Every finding on record at PruittHealth-Evans, LLC

Based on observation and interview, the facility failed to respect the residents right to personal privacy and confidentiality, including the right to privacy in his or her oral (spoken), written, and electronic communications where electronic medical records for two of 80 sampled residents were left open and unlocked and unattended at one of four Nurse's station and one of five medication carts. The facility failed to safeguard both a resident's physical privacy and their personal records. The sample size was 80, and the facility Census was 140. Findings include: 1.Observation on 07/20/2026 at 3:53 PM revealed the computer at the nurses' station on 100 hall was unlocked with a resident's information easily viewable. Further observation revealed no nurses were present at the nurses' station. Interview on 07/20/26 at 3:57 PM with Licensed Practical Nurse (LPN) AA revealed she stepped away from the computer to get ice for a family member. LPN AA confirmed the computer at the 100 hall nurses' station was unlocked and a resident's information was easily viewable to visitors. LPN AA revealed the protocol is to lock the computer screen when walking away from the computer. 2. During a medication administration observation on 07/22/2026 at 09:22 AM, LPN AA stopped at R58's room to obtain the resident's blood pressure. The LPN left the mobile medication cart positioned in the hallway outside R58's room with the tablet computer unlocked and facing the hallway. The tablet displayed the electronic medication administration record (eMAR), including resident names. LPN AA left the medication cart, with a tablet resting on top of it, unattended in the hallway while inside R58's room obtaining R58's blood pressure. During that time, the tablet remained unlocked, open, visible, and accessible from the hallway, displaying the eMAR for multiple residents. An interview with LPN AA on 07/22/2026 at 09:30 AM, revealed that she left the medication cart and tablet unattended while obtaining the R58's blood pressure. During an interview on 07/22/2026 at 1:22 PM with the Director of Health Services (DHS), the DHS revealed that staff are expected to protect resident health information by ensuring electronic medical records are not left visible or accessible to unauthorized individuals and that computers and tablets should be secured whenever left unattended. During an interview on 07/23/2026 at 2:37 PM with the Administrator, the Administrator stated that they take privacy seriously and that computers and tablets should be locked when unattended. 3. Review of the facility Policy titled Nursing: Patient/Resident Rights, Accommodation of Needs dated 10/01/2019 and Revised: 12/01/2023 revealed It is the policy of this healthcare center to promote and protect rights of the patients/residents residing in the center. Section C Confidentiality of the same Policy, Item number 1 reveals The patient/resident is assured of confidential treatment of all information contained in his/her record. On 07/23/2026 at 8:51 AM observed Nurse (N)BB at Medication Cart midway down the 100 hallway, talking with two wheelchair bound residents. There were no staff at the Nurses' station. Standing at the nurses' station in the 100 hallway, observed a computer monitor screen at Nurses Station 1 that had an electronic health record left open, unlocked, and unattended. The monitor screen was completely visible to passersby revealing protected health information for Resident (R) (R188). The computer monitor screen was unlocked and facility failed to ensure unintended access to R188's electronic health record. On 07/23/2026 at 8:53 AM Surveyor took photos of the computer monitor at Nurses' Station 1 as a staff member who identified herself as a therapist was walking past the Nursing station. She advised NBB was down the 100 hallway passing medications. On 07/23/2026 at 8:55 AM during an observation and interview with Staff Educator Nurse confirmed the computer monitor at Nurses Station 1 was unlocked and personal protected information was displayed and visible on the monitor screen. Staff Educator Nurse minimized the PHI images. She stated NBB was assigned to Unit, and confirmed NBB was on the 100-hallway conducting a medication pass. Staff Educator Nurse further shared NBB should have either minimized the computer screen to ensure health protected data is not visual to passersby or logged off before leaving the nurses station and beginning her medication pass. Staff Educator Nurse indicated she would conduct a staff inservice regarding privacy of health protected information that same day. On 07/23/2026 at 8:58 AM, NBB came to the Nurses station. An interview and observation with NBB at Station 1 revealed NBB confirmed and verified she left the computer monitor open prior to her medication pass. NBB stated she thought she had minimized the screen before leaving the nurse's station; but forgot to logoff. NBB indicated she has had prior education on the importance of protecting residents' privacy and health protected information. On 07/23/2026 at 2:38 PM Interview with Administrator and Director of Nursing revealed there are four Nurses Stations at the facility. Evidence of unattended computer monitors/screens at Nurses Stations and/or Medication Carts showing a residents' protected health information was not an accepted practice. The Administrator indicated screens should not be left unattended revealing any residents' protected health information. Electronic charts and records should always be attended and resident privacy protected. Staff are to always protect resident information and ensure screens are locked when away them. A negative outcome related to this deficit practice or observation is exposure to personal protected data, medications, and humiliation if resident rights are violated. Staff are expected to provide privacy to residents. The facility conducts regular training and pursues disciplinary action with staff violations, as appropriate.

Based on interviews, record review, and review of facility policy titled, Documentation: Charting Activities of Daily Living (ADLs), the facility failed to provide assistance with activities of daily living (ADLs) related to toileting frequently enough to meet the resident's needs for one of nine sampled residents (R), R171. This failure had the potential to create an environment for infection, compromise skin integrity, and adversely affect the resident's self-esteem and personal dignity. Findings include:Review of the facility policy titled, Documentation: Charting Activities of Daily Living (ADLs), revealed the following: Procedure #2: The responsibility of the person completing the documentation on the CNA/ADL Flowsheet is to code the maximum amount of support the patient/resident received over the entire shift irrespective of frequency. For facilities utilizing Care Assist, ADLs should be documented at the point of care each time care is given. The software will determine the most dependent episode.Review of the closed electronic medical record (EMR) for R171 revealed admission to the facility with diagnoses to include paroxysmal atrial fibrillation, unspecified fall, history of falling, other obesity due to excess calories, coronary artery dissection, generalized muscle weakness, difficulty in walking, and unspecified pain.Review of the admission Minimum Data Set (MDS) assessment, dated 02/07/2026 revealed the following: Section C, Cognitive Patterns: Brief Interview for Mental Status (BIMS) score=13, indicating no cognitive impairment, Section D, Mood: Mood Score=0, indicating no depression, Section E, Behavior: none documented, Section GG, Functional Abilities: -Functional Range of Motion: upper/lower impairment on one side; Self-care: independent for eating; substantial/maximal assist for toileting hygiene; Mobility: dependent for toilet transfer, Section H, Bladder and Bowel: frequently incontinent of bladder and bowel.Review of the R171's plan of care revealed a focus on risk for skin breakdown related to decreased mobility, obesity, and incontinence with a goal of resident's skin will remain intact and an approach to keep skin as clean and dry as possible; minimize skin exposure to moisture.R171 had a medication order from 02/04/2026 for furosemide tablet (diuretic (water pill) used to treat fluid retention) 40 milligrams (mg) by mouth (po) BID (twice daily).Review of the Point of Care history (computer documentation system) related to bladder/bowel function revealed no more than three entries for toileting per 24-hour period from 02/06/2026 through 03/02/2026. R171 was documented as incontinent for each day except on 02/16/2026 at 7:34 PM when she was documented as continent. The documentation revealed 14 number of toileting episodes documented for the month from 02/06/2026 through 03/02/2026.In an interview with Certified Nursing Assistant (CNA) GG on 07/23/2026 at 1:30 PM, CNA GG stated that staff should make resident rounds at least every two hours (q2h) and as needed (PRN) to provide care and service. She stated, for a resident who was known to be incontinent, she would expect him/her to require toileting at least four times per 12-hour shift. She stated each episode of service should be documented.In an interview with CNA HH on 07/23/2026 at 1:35 PM, she stated nursing staff should make resident rounds q2h and PRN. She stated she would make it a point to rounds on her incontinent residents more frequently when possible. She stated she would expect the incontinent resident to need check/change at least four times in a 12-hour shift.In an interview with CNA KK on 07/23/2026 at 1:40 PM, revealed resident rounds should occur q2h and PRN. She stated ideally that CNAs round q2h and nurses round q2h on the alternate hours so that residents get seen every hour. She stated that residents with special needs like incontinence or fall risk, need to be watched more closely. She stated she would expect a resident who was known to be incontinent and unable to go to the bathroom on his/her own to need toileting four times per 12-hour shift.In an interview with Licensed Practical Nurse (LPN) II on 07/23/2026 at 1:50 PM, revealed that staff should make resident rounds at least q2h and PRN. She stated that nurses try to round on the hours opposite the CNAs so that residents are seen every hour. She stated incontinent residents would likely need toileting or check change four to six times per 12-hour shift especially if they're on a diuretic, which makes the body produce more urine. She stated documentation of toileting twice in a 12-hour shift would not likely meet the incontinent resident's needs.In an interview with LPN BB on 07/23/26 at 2:00 PM, she stated that resident rounds should occur q2h and PRN with more attention paid to residents at risk for falls, certain behaviors, or incontinence. She stated that incontinent residents would need check/change more than twice in a 12-hour shift.In an interview with the Director of Health Services (DHS) on 07/23/2026 at 4:00 PM, she confirmed that resident rounds should occur at least q2h & prn and she would expect documentation of toileting for an incontinent resident more than twice during a 12-hour shift. She stated her expectation is for the nursing staff to round frequently enough to meet each resident's need for care and service, including check/change for toileting.

