area where there might be a Performance Improvement Plan (PIP) or where we might have a deficiency or something that needs corrected. The Administrator stated that a stand-down meeting is held every evening at the facility. The Administrator stated, We discuss what happened for the day or what is happening today and from the morning meeting. That's how we gather the information as to what we need to be focusing on and concentrating on. A review of the facility morning meeting notes dated 02/20/2023 did not reveal any report of Resident #2's behaviors. The meeting notes were signed by the Administrator, Director of Nursing, Assistant Director of Nursing, and the Director of Social Services. A review of the facility morning meeting notes dated 04/14/2023 did not reveal any report of Resident #2's behaviors. The meeting notes were signed by the Director of Nursing. A Performance Improvement Plan (PIP) was created on 04/17/2023: Reporting allegations of abuse, neglect, and misappropriation. The team facilitators for the PIP were the Administrator and the DON. The team members included members of the interdisciplinary team. The PIP included obtaining full and completed statements from any resident or staff member who has an allegation. The DON or designee will provide an in-service to all staff on abuse and unwanted touching. A second staff member will conduct a secondary interview for clarification or need for additional information. An audit will be completed for 90 days for any reportable to ensure compliance and reported to the monthly QAPI meeting for three months or until compliance is met. The PIP on 04/17/2023 was updated on 04/18/2023. The PIP was updated to include: Ensuring the staff were notifying the Administrator or DON of possible allegations and ensuring staff fully understand what to report as abuse. The Nurse Manager will read progress notes daily. Interviews were conducted with all residents to ensure no complaints of abuse were needed. An abuse competency was completed with all staff on abuse and reporting. A review of the facility QAPI plan dated 12/07/2022 revealed the need for guidance for the overall quality improvement program which coincides with our Vision and Mission Statements. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person-directed care, and resident transitions. The administrator will be Quality Assurance (QAA) committee. Further review of the QAPI plan revealed the principles of QAPI will be taught to all staff, volunteers, and board members on an ongoing basis. QAPI activities will aim for the highest levels of safety, excellence in clinical interventions, resident and family satisfaction and management practices. When the need is identified, we will implement corrective action plans or performance improvement projects to improve processes, systems, outcomes, and satisfaction. The administrator has responsibility and is accountable to the Internal Risk Management and Quality Assessment and Assurance Committee and for ensuring that QAPI is implemented throughout our Center. QAPI activities and discussion will be a standing item on our meeting agenda. The administrator is responsible for assuring that all QAPI activities and required documentation is provided to our corporation. The QAA committee will respond in a timely manner to ensure momentum is maintained. The team will develop an action plan. Interventions that will make change will be implemented by the team. The team will use root cause analysis (RCA) to ensure that the root cause and contributing factors are identified. When determining and implementing interventions, Plan-Do-Study-Act (PDSA) cycles will be used. The team will select and/or create measurement tools to ensure that the changes they are implementing are having the desired effect. A review of the facility Quality Assurance and Performance Improvement policy revealed that the facility develops a plan that describes the process for conducting QAPI/QAA activities, including to identify and correct quality deficiencies and opportunities for improvement. The facility policy stated the purpose of the policy was to develop, implement, and maintain an effective comprehensive, data-driven QAPI program that focuses on outcomes of care and quality of life. On 4/19/2023, the facility submitted a removal plan for F600 with immediate corrective actions to further prevent residents from further sexual abuse. The facility's removal plan included: 1. All current residents in the facility audited for concerns of abuse in the resident records completed 4/19/2023. 