Based on record review, staff interviews, and review of the facility's policy titled Physician's Orders, the facility failed to ensure a physician's order was transcribed into the electronic medical record (EMR) upon receipt and failed to obtain a physician-ordered aerobic and anaerobic culture as directed for one of one sampled residents (R) (R113). These deficient practices had the potential to place R113 at increased risk of medical complications and unmet care needs. Findings include:Review of the facility's policy titled, Physician Orders, last revised 3/1/2024, revealed under the Procedure section for Verbal and Telephone Orders: 1. All verbal and telephone orders will be immediately transcribed into the medical record by the licensed professional receiving the order.Record review revealed that R113 was admitted with but not limited to dementia, weakness, and conjunctivitisReview of the comprehensive care plan for R113 revealed a problem of bilateral conjunctivitis, with a goal for the resident to remain free from signs and symptoms of infection. Interventions, initiated on 06/15/2026 and last reviewed on 07/12/2026, included administering antibiotics as ordered by the physician, reporting signs and symptoms of worsening infection to the physician, and monitoring the resident for adverse reactions to medications. The interventions were assigned to nursing, with physician oversight for antibiotic management.Review of the admission Minimum Data Set (MDS) assessment for R113 dated 06/03/2026 revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment.Review of the progress notes for R113 revealed an entry dated 06/15/2026 at 7:42 AM (documented as a late entry on 06/16/2026 at 7:42 AM) that R113 had bilateral eye redness and drainage and was rubbing her eyes. The physician was notified, new orders were received for Polytrim (polymyxin B/trimethoprim) ophthalmic drops, the responsible party was notified, and the care plan was updated. Continued review revealed an entry dated 06/20/2026 at 9:42 PM (documented as a late entry on 06/21/2026 at 12:47 AM) that the resident continued to have bilateral eye redness with purulent drainage. The physician was notified, and orders were received to discontinue polymyxin drops, obtain culture, and, after culture, start gentamicin 0.3% ophthalmic drops, one drop to each eye every two hours while awake for two days, then every four hours for seven days. The resident and responsible party were notified.Review of the electronic medical record (EMR) revealed that on 06/15/2026 at 6:40 PM, a physician's order was entered for polymyxin B/trimethoprim (Polytrim) ophthalmic drops: administer one drop to the right eye every four hours with a start time of 12:00 AM, followed by one drop to the right eye four times daily for seven days, for the diagnosis of conjunctivitis.Review of the Medication Administration Record (MAR) for R113, dated June 2026, revealed the first dose of Polytrim ophthalmic drops was administered on 06/16/2026 at 12:00 AM.Review of the diagnostic orders, dated 6/20/2026 through 06/30/2026, revealed an order dated 06/22/2026 for an aerobic and anaerobic culture.Review of the EMR revealed no documentation that the culture was obtained nor any resulting culture report.During a joint interview on 07/23/2026 at 8:15 AM with the Infection Control (IC)/Licensed Practical Nurse (LPN) and Regional Senior Nurse Consultant (RNC) DD, when asked why the nursing note indicated the physician was notified of the resident's condition and an order for treatment was received on the morning of 06/15/2026, yet the medication order was not transcribed into the EMR until 6:40 PM on 06/15/2026, the IC/LPN stated that she was unsure why it took so long to transcribe the order. She stated that she did not remember what was occurring that day and may have been busy with other responsibilities. She stated that the facility's expectation was for orders to be transcribed into the EMR immediately upon receipt and for antibiotic treatment to begin as soon as possible, depending on medication availability. RNC DD stated that, based on the documentation available, the approximate 11-hour delay between receiving the physician's order for treatment for the resident's eye symptoms and entry of the antibiotic order was a long time. During the same interview, the surveyor asked whether the physician-ordered aerobic and anaerobic culture had been obtained, as the surveyor identified the physician's order but was unable to locate any culture results. Both the IC/LPN and RNC DD reviewed the available records but were unable to locate documentation that the culture had been obtained or any culture results. The IC/LPN stated that she was unsure whether the culture had been obtained.During an interview with the attending physician, Medical Doctor (MD) CC, on 07/23/2026 at 1:00 PM, the surveyor asked about his expectations regarding the transcription of physician orders and the implementation of those orders. MD CC stated that an 11-hour delay between issuing an order and entering it into the electronic medical record was a long time. He stated that he expects his orders to be entered promptly after they are issued. Although medications may require delivery from the pharmacy, he stated that the order itself should be entered without delay. MD CC further stated that he expects his orders to be carried out as written. He stated that he was unsure why the physician-ordered culture had not been obtained.During an interview with the Director of Health Services (DHS) and RNC DD on 07/23/2026 at 1:20 PM, they stated that physician orders were expected to be transcribed promptly and that an 11-hour delay in transcribing an order was not acceptable. They also stated that nursing staff are expected to carry out physician orders as written.

Based on observations, staff interviews, and review of the facility's policy titled, Medication Storage in Healthcare Centers, the facility failed to ensure medical supplies were not retained beyond their expiration dates in two of four medication storage rooms. This deficient practice had the potential to result in the use of expired medical supplies, which could compromise the quality and effectiveness of the supplies.Findings include:Review of the facility's policy, Medication Storage in Healthcare Centers, revised 03/12/2026, documented the following Policy statement: Medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier.During a facility tour on 07/22/2026 at 10:00 AM, accompanied by the Infection Control (IC) nurse, two out of four medication storage rooms were inspected. Medical supplies were organized in labeled containers. The following expired items were observed:-In the medication room at the 200/400 Hall nurse station, two available culture swabs were expired, with an expiration date of 03/18/2026.-In the [NAME] Haven Hall medication room, two available culture swabs were expired, with an expiration date of 03/18/2026. Also, one bin, fully stocked with 18-gauge needles, with an expiration date of 11/30/2025.An interview at the time of the observation, the IC nurse stated that nursing staff are responsible for routinely checking medications and medical supplies for expiration dates and discarding any expired items.An interview on 07/22/2026 at 1:22 PM with the Director of Health Services (DHS) revealed that staff are expected to routinely check medications and medical supplies for expiration dates, discard expired items, and ensure expired medications and medical supplies were not available for resident use.

Based on record review, interview, and facility policy review, the facility failed to ensure comprehensive care plan included the use of corrective lenses for one of 32 sampled residents (Resident (R) 52) reviewed for care planning. The failure had the potential to affect the resident's psychosocial needs not being met. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, indicated .develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. Review of R52's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/25 and located in the electronic medical record (EMR) under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The MDS revealed the resident had a diagnosis on age related nuclear cataracts and required corrective lenses. Review of R52's EMR located under the Care Plan tab revealed the resident's comprehensive Care Plan did not address the resident's vision issues and corrective lenses. During an interview on 05/21/25 at 11:00 AM, Licensed Practical Nurse (LPN)6 said impaired vision and glasses should be on the care plan to help communicate the care needed for that resident. During an interview on 05/21/25 at 12:40 PM, the MDS Coordinator (MDSC) confirmed that residents that have corrective lenses need to be included on the care plan so that staff know the needs of the resident. During an interview on 05/21/25 at 1:15 PM, the Director of Nursing (DON) stated that impaired vision and the use of corrective lenses should have been on R52's care plan to let the staff know that glasses are need to improve vision. The DON stated the care plan let's all nursing staff know how to properly take care of a resident.