2. The Administrator and Director of Nursing (DON) and department heads/ QAPI team educated by Director of Clinical Services on facility policy and procedures of sexual abuse, investigations, and reporting into allegations of abuse with consultation with Regional Administrator and the QAPI process with PIP development, system review, data collection and review, root cause analysis including fish bone and five why drill down on 4/19/2023. 3. DON or designee to audit progress notes and EMAR notes for any note with areas of concern to be investigated starting 4/20/2023. 4. The immediate jeopardy was removed on 4/20/23 as evidenced by resident #2 was placed on one-on-one supervision, Adult Protective Services state abuse agency notification 4/17/2023 and 4/18/2023, federal immediate reporting completed for all occurrences dates, staff education completed for all areas, system developed and implemented for auditing the residents' records daily to be aware of concerns not reported. 5. This issue was taken to Quality Assurance Performance Improvement at an ad-hoc meeting on 4/18/2023 with Medical Director, Administrator, Director of Nursing, Social Services Director, MDS Director, and Unit Managers for both Units to discuss the concerns with sexual abuse, investigations, reporting and adequate follow up with PIP with new system to audit and review notes daily for immediate response in any allegations or concerns. Abuse Policy reviewed for meeting requirements of regulation. No changes indicated. Corporate Compliance program reviewed for inclusion of Elder Justice Act reporting, Federal and State abuse reporting requirements, resident safety intervention guidelines and mandatory reporting requirements. No changes required. 6. Administrator and Director of Nursing have submitted for access to federal reporting system access. Regional Administrator has current access to assist until access granted. On 4/20/23 at approximately 3:15PM, Immediate Jeopardy deficiencies were reduced from a K level to an E, pattern no actual harm with potential for no more than minimal harm level. As evidenced by the following: On 4/20/23 at 11:04PM, Resident #2 was observed to be in bed while his 1:1 supervision staff was seated at the resident's open bedroom door. This started on 4/19/23 according to documentation reviewed. Evidence of the resident record audits was provided to surveyors and dated 4/20/23. Upon review all residents were audited and no additional concerns were identified. Staff education in-services for the Administrator, DON, and other Department Heads, related to sexual abuse reporting, sexual abuse, investigative processes, and investigations was reviewed. Training dated for 4/19/23. The facility provided a sign-in sheet with 18 staff signatures. Interviews with Administrator, DON, and at least 3 other Department Heads validating reeducation. One Hundred percent of staff received staff education on abuse policy and procedures, in-services verified to have been completed on 4/19-4/20/23. Staff interviews conducted with at least 10 staff(non-administrative) from various shifts and departments which indicated training was received. Staff were able to verbally recite abuse policies and procedures they recently received in re-education related to abuse. Review of staff files for verification of abuse training upon hire. Education provided included but not limited to an explanation of abuse, signs and symptoms of abuse, and reporting. 3 recently hired staff records reviewed verifying training had been completed. Review of records for Residents #8, #9, and #10 revealed orders dated 4/20/23 for Psych eval and treat for psychosocial support status post resident interaction in her room. Observed Psychiatric Provider seeing Resident #10 on 4/20/23 at approximately 11:47AM. The Facility developed and conducted a Questionnaire for interviewable residents on 4/18-4/19/23. Interviewed a total of 6 residents and all confirmed that facility staff had interviewed them about abuse and staff concerns. No additional concerns identified.