Based on observations, staff interviews, record review, and review of the facility's policies titled Water Management Program for Building Water System and Standard Precautions, the facility failed to maintain an effective infection control program by not providing evidence that legionnaires testing was done to prevent contamination of the facility water system. In addition, the facility failed to ensure one of one room doors (room [ROOM NUMBER]) was securely closed for a COVID-19 (Coronavirus Disease) positive resident and failed to post COVID -19 signage at the front entrance throughout the facility. In addition, the facility failed to follow infection control procedures during treatment for two of 28 sampled Residents (R) (R38 and R98). The facility census was 119. Findings include: 1. Review of the facility's policy titled, Water Management Program for Building Water System dated 3/1/2028 revealed, . to reduce risk associated with legionellae and other opportunistic pathogens that may be present in building water systems. The facility has partnered with a [Name of Water Company] to help assist with Program needs that cannot be currently met by the facility engineering team. Interview on 1/8/2024 at 12:01pm with the Infection Control Preventionist (IPC) confirmed that no residents had tested positive for legionella, and she had never been informed that she needed to follow up to ensure that maintenance was doing legionella testing. Interview on 1/18/2024 at 1:13 pm with the facility Regional Environmental Services (EVS) Consultant reported that facility had an established legionella plan. EVS Consultant confirmed that the facility had not done testing and that they had recently taken ownership of the building in October 2023, therefore he was unable to locate testing from the other company. Interview on 1/18/2024 at 3:35 pm with the Interim Director of Nursing (DON) confirmed no documentation of actual testing results was done. DON reported that the facility had scheduled testing for next Thursday 1/26/2024. In the meantime, the facility would contact the State Agency and the former owner to obtain the former testing results and date of the last test date. 2. Observations on 1/16/2024 from 11:38 am until 11:45 am of room [ROOM NUMBER] revealed the door was ajar and not securely closed with nursing and housekeeping staff on hall within close proximity to the door. A later observation on 1/16/2024 at 11:40 am revealed Licensed Practical Nurse (LPN) NN on the hall pushing med cart by the door. Interview on 1/18/2024 at 11:56 am with the IPC revealed that her expectations were for staff to follow the rules with preventing the spread of COVID -19 and contaminating the hallway. 3. Observations on 1/16/2024 at 10:00 am, 1/17/2024 at 7:35 am, and 1/18/2024 at 8:00 am revealed no COVID -19 signage sign on the door to provide notification of COVID-19 in the building. During an observation on 1/18/2024 at 11:54 am of the front exterior door with the IPC, the IPC confirmed the missing COVID-19 sign. She reported that it was her job to make sure the sign was up every day and that the importance of having the sign was to make sure that everyone was aware. Interview on 1/18/2024 at 2:41 pm, Registered Nurse Supervisor reported the facility expectations were the same as the State Agency that signage should be posted to ensure that guest, family members, staff, and residents were protected, and that staff had been educated on ensuring signs were posted on exterior doors. 4. Review of the facility's policy titled, Standard Precautions stated, Clean surfaces that are likely to be contaminated with pathogens including over-the-bed tables and frequently touched surfaces in the patient care environment. General surfaces should be cleaned and appropriately disinfected. Review of R38's clinical records revealed she had diagnoses that included but not limited to, Type 2 Diabetes Mellitus without complications, hypertension, atherosclerotic heart disease, and morbid obesity due to excess calories. Review of R38's physician orders included but not limited to, Lantus Solostar U (unit)-100 Insulin (insulin glargine)100 unit/mL (milliliter) give 3 (three) mL sq (subcutaneous) at hs (bedtime), Hemoglobin A1C every sixth month, Check and record blood sugar q.i.d. (four times a day) ac (before meals) and hs (bedtime), Glucagon emergency kit one milligram (mg) as needed (prn), Check and record blood sugars q.i.d. (four times a day) ac (before meals) and hs (bedtime), give Insulin aspart U-100 units per sliding scale: If blood sugar is less than 70, call MD (medical doctor). If blood sugar is 201 to 250, give 4 units. If blood sugar is 251 to 300, give 8 units. If blood sugar is 301 to 350, give 12 units. If blood sugar is 351 to 400, give 16 units. If blood sugar is 401 to 450, give 20 units. If blood sugar is 451 to 500, give 24 units. If blood sugar is greater than 500, call MD. Review of R38's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C-Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 15 which indicated she had intact cognition; Section I-Medically complex conditions indicated, hypertension, Alzheimer disease, diabetes mellitus; Section N-Medication, indicated she received insulin injections. Review of R38's care plan included but not limited to, risk for hyper/hypoglycemia related to diabetes mellitus, with a start date 1/16/2024. Interventions included but not limited to, monitor blood glucose ac and hs (before meals and at bedtime), administer meds/insulin as ordered. Observation on 1/17/2024 at 12:20 pm, and on 1/18/2024 at 8:31 am, R#38 was sitting up in a wheelchair inside her room eating from the meal tray. Observation on 1/17/2024 starting at 4:15 p.m. revealed Licensed Practical Nurse (LPN) AA cleaned the glucometer with sanitizing wipes and set aside to dry. LPN AA sanitized her hands, gathered supplies from the med cart drawer and laid them on top of the cart until she had all the supplies. LPN AA collected supplies in hand and entered R38's room. LPN AA placed supplies on the over-the-bed table. LPN AA did not clean the over-the-bed table and did not place a barrier before laying the supplies down on the table and proceed to perform the glucometer check. 5. Review of R98's clinical records revealed she had diagnoses that included but not limited to, Type 1 Diabetes Mellitus with hyperglycemia, hypertensive heart and chronic kidney disease with heart failure, unspecified chronic kidney disease. Review of physician orders included but not limited to, Lantus Solostar U-100 insulin (insulin glargine)100 unit/mL (milliliter) give 3 (three) mL sq hs, Hemoglobin A1C every 5th month, Glucagon emergency kit (human) 1 (one) mg prn, insulin aspart U-100 units per sliding scale: If blood sugar is less than 65, call MD. If blood sugar is 150 to 200, give 2 units. If blood sugar is 201 to 250, give 4 units. If blood sugar is 251 to 300, give 6 units. If blood sugar is 301 to 350, give 8 units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, give 12 units. If blood sugar is 451 to 500, give 14 units. If blood sugar is greater than 500, call MD. Review of R98's Quarterly Minimum Data Set (MDS) dated [DATE] revealed for Section C-Cognition, a Brief Interview Mental Status Score of 15, which indicated her cognition was intact. Section I-Diagnoses-Medically complex conditions indicated stage 4 chronic kidney disease, hypertension, renal insufficiency, Diabetes Mellitus (DM). Section N-Medications- indicated she received insulin injections and hypoglycemic medications. Review of R98's care plan included but not limited to, resident had diagnosis of insulin dependent type 1 diabetes mellitus with start date 2/4/2022; Interventions included but not limited to, obtain labs as ordered, and administer insulin as ordered. Observation on 1/17/2024 at 4:35 pm LPN AA cleaned the glucometer and set aside to dry. LPN AA used hand sanitizer, gathered supplies in hand and entered R98's room and placed supplies on the over-the-bed table. LPN AA did not clean the over-the-bed table and did not put down a barrier before placing supplies on the table. LPN AA performed glucometer check, results 169 which required insulin coverage per sliding scale. Observation on 1/17/2024 at 4:41 pm LPN AA sanitized hands and donned gloves, gathered supplies and drew up two units of Humalog Lispro insulin per sliding scale coverage for Fingerstick Blood Sugar (FSBS) of 169. Observation on 1/17/2024 at 4:45 pm LPN AA entered R98's room with supplies hand, placed supplies on the over-the-bed table. LPN AA did not clean the table or lay down a barrier before placing supplies on the table. LPN AA asked R98 if she had a preference for the site of the insulin injection, R98 said her abdomen. LPN AA pulled up R98's shirt exposing her abdomen/skin, administered insulin in her right lower abdomen. LPN AA discarded the supplies and left the room. Interview on 1/18/2024 at 4:45 pm with LPN AA acknowledged and confirmed she did not place a barrier under supplies or clean the table. LPN AA revealed she knew she should have used infection control practices by laying supplies on a barrier or cleaning the table prior to laying the supplies down. LPN AA revealed she did not recall any orientation or specific education on infection control but as a nurse she knew what she should do. Interview on 1/18/2024 at 2:30 pm with the Administrator revealed they cover infection control and privacy/dignity during orientation, plus staff have routine education on infection control quarterly, and as needed, and therefore staff should know. The Administrator stated her expectation was that staff should always follow infection control precautions when they are performing any procedure, treatment, or care. She revealed they would start immediately to reeducate staff.

Based on staff interview, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for Fourth Quarter (Q4) of fiscal year 2023, the facility failed to accurately report its staffing data to the Centers for Medicare and Medicaid (CMS) related to Registered Nurse (RN) coverage. The facility census was 119 residents. Findings include: Review of the PBJ [NAME] Report for Q4 2023, July 1 through September 30, revealed the facility reported data declaring there was no coverage by an RN for at least eight hours for the following dates: 1. July 1-31 2. August 4-6, 12-13, 18-20, 25-27 3. September 2-3, 10, 15-17, 23-24, 30 Interview on 1/18/2024 at 3:46 pm with the Senior Regional Nurse Consultant (SRNC) stated, her company did not acquire this facility until October 2023, and she could not obtain payroll data for the identified time period. She did, however, obtain the Daily Nursing Hours Report Sheets which documented at least one RN on duty for at least eight hours each day of Q4. She stated staffing data would be reported accurately moving forward.