Based on observations, staff interviews, resident interviews, record reviews and policy review, the facility failed to implement smoking care plans for smoking supervision and/or assistance requirements and failed to develop a care plan for use of a smoking apron for 1 of 3 residents observed (#50) while smoking. Resident #50, who has paralysis on his left side and limited range of motion on the right, and was assessed as requiring supervision while smoking, was observed on the smoking patio with burning embers on a neck pillow around his neck from a lit cigarette, no staff was observed on the smoking patio. The facility's failure to develop and implement the smoking plan of care places residents at likelihood of serious injuries which may result in serious [CONDITION(S)], injury and/or death and has the potential to affect all 18 residents identified as smokers, (residents #15, 19, 26, 36, 38, 49, 50, 52, 55, 58, 60, 64, 66, 70, 73, 77, 378 and 379). This situation resulted in a finding of Immediate Jeopardy at a scope and severity of K pattern. The facility Administrator was notified of the Immediate Jeopardy finding on 5/19/22 at 11:16 AM (CST). The Immediate Jeopardy was determined to have begun on 5/17/22, the day that resident #50 was observed unattended on the smoking patio with smoking coming from the neck pillow around his neck. Immediate Jeopardy was found removed on 5/19/22 when the facility provided evidence of immediate actions to remove the serious threat. The deficient practice was reduced to a scope and severity level of an E. Cross Reference F689. The findings include: On 05/17/22 at approximately 3:25 PM, the facility's smoking patio was observed. Approximately 11 residents were observed on the smoking patio and no staff were present on the patio. During this observation several residents were heard to say hey, hey, hey. At that time, the surveyor observed Resident #50, who was reclined back in a medical recliner with smoke coming from a neck pillow (a poly fiber filled, u-shaped pillow used to support the neck and head in a natural position) that was around his neck. The surveyor immediately approached resident #50 and noted a lit cigarette resting on the neck pillow. Resident #50 made no attempt to lift his upper extremities to remove the lit cigarette or to brush the hot ashes off the neck pillow. The surveyor brushed embers off the pillow at which time the lit cigarette fell to the ground and rolled under the resident's medical recliner. At this time Staff member A, Certified Nursing Assistant (CNA), arrived from inside the facility and removed the pillow from around resident #50's neck. The staff member cleaned cigarette ashes from the resident's clothing and assisted the resident with raising his left arm. A burn mark was noted on the neck pillow. (Photographic evidence obtained) On 05/17/22 at approximately 3:28 PM, an interview was conducted with Staff member A, CNA, who reported being assigned to monitor the smoking area. When asked if resident #50 should have been wearing a smoking apron (protects a residents clothing and wheelchair from burning ash) she stated that she did not know but the resident did not like wearing the apron. The CNA then asked the surveyor which other residents on the smoke patio where required to wear a smoking apron. At this time the CNA was observed to place a smoking apron on resident #50. A record review was conducted for Resident #50 which revealed a care plan initiated on 2/25/21 with a revision date of 10/28/21 for smoking with interventions that included Will not smoke without supervision. Requires supervision for smoking. There was no notation that the resident required a smoking apron or that the resident needed assistance with smoking due to his functional limitations in his arms and hands. Review of the last smoking evaluation dated 3/3/22, indicated the resident was an unsafe smoker who needs constant supervision and needed a smoking vest (smoking apron) while smoking. The evaluation answered no to has fine motor skills needed to securely hold cigarette. Resident able to light cigarette safely with lighter, and does not allow ashes or lit material to fall while smoking. The record review further revealed that Resident #50 was admitted to the facility on [DATE] with left sided [CONDITION(S)] and [CONDITION(S)] (partial paralysis) and limited range of motion on his right side. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with eating, locomotion, dressing, transfers and toilet use. Review of the Braden Scale for predicting pressure sore risk dated 4/3/22 stated Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. On 05/18/22 at approximately 9:02 AM, Resident #50 was observed on the smoking patio and again no staff was present on the patio. Resident #50 was reclined back in a medical recliner with a neck pillow positioned around his neck, the smoking apron was in place. The resident held a lit cigarette between his lips. Cigarette ashes were observed collecting on the left edge of the resident's neck pillow, on his left shoulder and on the medical recliner. The resident made no attempts to lift his upper extremities to brush off the ashes. The surveyor observed Staff member A, CNA, seated inside the facility's dining room, positioned at the glass door leading to the smoking patio, approximately 24 feet from the smoking residents. Resident #50 was unable to put or remove the cigarette in his mouth with his hands and did not receive assistance with smoking. On 05/18/22 at approximately 10:58 AM, Staff member A, CNA, was observed seated inside the facility's dining room by the glass door leading to the smoking patio. Resident #50 was observed on the smoking patio. Resident #50 was fully reclined in a medical recliner covered with a smoking apron. Resident #50 was observed with a lit cigarette between his lips. No staff were present to assist resident #50 with smoking safely, as he was unable to put cigarettes in his mouth or remove them by himself with his hands. On 05/18/22 at approximately 10:58 AM, an interview was conducted with Staff member A, CNA, in the facility's dining room. Staff member A stated that monitoring the smoking patio was her regular assignment, she monitors the residents from inside the facility. Staff member A stated she is not able to hear residents through the glass door separating the facility's dining room from the smoking patio. When asked how she knows when residents need assistance, Staff member A stated that residents wave their arms. She stated that the older residents educate the newer residents on how the smoking area works. She confirmed that she works 5 days a week Monday through Friday and that she does not need to leave her post by the window during her shift. The surveyor asked Staff member A to stand on the smoking patio approximately 6 feet just outside by the closed glass door, the surveyor remained inside the facility next to where the CNA observed the smoke area from. The surveyor and Staff member A attempted to speak to each other and were not able to hear each through the glass. On 5/18/22 at approximately 1:54 PM, an interview was conducted with the Director of Nursing (DON) who stated Staff A, CNA is responsible for supervising the smoking area, her hours are 8:00 AM until 6:30 PM Monday through Friday. In her absence someone from the activities department would replace her. On the weekends the weekend supervisors would assign a CNA to do the tasks. She stated that the CNA would provide assistance with what is needed according to resident assessment, She (Staff Member A) is present there, observing for safety. For the ones that need smoke aprons, ensures that they are in place. She provides lighters to the residents that can or light the cigarettes for them. In reference to resident #50, I'm aware that he spits out the cigarette. CNA should be in the area where the residents are smoking instead of the dining area because of the ones that need assistance she should be in close proximity. I am aware that Resident #50 does not have mobility on upper extremity, he needs assistance with feeding. On 05/19/22 at approximately 9:28 AM, a follow-up interview was conducted with DON and the facility Administrator. The administrator stated that she was aware the CNA was monitoring the smoking residents from behind a window but felt this was adequate because the window was clear, and that it was better than not having anyone at all. The DON stated that they were aware that resident #50 could not hold his cigarette independently but that he could hold it in his mouth really well and could spit it out on his own. She reported the resident had been doing this for about a year and there had not been issues until 2 days ago. Immediate Jeopardy was removed onsite after the receipt of an acceptable Immediate Jeopardy removal plan. The survey team verified the facility's immediate actions to remove the likely serious harm: On 5/19/22 All 18 residents who smoked were reassessed for safe smoking practices and interventions and all smoking care plans were reviewed and updated. Staff were assigned to provide stand-by assist to resident #50 while smoking and were observed to hold the cigarette up to his mouth, remove it and flick the ashes from the cigarette away from the resident. Staff designated for smoking supervision will remain in the designated smoking area at all times. The MDS Coordinator was educated on the importance of updating the care plans regarding smoking supervision and safety measures are implemented. Smoking list was updated with safe accommodations. A smoking monitoring book was developed and posted in the smoking area that provides a detailed list of all smokers, lists all safety interventions/accommodations such as aprons and stand by assist. Staff have been educated on documenting daily any concerns. The book was reviewed prior to exit without concerns. 100% of personnel in-house on 5/19/22 were educated on how to assist residents who smoke, safety while residents smoke, usage of the smoking apron, staying in the smoking area with residents at all times. Plans were in place that all staff would be educated prior to the start of their next shift.