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to assess and obtain a physician order for one out of 28 sampled Residents (R) (R98) to safely self-administer and store medication at bedside. Findings include: Review of the facility's policy titled, Self-Administration of Medications by Patients/Residents dated 12/2/2022 under the Policy Statement revealed, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and Physician have determined that the practice would be safe for that patient/resident and other patients/residents of the healthcare center. Observation and interview on 1/16/2024 at 1:00 pm revealed the following medication, Major Deep Sea Premium Saline -nasal moisturizing spray 1.5 fl oz (44 ml) on a bedside table located in R98's room. R98 stated the nurse gave her the medication (nasal spray), but she was unable to recall who the nurse was. R98 reported she used the nasal spray daily. Observation on 1/17/2024 at 9:00 am revealed the medication (nasal spray) on R98's bedside table. Review of R98 's clinical record revealed the following diagnoses but not limited to anxiety disorder, unspecified, major depressive disorder, recurrent, unspecified, mild cognitive impairment of uncertain or unknown etiology, Type 1(one) diabetes mellitus with hyperglycemia. Review of R98's Quarterly Minimum Data Set (MDS) dated [DATE] revealed for Section C-Cognition, a Brief Interview Mental Status Score of 15, which indicated her cognition was intact. Review of R98's January 2024 Physician Orders revealed there were no orders for R98 to self-administer or store medications at bedside. Interview on 1/17/2024 at 1:12 pm with Unit Manager Licensed Practical Nurse (LPN) Supervisor DD reported that no resident on her unit had been assessed for self -administration of medications. Interview on 1/17/2024 at 1:23 pm, with LPN GG reported that she had not been informed of any residents on her hall who was able to self-administer medications. She reported she had not received any training related to residents self-administering medications. Interview on 1/18/2024 at 5:10 pm with the Director of Nursing (DON) reported that the facility had no residents coded and assessed for self -administration of medications. Observation and interview on 1/18/24 at 8:56 am with Register Nurse (RN) Nurse Supervisor, she confirmed the medication was in the resident room. During the interview, RN Supervisor revealed that residents are not allowed to keep medications in their room. She reported that R98 's medication incident was an oversight by the nurse and that any resident assessed for self -administration would have participated in a self -administration training program.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Patient/Resident Rights, Accommodations of Needs, the facility failed to ensure visual privacy during treatment for two of 28 sampled Residents (R) (R38 and R98). Findings included: Review of policy titled, Patient/Resident Rights, Accommodations of Needs, Privacy dated 12/1/2023 revealed, Patient/residents will be provided full visual privacy during routine care and treatments by means of privacy curtains and closed doors. 1. Review of R38's clinical records revealed she had diagnoses that included but not limited to, Type 2 Diabetes Mellitus without complications, hypertension, atherosclerotic heart disease, and morbid obesity due to excess calories. Review of R38's physician orders included but not limited to, Lantus Solostar U (unit)-100 Insulin (insulin glargine)100 unit/mL (milliliter) give 3 mL sq (subcutaneous) at hs (bedtime), Hemoglobin A1C every sixth month, Check and record blood sugar q.i.d. (four times a day) ac (before meals) and hs (bedtime), Glucagon emergency kit one milligram (mg) as needed (prn), Check and record blood sugars q.i.d. (four times a day) ac (before meals) and hs (bedtime), give Insulin aspart U-100 units per sliding scale. Review of R38's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C-Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 15 which indicated she had intact cognition; Section I-Medically complex conditions indicated, hypertension, Alzheimer disease, diabetes mellitus; Section N-Medication, indicated she received insulin injections. Review of R38's care plan included but not limited to, risk for hyper/hypoglycemia related to diabetes mellitus, with a start date 1/16/2024. Interventions included but not limited to, monitor blood glucose ac and hs (before meals and at bedtime), administer meds/insulin as ordered. Observation on 1/17/2024 at 4:15 pm revealed Licensed Practical Nurse (LPN) AA sanitized her hands, gathered supplies from the med cart drawer and entered R38's room. Another resident was in the same room standing between bed A and bed B, talking to R38. LPN AA placed the supplies on the over-the-bed table and performed the glucose check, LPN AA discarded supplies and left the room. LPN AA did not close the door or pull the privacy curtain during the blood sugar check. Residents were in the hallway during the treatment which was visible from the hallway. 2. Review of R98's clinical records revealed she had diagnoses that included but not limited to, Type 1 Diabetes Mellitus with hyperglycemia, hypertensive heart and chronic kidney disease with heart failure, unspecified chronic kidney disease. Review of R98's physician orders included but not limited to, Lantus Solostar U-100 Insulin (insulin glargine)100 unit/mL (milliliter) give three mL subcutaneous (sq) at bedtime (hs), Hemoglobin A1C every fifth month, Glucagon emergency kit one milligram (mg) as needed (prn), Insulin aspart U-100 units per sliding scale. Review of R98's Quarterly Minimum Data Set (MDS) dated [DATE] revealed for Section C-Cognition, a Brief Interview Mental Status Score of 15, which indicated her cognition was intact. Section I-Diagnoses-Medically complex conditions indicated stage 4 chronic kidney disease, hypertension, renal insufficiency, Diabetes Mellitus (DM). Section N-Medications- indicated she received insulin injections and hypoglycemic medications. Review of R98's care plan included but not limited to, resident had diagnosis of insulin dependent type 1 diabetes mellitus with start date 2/4/2022; Interventions included but not limited to, obtain labs as ordered, and administer insulin as ordered. Observation on 1/17/2024 at 4:35 pm revealed LPN AA gathered supplies, entered room R98's room with supplies in hand. LPN conversed with R98 who was sitting in a wheelchair next to the window/bed B. LPN AA placed supplies on the over-the-bed table and performed glucometer check, the result was 169 which required insulin coverage per sliding scale. LPN AA did not close the door or pull the privacy curtain. Residents were in the hallway during the treatment which was visible from the hallway. Observation on 1/17/2024 at 4:41 pm revealed LPN AA sanitized hands and donned gloves, gathered supplies and drew up two units of Humalog Lispro insulin per sliding scale coverage and then entered R98's room with supplies in hand. LPN AA placed supplies on the over-the-bed table and asked R98 if she had a preference for insulin injection site and R98 stated, her abdomen. LPN AA pulled up R98's shirt exposing her abdomen/skin, administered insulin in her right lower abdomen. LPN AA did not close the door or pull the privacy curtain during treatment. Residents were in the hallway during the treatment which was visible from the hallway. Interview on 1/18/2024 at 4:45 pm with LPN AA acknowledged and confirmed she did not close the door or pull the privacy curtain. Interview on 1/18/2024 at 2:30 pm with the Administrator confirmed they cover privacy/dignity during orientation, resident rights (privacy/dignity) quarterly, and as needed, and therefore staff should know to provide privacy during care. The Administrator stated her expectation was that staff should always close the door, and/or pull the curtains and should always provide privacy when performing any procedure, treatment, or care. She revealed they would start immediately to reeducate staff.

Based on the observations and staff interviews, the facility failed to ensure that it was maintained in a safe, clean, comfortable environment for three out of 21 rooms (Rooms 132, room [ROOM NUMBER], and room [ROOM NUMBER]). These rooms contained light bulbs out/not working, multiple scuffed walls, and large cracks in the floor. Findings include: Observation on 1/16/2024 at 11:30 am of room [ROOM NUMBER] revealed there was one of two light bulbs out/not working in the room. Observation on 1/16/2024 at 1:43 pm in room [ROOM NUMBER] revealed multiple scuffed walls, a large crack in the floor and one of two light bulbs out/not working in the bathroom. Observation on 1/16/2024 at 1:53 pm in room [ROOM NUMBER] revealed a large crack in the floor and multiple scuffed walls. Interview on 1/18/2024 at 9:50 am with the Maintenance Director, confirmed the findings in room [ROOM NUMBER] of the one light bulb that was out/not working: in room [ROOM NUMBER], multiple scuffed walls, a large crack in the floor with one of two light bulbs out/not working in the bathroom and in room [ROOM NUMBER], the large crack in the floor and multiple scuffed walls. Interview on 1/18/2024 at 2:00 pm with the Maintenance Director stated, that all employees were to place work orders as needed and that he and his assistant director collected these orders each morning from the book kept at the nurse ' s station on each hall. He stated that he made daily rounds through each hallway every morning. Interview on 1/18/2024 at 2:30 pm with the Assistant Director of Nursing (ADON) revealed she was unsure if the facility had a maintenance policy when asked by the surveyor. She stated, if available she would provide it. The maintenance policy was requested but not provided.

Based on observations, resident and staff interviews, and record review, the facility failed to assist one of 28 sampled Residents (R) (R38) with necessary arrangements to obtain routine dental services for replacement of her missing dental partial. Findings include: Observation and interview on 1/16/2024 at 12:01 pm, revealed R38 in her room during lunch. R38 reported that her upper dental partial was missing. She opened her mouth to show that the upper dental partial was missing. The lower dental partial was present. She revealed that her dental partial had been missing two months or more. R38 revealed that she removed her dentures every night without assistance. She reported that the upper dental partial was in her bed sheets and had been mistakenly taken to laundry by a laundry aide. R38 revealed that the laundry aide and several facility staff (whom she had informed) refused to assist her with searching for the upper dental partial on that day. R38 was unable to identify staff. Observation on 1/17/2024 at 12:20 pm, revealed R38 in her room eating lunch without upper partial dentures and only the fitted lower dental partial in place. R38's lunch consisted of mashed potatoes mixed in with peas, black forest chocolate cake, and tea. She was observed to eat only 80% of her meals. She displayed no problems with eating. Observation on 1/18/2024 at 8:31 am, revealed R38 in room eating breakfast without upper partial dentures and only the fitted lower dental partial in place. R38's breakfast consisted of toast, eggs, sausage, cereal, coffee, and milk. She consumed 60% of her breakfast. She displayed no problems with eating. Record review of R38's clinical record revealed the following diagnoses but not limited to impaired vision, diabetes mellitus type 2 without complications, morbid (severe) obesity due to excess calories, cognitive communication deficit, and Alzheimer's disease unspecified. Record review of R38's physician order for January 2024 revealed a diet order for a Liberated diabetic -Mechanical Soft diet. Record review of R38's Annual Minimum Data Set (MDS) dated [DATE] revealed for Section C: Cognitive Patterns, a Brief Mental Status Score of 15 which indicated her cognition was intact; Section GG: Functional Status revealed, an assessment for eating independently, independent for oral hygiene Section K: Swallowing/Nutritional status revealed , no assessment coding for weight loss or weight gain, no problem with swallowing disorder; Section L: Oral/Dental status, revealed no natural teeth. Record review of R38's nutrition care plan listed identified Problem: Nutrition/Hydration/Fluid Balance: At risk for alteration r/t (related to) syndrome of inappropriate diuretic hormone, hx (history) CKD (chronic kidney disease), DM (diabetes mellitus), diuretic therapy, morbid obesity, vitamin deficiency, edentulous, lower dentures only. The following interventions/approaches were listed: Assist with oral care as needed (start date 1/16/2024) Assist with tray set up of meals as needed (start date 1/16/2024) Monitor for difficulty chewing or swallowing (start date1/16/2024). Interview on 1/17/2024 at 12:20 pm with R38 revealed she had no problems eating without her upper dentures. She stated that she prefers to have both of her dentures for her looks (personal appearance). She stated that she wants a dental appointment to get more dentures. Interview on 1/17/2024 at 12:30 pm with Licensed Practical Nurse (LPN) DD reported that she was informed by staff and R38 about the missing upper partial dentures. LPN DD confirmed that R38 's dental partial has been missing for approximately four months. She reported that evening shift Certified Nursing Assistants (CNA) were responsible for assisting residents with cleaning/removing their dentures. During the interview LPN DD began a search of R38's room and could not locate resident denture cup and dentures cleansing products. She revealed that R38 was known to be independent with removing her dentures and rearranging items in her room. Interview on 1/17/2024 at 12:40 pm, Charge Nurse, LPN FF revealed being unaware of R38 missing upper partial dentures. Interview on 1/17/2024 at 1:15 pm, Unit Desk Clerk GG reported informing the previous social worker about R77's missing upper denture partial approximately three to four months ago. She stated that R38 had informed her and her family members. She spoke with R38 's family. She could not recall which family member. She revealed that this family member was aware of the missing upper partial dentures and wanted information about assisting with placement. The previous Social Worker was aware of the family inquiry. The previous Social Worker had stated that she would place R38 on the dental list for an appointment for new dentures. Interview on 1/18/2024 at 2:34 pm, Register Nurse (RN) Supervisor II revealed that her expectation was for staff to search the resident 's room and check the denture cup for missing dentures. If dentures were not located, a grievance form should be completed, an investigation started, a review by the Interdisciplinary Team (IDT), and a referral for a dental appointment. She stated, to modify the fit for dentures the dentist would come to the facility to complete an examination and fit testing for the dentures and once the dentures were received, the facility staff would ensure the safety of the dentures. Interview on 1/18/24 at 3:35 pm with the Interim Director of Nursing (DON) and Assistant Director of Nursing (ADON) LL. The DON and ADON LL confirmed being unaware of R38 missing dental partial. ADON and DON revealed that staff would be educated to follow through with services for residents requiring dental. Interview on 1/18/2024 at 3:57 pm, with the Financial Counselor KK revealed that R38 's family inquired about obtaining missing dentures and paying for dentures. This information was referred to the prior Social Worker. The Social Worker reported planning to follow up with family. She stated that the Dental Clinic comes quarterly and November 2023 was the last dental clinic visit. A policy was requested and was not provided.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop policies and procedures to ensure that reasonable suspicion of a crime against any resident was immediately reported to local law enforcement for four of five residents (R) (R#58, R#62, R#86, and R#277) reviewed for abuse. Specifically, the facility failed to ensure sexual assaults perpetrated by R#58 against R#62 and R#86 were reported to the police, and that an allegation of staff-to-resident abuse directed toward R#277 was reported to the police. Subsequently, the abuse continued. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/2022 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed Purpose/Instructions: To establish procedures and mechanisms to prevent the occurrence of abuse, neglect, exploitation of resident, and misappropriation of residents property. To outline the reporting procedures for suspected abuse, neglect, injuries of unknown origin, exploitation, and misappropriation of resident's property. To identify events that cause reasonable suspicion and to report those events to the appropriate facility staff and state agencies in accordance with existing State/Federal laws and regulations. Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. It is nonconsensual sexual contact of any type with a resident. 1. A review of a significant change in status Minimum Data Set (MDS) assessment, dated 6/30/22, revealed R#58 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. The resident was not coded as exhibiting behavioral symptoms, though section E1100. Change in Behavior or Other Symptoms was coded as Worse. Per the MDS, R#58 was independent with bed mobility, transfers, walking in the room, walking in the corridor, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated that R#58 required one person assistance to transfer for bathing only and used a walker as a mobility device. A review an annual MDS assessment, dated 7/1/22, revealed R#62 had a BIMS score of four, indicating the resident had significant cognitive impairment. Per the MDS, R#62 required extensive staff assistance with bed mobility, transfers, and locomotion on the unit. A review of R#86's quarterly MDS, dated [DATE], revealed R#86 had a BIMS score of four, indicating the resident had significant cognitive impairment. Per the MDS, the resident was dependent on staff for bed mobility and locomotion off the unit. A review of the written statement dated 6/18/22 at 10:30 p.m. by Certified Nursing Assistant (CNA) NNN, indicated R#58 was caught standing over a resident (R#62) with R#58's hand under R#62's gown, feeling R#62's breast. Review of a Facility Incident Report Form, dated 6/20/22, revealed an incident of sexual aggression had occurred when R#58 was observed in R#62's room with his hands inside R#62's gown. The date and time of the incident was erroneously identified as 6/20/22 at 4:00 p.m. On 8/17/22 at approximately 9:00 a.m., the survey team was made aware that there had been a second incident involving R#58. The survey team learned R#58 entered R#86's room during the late evening on 8/16/22, pulled down his pants, and exposed his genitalia while standing near the head of R#86's bed, where the resident was sleeping. A review of a Facility Incident Report Form, dated 8/17/22, revealed an incident that occurred on 8/16/22 at 10:05 p.m. A CNA reported that R#58 was in a female resident's room (R#86) with R#58's pants down. A review of R#86's nursing note, dated 8/16/22 at 10:05 p.m., revealed an unidentified CNA reported that R#58 was noted to have been in R#86's room. Review of R#58's clinical record and investigative notes revealed no documentation to denote that law enforcement officials were contacted following the incidents of alleged sexual misconduct on 6/18/22 or 8/16/22. During an interview on 8/17/22 at 11:17 a.m., Assistant Director of Nursing (ADON) EE stated that CNA NNN reported at the end of the 3:00 p.m. to 11:00 p.m. shift on 8/16/22 to the DON, the Administrator, and ADON EE that R#58 was found in another resident's room (R#86). She stated CNA NNN had observed R#58 with his pants down below the waist level with genitalia exposed. During an interview on 8/17/22 at 1:30 p.m., ADON EE stated for any type of injury of unknown origin or physical, sexual, or mental/verbal abuse, the police would be notified. ADON EE stated she would not contact the police if the facility had knowledge as to what had caused a resident injury. During an interview on 8/17/22 at 3:08 p.m., CNA NNN stated she knew her residents well. CNA NNN stated she consistently worked on the same hallway and paid a great deal of attention to the residents on her hallway. CNA NNN stated that she was familiar with R#58 and had observed the resident going into other resident rooms too much. She stated she had previously found R#58 behind a curtain messing with R#62 and had to take R#58 out of the room. CNA NNN stated she had reported this behavior to the nurses and her supervisor. CNA NNN stated that R#58 was allowed to come and go, knew the codes to the doors, and moved freely around the facility. CNA NNN stated that on 8/16/22, she had just finished showering a resident, walked to a linen cart, and then walked to R#86's room. CNA NNN identified that R#86 and R#62 were roommates. CNA NNN stated she observed R#58 with his right leg on R#86's bed and his pants down. CNA NNN stated she called two nurses to come to the room and asked R#58 what was going on, and at that point R#58 pulled up his pants. The nurses asked the resident what was happening, and R#58 stated, I don't know. CNA NNN stated that R#86 was lying in the bed with his mouth open. R#58 was in a state of obvious sexual arousal while standing beside the resident. CNA NNN stated R#58 had a knee up on the bed, so he was positioned close to R#86's face, with his pants down and his hand making a stroking motion up and down by his genitals. Per CNA NNN, R#86 was not responsive and could not move. CNA NNN noted she believed R#58 was aware that R#62 and R#86 were unable to talk and that was why he preyed on those residents. During an interview on 8/18/22 at 9:10 a.m., Licensed Practical Nurse (LPN) BB stated staff would call the police if a staff member perpetrated resident abuse. During an interview on 8/20/22 at 11:43 a.m., the DON stated that the police would be notified if warranted; however, the DON noted if a resident's family indicated a desire not to involve the police, then the facility would not call the police. During an interview on 8/20/22 at 1:12 p.m., the Administrator stated that law enforcement was contacted if necessary and for any physical contact, sexual assault, or any other potential crime. 2. A review of R#277's Face Sheet, printed 3/14/22 at 11:32 a.m., revealed the facility admitted R#277 on 3/11/22 with diagnoses including urinary retention, muscle weakness, hypertension, and cataracts. A review of an admission MDS, dated [DATE], revealed R#277 had a BIMS score of 15 of 15, which indicated the resident was cognitively intact. Per the MDS, the resident required extensive assistance with bed mobility, transfers, walking in the room, dressing, eating, toilet use, personal hygiene, and bathing. A review of a Care Plan, dated 3/11/22, revealed that R#277 was at increased risk for pressure/skin breakdown related to immobility. A review of R#277's Weekly Skin Integrity Review revealed entries on 5/5/22 which indicated that there was discoloration noted to the top of the resident's right hand, left elbow, and the back of the left forearm. The form included no description of the size or appearance of the discoloration. A review of a Facility Incident Report Form, dated 5/5/22, revealed R#277 had areas of discoloration to the left forearm, left elbow, and the top of the right hand. The form indicated an investigation was immediately started. A review of a two-page letterhead document, dated 5/12/22, and addressed to the Office of Regulatory Services, revealed the facility indicated, A full investigation was completed. The document revealed R#277 alleged an agency CNA BBB yelled at the resident, called the resident a whiner inches from the resident's face, and was rough when handling the resident, causing discoloration to R#277's bilateral arms. Per the document, R#277's arms were assessed and confirmed to have areas of discoloration on the right anterior hand, left elbow, and left forearm. The report indicated facility staff concluded there was not enough information to substantiate abuse. According to the report, R#277 was interviewed by facility staff and stated that she felt safe at the facility and declined to inform the sheriff's department. During an interview on 8/17/22 at 1:30 p.m., ADON EE stated that any time abuse was suspected, the abuse coordinator (Administrator) was to be contacted, and the incident was reported to the SSA. Per ADON EE, if a patient had a bruise and the facility staff did not know where it came from, that would constitute suspected abuse. ADON EE reported that she also notified police to see if they would investigate but not in all cases, such as in cases where the facility knew precisely what happened or if an incident had been witnessed. During an interview on 8/18/22 at 9:10 a.m., LPN BB stated the process for suspected abuse was to report incidents to the Administrator, assess the resident, and let the DON know. LPN BB stated the alleged abuser would be removed from the area and the other residents would be monitored for safety. If a staff member were involved, LPN BB stated she would report to local law enforcement. LPN BB stated that R#277 required total care, had to be assisted with feeding, could not use her arms, and was incontinent of bowel and bladder. LPN BB stated she remembered the resident's family member reporting to her on behalf of the resident that R#277 was being abused by an agency aide, CNA BBB. Per LPN BB, local law enforcement was not contacted in this situation as it was an allegation and she was not involved in the investigation, but added that if she had witnessed abuse, she would have called the police. During an interview on 8/20/22 at 11:43 a.m., the DON stated she was aware of the incident involving CNA BBB and R#277. She stated an investigation was completed and the Administrator was involved in the investigation. In the case of R#277, which involved alleged physical abuse, the DON stated she asked for the family's preference regarding notifying the police, and the indication was the family did not wish to notify the police. The DON stated she expected each team member to follow through with their own responsibilities, and that each entity played a role in each incident. During an interview on 8/20/22 at approximately 1:13 p.m., the Administrator stated she was made aware of alleged incidents either in person or by phone if she was not in the facility. She stated she directed the DON and ADON to conduct interviews with all staff based on knowledge of the resident involved, the situation, or if either were in the area. She reported that other residents in the area should also be interviewed, and her expectation was that staff members reported the incidents. She also stated the staff were provided education and training and she expected staff to follow through with the process and ensure the residents were in a safe environment and were kept safe. The Administrator stated that law enforcement should have been notified about the incident that occurred on 6/18/22. She further stated she knows now it was not the family's role to be allowed to make decisions for other residents to not notify law enforcement, and that law enforcement should have been notified.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure allegations of abuse were immediately reported to the State Survey Agency (SSA) for four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility failed to ensure allegations of resident-to-resident sexual abuse and staff-to-resident abuse were reported to the SSA immediately. Subsequently, the abuse continued. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/2022 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: A review of the facility's policy, titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed Purpose/Instructions: To establish procedures and mechanisms to prevent the occurrence of abuse, neglect, exploitation of resident, and misappropriation of residents property. To outline the reporting procedures for suspected abuse, neglect, injuries of unknown origin, exploitation, and misappropriation of resident's property. To identify events that cause reasonable suspicion and to report those events to the appropriate facility staff and state agencies in accordance with existing State/Federal laws and regulations. Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. It is non-consensual sexual contact of any type with a resident. 1. A review of a Facility Incident Report Form, submitted to the SSA on 6/20/22 at 4:00 p.m., revealed an incident of sexual aggression had occurred when R#58 was discovered in R#62's room with his hands observed inside R#62's gown. A review of the written statement dated 6/18/22 at 10:30 p.m. by Certified Nursing Assistant (CNA) NNN, indicated R#58 was caught standing over a resident (R#62) with R#58's hand under R#62's gown, feeling the resident's breast. A review of a written statement, undated, by Licensed Practical Nurse (LPN) UUU, indicated CNA NNN reported to the LPN that CNA NNN discovered R#58 standing over a female resident with R#58's hand under R#62's gown. The written statements were dated 6/18/22, however the incident was not reported to the state until 6/20/22. A review of a Facility Incident Report Form, dated 8/17/22, revealed an incident that occurred on 8/16/22 at 10:05 p.m. A CNA reported that R#58 was in a female resident's room (R#86) with his pants down. This was not reported to the SSA until the following day on 8/17/22 at 4:55 p.m. During an interview on 8/17/22 at 11:17 a.m., the Assistant Director of Nursing (ADON) EE stated that on 8/16/22 and at the end of the 3:00 p.m. to 11:00 p.m. shift, CNA NNN reported to the DON, the Administrator and ADON EE that R#58 was found in another resident's room (R#86). CNA NNN reported that R#58 was observed with his pants down and genitalia exposed. During an interview on 8/20/22 at 11:42 a.m., the DON revealed the incident that occurred in June of 2022 should have been reported within two hours, but she was not sure why it was reported two days after staff statements were taken regarding the incident. The DON further stated that when the second incident occurred on 8/16/22 that involved R#86 and R#58, she met with the ADON EE at the facility, and had met with the Administrator and Director by phone. The facility's administrative staff decided as a team that there was not enough information to make a report to the SSA, and that was why the incident was not reported until 14 hours later. She agreed that it should have been reported initially within the required two hours. During an interview on 8/20/22 at 1:13 p.m., the Administrator revealed she was made aware of all abuse allegations either in person or by phone and would instruct nursing staff at that time to report it to the SSA if they had not already done so. However, she could report abuse allegations to the state, too. The Administrator stated she was not sure why the statements by staff regarding the June 2022 incident with R#58 and R#62 were dated 6/18/22, but the report was made 6/20/22. She also stated the incident that occurred on 8/16/22 with R#58 and R#86 was reported the next day after staff were able to gather additional information but stated it should have been reported timely. The Administrator stated she expected staff to report all allegations and follow any education and training they had received to ensure residents were safe. 2. A review of a Facility Incident Report Form, dated 10/25/21, indicated an incident categorized as other had occurred on 10/25/21, in which Family Member SSS had reported to the facility that R#5 had stated, during a visit, that there were rumors regarding R#5 and a male CNA's relationship. The form further indicated that the police and other agencies had been notified. A review of a written correspondence, dated 10/26/21, indicated the facility communicated with the SSA that there had been an allegation of a possible inappropriate relationship between CNA III and R#5. The correspondence indicated that the facility had concluded there had not been any inappropriate behavior. During an interview on 8/19/22 at 10:39 a.m., Family Member SSS stated sometime in the spring/beginning of summer 2021, R#5 talked about CNA III a lot and the two were spending a lot of time together, but Family Member SSS did not believe there was ever anything physical. Family Member SSS stated having spoken with a nursing supervisor and requested that CNA III be placed somewhere else and not be with R#5. Family Member SSS stated they did not want R#5 to take it to another place but he did not think CNA III ever did anything. Family Member SSS stated they thought CNA III was showing R#5 extra attention; CNA III was being extra special to the resident. Continued interview Family Member SSS stated having remembered a nurse supervisor called him asking questions since people were noticing that R#5 and CNA III were spending a lot of time together. Family Member SSS stated it was probably more R#5 seeking CNA III out and maybe some mild flirting, more from R#5 than CNA III. Family Member SSS did state that R#5 told him CNA III was very gentle and gave R#5 baths. After CNA III was moved to another area, Family Member SSS did not hear anything more from R#5 about CNA III until a couple of months ago, in May of 2022. Family Member SSS stated R#5 called to ask if R#5 could go to [NAME] Beach with CNA III. Family Member SSS stated he did not know if CNA III personally invited R#5 but a message was left for the nursing supervisor to regarding the matter. Family Member SSS stated there was no returned call from the nursing supervisor. During an interview on 8/19/22 at 11:44 a.m., Licensed Practical Nurse/Supervisor (LPN) BB revealed she had no facts regarding R#5. She had heard rumors that R#5 was messing around with CNA III, but she never witnessed this personally. LPN Supervisor BB stated she did speak with Family Member SSS about R#5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, LPN Supervisor BB did state she reported the rumors about R#5 and CNA III to LPN HH, who was the ADON at the time, but she did not know if LPN HH followed up on the allegations. An interview on 8/19/22 at 12:21 p.m. with LPN HH revealed she was not considered a supervisor, but another charge nurse may inform her of any allegations of abuse, since she had been employed at the facility for a long time. LPN HH stated she did not remember a report being made to her about a rumor involving R#5 and CNA III and she did not remember any reports to her being about R#5. LPN HH stated she was not aware of the allegations of R#5 and CNA III having an inappropriate relationship, but if she were aware she would have reported it to the Administrator. LPN HH also said she did not recall any concerns investigated in relation to R#5. A review of the facility incident reports, which were reported to the SSA for the period of May 2021 through May 2022, revealed no evidence that the facility reported the alleged inappropriate relationship between R#5 and CNA III to the SSA. During an interview on 8/20/22 at 1:13 p.m., the Administrator revealed she was made aware of all abuse allegations either in person or by phone and would instruct nursing staff at that time to report it to the SSA. The Administrator stated she was not aware of the second allegation in May 2022 by R#5's son, who stated R#5 reported that CNA III invited R#5 to the beach, but the Administrator agreed that if there had been another allegation, it should have been reported and investigated.