Based on observations, staff interviews, resident interviews, record reviews and policy review, the facility failed to ensure adequate supervision of, and assistance for, residents who smoke tobacco products for 1 of 4 residents (#50) who required supervision while smoking. Resident #50, who has paralysis on his left side and limited range of motion on the right, and was assessed as requiring supervision while smoking, was observed on the smoking patio with burning embers on a neck pillow around his neck from a lit cigarette, no staff was observed on the smoking patio. The facility failed to implement their policy to ensure adequate supervision of residents who smoke. This had the potential to affect all 18 residents identified as smokers,(residents #15, 19, 26, 36, 38, 49, 50, 52, 55, 58, 60, 64, 66, 70, 73, 77, 378 and 379). The facility failed to implement smoking care plans which included smoking supervision requirements and failed to develop a care plan for use of a smoking apron for 1 of 3 residents observed (#50). The facility's failure to provide adequate supervision of residents while smoking and to ensure smoking places residents at likelihood of serious injuries which may result in serious [CONDITION(S)], injury and/or death. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of K pattern. The facility Administrator was notified of the Immediate Jeopardy finding on 5/19/22 at 11:16 AM (CST). The Immediate Jeopardy was determined to have begun on 5/17/22, the day that resident #50 was observed unattended on the smoking patio with smoking coming from the neck pillow around his neck. Immediate Jeopardy was found removed on 5/19/22 when the facility provided evidence of immediate actions to remove the serious threat. The deficient practice was reduced to a scope and severity level of an E. Cross reference F656 The finding include: On 05/17/22 at approximately 3:25 PM, the facility's smoking patio was observed. Approximately 11 residents were observed on the smoking patio and no staff were present on the patio. During this observation several residents were heard to say hey, hey, hey. At that time, the surveyor observed Resident #50, who was reclined back in a medical recliner with smoke coming from a neck pillow (a poly fiber filled, u-shaped pillow used to support the neck and head in a natural position) that was around his neck. The surveyor immediately approached resident #50 and noted a lit cigarette resting on the neck pillow. Resident #50 made no attempt to lift his upper extremities to remove the lit cigarette or to brush the hot ashes off of his neck pillow. The surveyor brushed embers off the pillow at which time the lit cigarette fell to the ground and rolled under the resident's medical recliner. At this time Staff member A, Certified Nursing Assistant (CNA), arrived from inside the facility and removed the pillow from around resident #50's neck. The staff member cleaned cigarette ashes from the resident's clothing and assisted the resident with raising his left arm. A burn mark was noted on the neck pillow. (Photographic evidence obtained) On 05/17/22 at approximately 3:28 PM, an interview was conducted with Staff member A, CNA, who reported being assigned to monitor the smoking area. When asked if resident #50 should have been wearing a smoking apron (protects a residents clothing and wheelchair from burning ash) she stated that she did not know but the resident did not like wearing the apron. The CNA then asked the surveyor which other residents on the smoke patio required an apron. At this time the CNA was observed to place a smoking apron on resident #50. On 05/18/22 at approximately 9:02 AM, Resident #50 was observed on the smoking patio and again no staff was present on the patio. Resident #50 was reclined back in a medical recliner with a neck pillow positioned around his neck, the smoking apron was in place. The resident held a lit cigarette between his lips. Cigarette ashes were observed collecting on the left edge of the resident's neck pillow, on his left shoulder and on the medical recliner. The resident made no attempts to lift his upper extremities to brush off the ashes. The surveyor observed Staff member A, CNA, seated inside the facility's dining room, positioned at the glass door leading to the smoking patio, approximately 24 feet from the smoking residents. Resident #50 was unable to put or remove the cigarette in his mouth with his hands and did not receive assistance with smoking. At the time of the observation an interview was conducted with Resident #50 and Resident #49. Resident #50 stated he smokes 5 days per week, each session the facility permits. He states staff put the lit cigarette in his mouth and then they go back inside. He keeps the cigarette in his mouth the whole time he smokes because he is unable to lift his upper extremities. When asked how he removes the cigarette, Resident #50 stated, I can spit this thing 6 feet. Resident #50 stated, the facility staff monitor residents from inside the facility. Resident #49 stated he is a light smoker, and that he comes to the smoking patio frequently to check on Resident #50 to monitor his safety and to collect his discarded cigarettes. Resident #49 stated facility staff monitor from the window