Based on observations, interviews, record review, document review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse or exploitation involving four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility: - Failed to thoroughly investigate an incident of resident-to-resident sexual abuse when R#58 was found in R#62's room with his hand inside the resident's gown on 6/20/22. Other residents were not interviewed as to whether they had been exposed to, or had knowledge of R#58's sexually aggressive behaviors as a part of the facility's investigation. Staff who were not on duty at the time of the 6/20/22 incident were not interviewed as to any knowledge they may have had regarding R#58's sexually aggressive behaviors. R#58 was subsequently found on 8/16/22 in the same room with his pants down, genitals exposed, and one knee in the bed with R#86 (R#62's roommate). - Failed to thoroughly investigate an allegation of possible staff-to-resident abuse or exploitation for R#5 when rumors of an inappropriate relationship with a facility employee were identified. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/22 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed, Investigation. A. All investigations of alleged abuse will be conducted by the Director of Nursing or designee and/or the Administrator. The policy also indicated, B. Investigations will include interviews with person reporting the violation, interviews with other staff members, visitors, family members, or residents who may have knowledge of the alleged incident. Only factual information will be documented. Additionally, the policy indicated, C. A review of the resident's medical record will be completed to determine the resident's past history and condition, and its relevance to the alleged violation. 1. Review of a Face Sheet revealed R#58 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#58 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, R#58's behavioral symptoms had improved, and the resident had no behavioral symptoms (wandering, sexual abuse, public sexual acts, et cetera) during the seven-day assessment period. The MDS revealed the resident was independent with activities of daily living (ADLs), including walking. Review of R#62's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#62's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8, indicating moderate cognitive impairment. The MDS indicated the resident had adequate hearing and speech, had impaired vision, and had no mood/behavior symptoms. Per the MDS, the resident required extensive assistance of two staff for bed mobility, transfers, and dressing. Additionally, the MDS revealed the resident had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Facility Incident Report Form, dated 6/20/22 at 4:00 p.m., revealed there was an incident of resident-to-resident sexual aggression, in which R#58 was caught in R#62's room with his/her hands in R#62's gown. Review of a witness statement, dated 6/18/22 at 10:30 p.m. by Certified Nursing Assistant (CNA) NNN, revealed R#58 was caught standing over R#62's bed. The statement indicated R#58's hand was in R#62's gown, feeling the resident's breast. Review of a witness statement signed by Licensed Practical Nurse (LPN) UUU revealed on 6/18/22, CNA NNN reported to the LPN that she discovered R#58 standing over a resident of the opposite sex with his hand under the resident's gown. The statement indicated R#58 was immediately removed from the room and escorted back to his room. The LPN spoke with R#58 about entering other residents' rooms, and R#58 verbalized understanding. The statement indicated two CNAs alternated sitting outside R#58's room to monitor the resident, and no further incidents were noted. A review of the facility's investigation revealed the above two witness statements. There was no evidence to indicate the facility interviewed any other residents specifically regarding whether they had been exposed to or had witnessed any inappropriate touching or other sexual behavior by R#58. The interviews with other residents consisted only of general questions as to whether they had been abused or witnessed abuse, with check boxes for the interviewer to mark Yes or No to the questions asked. Additionally, there was no evidence any staff other than the ones working at the time of the incident were reviewed as to their knowledge of R#58's sexual behaviors toward residents of the opposite sex. Review of a quarterly MDS, dated [DATE], revealed R#86 had a BIMS score of four, which indicated severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for bed mobility. According to the MDS, the resident had highly impaired vision. Review of Nurse's Notes, dated 8/16/22 at 10:05 p.m., revealed a CNA (not identified) reported another resident was found in R#86's room. (R#86 was the roommate of R#62). Review of R#58's medical record revealed a Nurses Note dated 8/16/22 at 10:00 p.m. and signed by the Assistant Director of Nursing (ADON), which indicated R#58 was in another resident's room. During an interview on 8/17/22 at 3:08 p.m., CNA NNN revealed that on 8/16/22, she walked into the room shared by R#86 and R#62 and observed R#58 with his right leg on R#86's bed. R#58's pants were down. CNA NNN stated R#86 was lying in the bed with her mouth open. CNA NNN stated R#58 was in an obvious state of sexual arousal, had his knee up on the bed, and was positioned close to R#86's face. R#58 was making a stroking motion up and down by his genitals. According to CNA NNN, she believed R#58 was aware that R#62 and R#86 were unable to talk and that is why R#58 preyed on those residents. During an interview on 8/20/22 at 11:42 a.m., the DON asserted there were additional interviews done as part of the investigation when R#58 was found fondling R#62 breasts, but she was not sure why there was no documentation to show this occurred. During an interview on 8/20/22 at 1:13 p.m., the Administrator agreed that staff should have completed a more thorough investigation into the incident that occurred on 6/20/22 with R#58 and R#62. She stated staff should have interviewed additional residents on other halls and additional staff on different shifts and other halls as well, to ensure there were not additional incidents. The Administrator stated she expected her staff to investigate abuse allegations thoroughly and follow any education and training they received to ensure residents were safe. 2. Review of an annual MDS, dated [DATE], revealed R#5 had a BIMS score of 15, which indicated the resident was cognitively intact. Per the MDS, the resident required limited assistance with transfer, toileting, dressing, toileting, personal hygiene, and bathing. Review of a Facility Incident Report Form, dated 10/25/21, revealed R#5 stated to a family member during a visit that rumors were going around regarding R#5 and a male Certified Nursing Assistant (CNA). The report indicated the resident's family member stated R#5 enjoyed male company and attempted to become very close with men who showed her any type of attention. Review of the facility's investigation revealed on 10/25/21, R#5 had a visit with her family member, during which the resident repeatedly spoke of a male CNA and how wonderful he was. The family member indicated R#5 spoke about the CNA for almost the entire visit. The family member contacted the Director of Nursing (DON) and stated they were concerned because the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The family member indicated they did not want the resident kicked out for this behavior and did not want any employee getting in trouble and losing their job due to the resident's issues. The investigation indicated the DON spoke with R#5 and asked specifically if anything inappropriate had ever occurred between R#5 and the male CNA. The resident's response was, Absolutely not! He is a very nice guy who gives me the best care. The investigation notes indicated upon conclusion of the investigation, it was determined that no inappropriate behavior had occurred and there was no harm to the resident. The male CNA was reassigned and would no longer provide care to R#5. Review of an undated handwritten witness statement signed by R#5 indicated the DON had questioned the resident regarding CNA III and whether he had been inappropriate with the resident. The statement indicated R#5 told the DON that CNA III, would hug me when he came back to work after being off. The statement further indicated the CNA, has not touched me out of the way at all. There was no evidence any other witness statements were collected as a part of the facility's investigation. There were no interviews with other residents or staff as to whether they had any knowledge of any inappropriate behavior exhibited toward residents by CNA III. During an interview on 8/19/22 at 10:39 a.m., Family Member (FM) SSS revealed he was a family member of R#5. FM SSS stated sometime in the spring/beginning of summer 2021, R#5 talked about CNA III a lot, but the family member did not believe there was ever anything physical. The FM stated they spoke with a nursing supervisor and requested that CNA III be placed somewhere else and not be with R#5. FM SSS stated they did not think CNA III ever did anything inappropriate but thought CNA III was showing R#5 extra attention. The family member stated they remembered a nurse supervisor called to ask questions, since people were noticing that R#5 and CNA III were spending a lot of time together. FM SSS stated it was more R#5 seeking CNA III out and maybe some mild flirting, more from R#5 than CNA III. The family member indicated that R#5 said CNA III was very gentle and gave R#5 baths. After CNA III was moved to another area, the family member did not hear anything more from R#5 about CNA III until a couple of months ago. Family Member SSS stated R#5 called to ask if she could go on a trip with CNA III. The family member stated they did not know if CNA III personally invited R#5. FM SSS stated they attempted to contact the nursing supervisor and left a message requesting a return call but never received a call back. A review of facility investigations for the period of August 2021 through August 2022 revealed no evidence that a facility investigation related to R#5 accompanying, or being asked to accompany, CNA III on a trip. During an interview on 8/20/22 at 11:42 a.m., the DON stated she assumed the Administrator reviewed all the abuse investigations to ensure they were completed and reported timely. The DON stated she just became aware of the allegation involving R#5 and a staff member allegedly having an inappropriate relationship during the survey process, and she was not aware there had been a second allegation by the family about an invitation to go on a trip with the CNA. The DON stated she was not sure why a complete investigation was not completed in October 2021, but it should have been, and if there was another allegation, that should have been investigated, too. During an interview on 8/20/22 at 1:13 p.m., the Administrator stated the DON identified which staff should be interviewed for abuse investigations and reviewed the completed investigation to ensure no additional steps were needed during the 5-day investigation window. The Administrator stated she became aware of the allegation involving R#5 in October 2021, but administrative staff interviewed R#5, who denied anything inappropriate had occurred; therefore, she did not feel like anything additional needed to be done. The Administrator stated she did not feel there was any real allegation, since the family member's only expressed concern was that R#5 had a fixation on the staff member. She agreed that a more thorough investigation should have been completed at that time. The Administrator indicated she was not aware of the second allegation by R#5's family member, regarding the resident asking to accompany the CNA on a trip. The Administrator agreed this should have been investigated.