from inside the building but do sometimes walk around outside but then they go back inside. On 05/18/22 at approximately 10:58 AM, Staff member A, CNA, was observed seated inside the facility's dining room. Staff member A was positioned at the glass door leading to the smoking patio. Resident #50 was observed on the smoking patio. Resident #50 was fully reclined in a medical recliner covered with a smoking apron. Resident #50 was observed with a lit cigarette between his lips. No staff were present to assist resident #50 with smoking safely, as he was unable to put cigarettes in his mouth or remove then by himself with his hands. On 05/18/22 at approximately 10:58 AM, an interview was conducted with Staff member A, CNA, in the facility's dining room, the CNA was seated inside the dining area next to a set of closed glass doors which overlooked the smoking area. Staff member A stated that monitoring the smoking patio was her regular assignment and that she monitors the residents from inside the facility. Staff member A stated she is not able to hear residents through the glass door separating the facility's dining room from the smoking patio. When asked how she knows when residents need assistance, Staff member A stated that residents wave their arms. She stated that the older residents educate the newer residents on how the smoking area works. The surveyor asked Staff member A to stand on the smoking patio approximately 6 feet just outside by the closed glass door, the surveyor remained inside the facility next to where the CNA observed the smoke area from. The surveyor and Staff member A attempted to speak to each other and were not able to hear each through the glass. On 05/18/22 at approximately 11:41 AM, an interview was conducted with Resident #50. When asked if a cigarette had ever fallen on his neck pillow Resident #50 stated, it has not. When asked what he would do if that were to happen, Resident #50 stated he would remove the neck pillow using his shoulder. Resident #50 stated it would take him approximately 30 seconds to remove his neck pillow. Resident #50 was not able to demonstrate how he would remove his neck pillow. On 5/18/22 at approximately 1:54 PM, an interview was conducted with the Director of Nursing (DON) who stated Staff A, CNA is responsible for supervising the smoking area, her hours are 8:00 AM until 6:30 PM Monday through Friday. In her absence someone from the activities department would replace her. On the weekends the weekend supervisors would assign a CNA to do the tasks. She stated that the CNA would provide assistance with what is needed according to resident assessment, She (Staff Member A) is present there, observing for safety. For the ones that need smoke aprons, ensures that they are in place. She provides lighters to the residents that can or light the cigarettes for them. In reference to resident #50, I'm aware that he spits out the cigarette. CNA should be in the area where the residents are smoking instead of the dining area because of the ones that need assistance she should be in close proximity. I am aware that Resident #50 does not have mobility on upper extremity, he needs assistance with feeding. On 5/18/2022 at approximately 4:23 PM, an interview was conducted with the facility administrator who stated that her expectations for staff in the smoking area is to monitor all residents who smoke. She was asked to define monitoring Monitoring means eyes on residents where staff can react immediately. Staff are expected to ensure residents are following all assessments and report any issues to the DON. On 05/19/22 at approximately 9:28 AM, a follow-up interview was conducted with the DON and the facility Administrator. The administrator stated that she was aware the CNA was monitoring the smoking residents from behind a window but felt this was adequate because the window was clear, and that it was better than not having anyone at all. The DON stated that they were aware that resident #50 could not hold his cigarette independently but that he could hold it in his mouth really well and could spit it out on his own. She reported the resident had been doing this for about a year and there had not been issues until 2 days ago. On 05/19/22 at approximately 9:29 AM, an interview was conducted with the Therapy Manager (TM) and Staff member P, Occupational Therapist (OT). The TM stated occupational therapy does not routinely evaluate for resident smoking ability. Staff member P stated, Resident #50 was evaluated for mobility related to feeding only but that, she observed other residents putting cigarettes in Resident #50's mouth, which she deemed unsafe. Staff member P stated, OT educated the nursing staff assigned to Resident #50 that if he needs assistance with feeding due to limited range of motion Resident #50 will need assistance with everything else. A record review was conducted for Resident #50 which revealed that he was admitted to the facility on [DATE] with left sided [CONDITION(S)] and [CONDITION(S)] (partial paralysis) and limited range of motion on his right side. Review of the last smoking evaluation dated 3/3/22, indicated the resident was an unsafe smoker who needs constant supervision and needed a smoking vest (smoking apron) while smoking. The evaluation answered no to has fine motor skills needed to securely hold cigarette, Resident able to light cigarette safely with lighter, and does not allow ashes or lit material to fall while smoking Review of Resident #50's care plan initiated on 2/25/21 with a revision date of 10/28/21 revealed a smoking care plan with interventions that included Will not smoke without supervision. Requires supervision for smoking. There was no notation that the resident required a smoking apron. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with eating, locomotion, dressing, transfers and toilet use. Review of the Braden Scale for predicting pressure sore risk dated 4/3/22 stated Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. A review of the facility provided Residents Smoker's List identified 18 residents who smoke. 2 current residents (#36 and #50) were identified as requiring smoking aprons. A review of the most recent Smoking evaluations dated 3/3/22 for residents #58, #26, and#36 revealed the residents required supervision with smoking. Resident #378 had a smoking evaluation completed on 4/21/22 which noted the resident required visual supervision while smoking. On 05/18/22 at 10:17 AM, a review of the facility's Smoking - Supervised policy and procedure effective 11/30/14 and revised 2/7/20 was conducted. Review of the policy revealed For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Further review of the policy revealed The Center will have safety equipment available in designated smoking areas including smoking blankets, smoking aprons, a fire extinguishers and non- combustible self-closing ashtrays. Review of the procedure revealed If a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the Center will include the appropriate information in the care plan. Further review of the procedure revealed During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. Immediate Jeopardy was removed onsite after the receipt of an acceptable Immediate Jeopardy removal plan. The survey team verified the facility's immediate actions to remove the likely serious harm: On 5/19/22 staff were assigned to provide stand-by assist to resident #50 while smoking and were observed to hold the cigarette up to his mouth, remove it and flick the ashes from the cigarette away from the resident. Staff designated for smoking supervision will remain at the designated smoking area at all times. All 18 residents who smoked were reassessed for safe smoking practices and interventions. Smoking list was updated with safe accommodations. A smoking monitoring book was developed and posted in the smoking area that provides a detailed list of all smokers, lists all safety interventions/accommodations such as aprons and stand by assist. Staff have been educated on documenting daily any concerns. The book was reviewed prior to exit without concerns. 100% of personnel in-house on 5/19/22 were educated on how to assist residents who smoke, safety while residents smoke, usage of the smoking apron, staying in the smoking area with residents at all times. Plans were in place that all staff would be educated prior to the start of their next shift.

Based on staff and resident interviews and record reviews, the facility failed to provide pain management as ordered which resulted in harm, requiring transfer to a higher level of care for 1 of 1 resident sampled for pain management (#69). Findings included: During an interview on 10/01/2018 at approximately 1:54PM, resident #69 stated that she went to the hospital last week because they didn't have pain medication available at the facility. Resident #69's medical record contained a physician's orders [REDACTED]. The resident's Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. A nurses' note dated 9/27/2018 at 12:00PM stated, Resident complaining of pain. Out of narcotic pain medication. Pharmacy notified and advised new Rx (prescription) needed. Would not allow EDK (emergency drug kit) pull. Fax request sent to attending physician with message left to address issue. Resident notified of situation. The next entry in the nurses' notes was on 9/28/18 at 5:30am and stated, Patient woke up in pain scale 10 complaining of pain all over lower back, flank, pelvic, and leg pain. Patient request for EMS (emergency medical services transport) to local hospital. Contacted on call ARNP (advance registered nurse practitioner). Patient left via EMS at 6:00am. A verbal order acknowledged by the on call ARNP was documented in the record on 9/28/2018 at 6:00AM. The resident's medical record also contained a copy of discharge instructions from a local hospital dated 9/28/2018 which contained patient education materials for chronic back pain. On 10/05/18 at 10:42 AM, an interview was conducted with staff K regarding the pain notation for not having the [MEDICATION NAME] on 9/27/2018. Staff K stated that the resident went without pain medication because after calling and faxing the pharmacy the medication was not available and pharmacy would not authorize an EDK pull. Staff K described this as a problem and stated that the physician would send another prescription if that would solve it, but the problem is that the pharmacy won't check their fax machine or tell us that they haven't received the fax.