Based on observations, interviews, record reviews, and facility policy review, the facility's administration failed to provide oversight and leadership that ensured: (1) Residents were free from sexual and physical abuse, which affected two of five sampled residents (R) (R#62 and R#86) reviewed for abuse; (2) A thorough investigation of allegations of resident-to-resident sexual abuse and staff-to-resident abuse were completed involving three of five sampled residents (R#58, R#62, and R#5) reviewed for abuse; (3) To report allegations of resident-to-resident sexual abuse and staff-to-resident physical abuse to the local law enforcement for four of five residents (R#58, R#62, R#86, and R#277) reviewed for abuse; and (4) To report allegations of resident-to-resident sexual abuse and staff-to-resident physical abuse to the State Survey Agency (SSA) for four of five residents (R#58, R#62, and R#86, and R#5) reviewed for abuse. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/22 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: Per the Administrator, the facility did not have a policy that spoke on administration and/or the administrative role in the facility. However, a policy was created on 8/20/22 and provided to the survey team. 1. Cross refer F600: The facility failed to ensure residents were free from resident-to-resident sexual abuse for two (R#62 and R#86) of five sampled residents reviewed for abuse. R#58 displayed behaviors of wandering into the rooms of residents of the opposite sex. The facility failed to develop and implement interventions to address the resident's behavior, and on 6/20/22, staff found R#58 in R#62's room with his hand inside R#62's gown. The facility failed to consistently supervise/monitor R#58 to prevent further incidents of sexual abuse, and on 8/16/22, staff found R#58 in the room shared by R#62 and R#86, with his pants down, genitals exposed, and one leg on R#86's bed. 2. Cross refer F610: The facility failed to thoroughly investigate allegations of abuse or exploitation involving three (R#58, R#62, and R#5) of five sampled residents reviewed for abuse. Specifically, the facility: - Failed to thoroughly investigate an incident of resident-to-resident sexual abuse when R#58 was found in R#62's room with his hand inside the resident's gown on 6/20/22. Other residents were not interviewed as to whether they had been exposed to or had knowledge of R#58's sexually aggressive behaviors as a part of the facility's investigation. Staff who were not on duty at the time of the 6/20/22 incident were not interviewed as to any knowledge they may have had regarding R#58's sexually aggressive behaviors. R#58 was subsequently found on 8/16/22 in the same room with his pants down, genitals exposed, and one knee in the bed with R#86 (R#62's roommate). - Failed to thoroughly investigate an allegation of possible staff-to-resident abuse or exploitation for R#5 when rumors of an inappropriate relationship with a facility employee were identified. 3. Cross refer F608: The facility failed to develop policies and procedures to ensure that reasonable suspicion of a crime against any resident was immediately reported to local law enforcement for four (R#58, R#62, R#86, and R#277) of five residents reviewed for abuse. Specifically, the facility failed to ensure sexual assaults perpetrated by R#58 against R#62 and R#86 were reported to the police, and that an allegation of staff-to-resident abuse directed toward R#277 was reported to the police. 4. Cross refer F609: The facility failed to ensure allegations of abuse were immediately reported to the SSA for four (R#58, R#62, and R#86, and R#5) of five residents reviewed for abuse. An interview on 8/20/22 at 11:42 a.m. with the DON revealed that she submitted the clinical piece, such as falls and rehospitalization s, during Quality Assurance Performance Improvement (QAPI) meetings. The DON stated during QAPI meetings, staff would identify concerns related to abuse incidents and create a plan of action. Administration would review a sample of abuse incidents and try to identify things that may or may not have occurred during the process. The DON stated all the facility-reported incidents had been reviewed during QAPI, but staff did not identify any concerns with timely reporting, thorough investigations, or preventing abuse. The DON stated abuse investigations were completed by the Administrator, Director of Extended Care, Assistant Director of Nursing (ADON), and herself (the DON). The DON stated she assumed the Administrator reviewed all the abuse investigations to ensure they were complete and reported timely. The DON stated she was not sure if abuse allegations or investigations were being reviewed in QAPI and stated the abuse protocol was not currently an issue identified by QAPI. An interview on 8/20/22 at 1:13 p.m. with the Administrator revealed that during their monthly QAPI meeting, all departments would talk about what was working or not working to identify areas of concern. The Administrator stated staff would then discuss what needed to be put in place to correct the issue and put the action plan in place with a target completion date and try to have it corrected before next the QAPI meeting. The Administrator stated they would review the action plan until the issues were resolved. The Administrator stated the facility did not identify any concerns with their abuse protocol prior to the survey, but she did see now there were opportunities to improve their process and had reviewed and revised their abuse process due to the survey findings. An interview on 8/20/22 at 2:33 p.m. with Director JJJ revealed she was the Director of Extended Care, and her role was to provide oversight for this facility and their sister facility. Director JJJ stated she visited both facilities at least once weekly and would meet with the Administrator during that time to go over any identified issues at the facility, or she may bring concerns to the Administrator's attention. Director JJJ stated it was the Administrator's responsibility to inform her of any facility reportable. Director JJJ stated she expected her staff to be an expert at what they do, expected them to function autonomously, and to communicate. She stated she could not say she knew 100% of the time the outcome of every incident/reportable. Director JJJ stated there was a system called Fair and Just Culture that was an algorithm to identify system failures, and they used this process to review all incident reports. She stated the issue was it was only used to identify issues with fall incidents or pressure ulcers, and not for abuse reportable events. Director JJJ stated she expected staff to err on the side of caution and report anything, for everything to be brought to staff's attention, and to ensure all allegations were thoroughly investigated. Director JJJ stated she felt this was a good opportunity for coaching staff on the abuse process, and she agreed without question there were issues with their abuse process that needed to be corrected. Director JJJ stated the evidence presented to her during the survey process was very disappointing and certainly less than she expected her staff to be doing to address abuse allegations.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse for two of five sampled residents (R) (R#62 and R#86) reviewed for abuse. R#58 displayed behaviors of wandering into the rooms of residents of the opposite sex. The facility failed to develop and implement interventions to address the resident's behavior, and on 6/20/22, staff found R#58 in R#62's room with his hand inside R#62's gown. The facility failed to consistently supervise/monitor R#58 to prevent further incidents of sexual abuse, and on 8/16/22, staff found R#58 in the room shared by R#62 and R#86, with his pants down, genitals exposed, and one leg on R#86's bed. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/22 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed, Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. It is non-consensual sexual contact of any type with a resident. The policy also indicated, Protection of Residents A. When circumstances require it, the DON or designee will remove a resident suspected of being the recipient of an alleged violation, to an environment where the resident's safety can be assured. 1. If the suspected perpetrator is another resident, the DON or designee will separate the residents, prohibiting access to each other until such time the circumstances of the alleged incident/violation can be determined. Further review of the policy revealed the facility would prevent abuse through analysis of the following: - 2. The assignment of appropriate staff on each shift in sufficient number to meet the needs of the residents and assure that staff assigned have knowledge of the individual residents care needs and the skills to provide proper care. - 4. Assessing, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as but not limited to, residents with a history of aggressive behaviors, residents who exhibit behaviors of wandering into other residents [sic] rooms or unsafe areas, residents with self-injurious behaviors, residents with communication deficits, residents that require heavy nursing care and/or are totally dependent on staff for all their needs. 1. Review of a Face Sheet revealed R#58 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#58's medical record revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] - Review of Nurse's Notes revealed on 12/22/21 at 6:25 a.m., R#58 went into the room of a resident of the opposite sex and closed the door. The nurse assisted R#58 from the room and asked the resident not to enter other residents' rooms. - Review of Nurse's Notes revealed on 12/27/21 at 7:40 p.m., R#58 was observed leaving the room occupied by R#62 and R#86, who were of the opposite sex of R#58. - Review of Nurse's Notes, dated 12/28/21 at 10:00 p.m., revealed R#58 continued to enter the room where R#62 and R#86 resided. The note indicated the nurse noted R#58 leaving the room at 7:50 p.m. - Review of Nurse's Notes, dated 4/14/22 (not timed), revealed R#58 was observed looking into the room of a resident of the opposite sex while that resident was in bed. Continued review revealed the same nurse documented on 4/14/22 (not timed) that a Certified Nursing Assistant (CNA) found R#58 inside the room of a resident of the opposite sex. Review of R#58's comprehensive care plan revealed no evidence the facility developed and implemented any interventions to address R#58's behavior of repeatedly entering the rooms of residents of the opposite sex. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#58 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, R#58's behavioral symptoms had improved, and the resident had no behavioral symptoms (wandering, sexual abuse, public sexual acts, et cetera) during the seven-day assessment period. The MDS revealed the resident was independent with activities of daily living (ADLs), including walking. Further review of the care plan revealed R#58 was independent with most ADLs, with an intervention for the resident to ambulate with a rolling walker with supervision for safety. Further review revealed the resident had difficulty making his self understood due to [CONDITION(S)] (a condition in which an individual knows what they want to say but is unable to produce the word or sentence) and unclear, soft mumbled speech from a history of [CONDITION(S)] ([CONDITION(S)]) stroke. Review of a Facility Incident Report Form dated 6/20/22 at 4:00 p.m., revealed there was an incident of resident-to-resident sexual aggression, in which R#58 was caught in R#62's room with his hands in R#62's gown. Review of a witness statement, dated 6/18/22 at 10:30 p.m. by CNA NNN, revealed R#58 was caught standing over R#62's bed. R#58's hand was in R#62's gown, feeling the resident's breast. Review of Nurse's Notes, dated 6/20/22 at 5:00 p.m. for R#62, revealed staff reported a resident of the opposite sex was standing over the resident's bed and appeared to be reaching into the resident's gown. A full head-to-toe assessment was completed with no findings. The resident's responsible party and physician were notified. According to the note, ongoing physical and emotional support would be provided. Further review of Nurse's Notes for R#62 revealed on 6/22/22 at 5:30 p.m., the resident's physician ordered a behavioral health referral to provide physical and emotional support. Review of R#62's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#62's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of eight, indicating moderate cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, and dressing. Review of R#62's care plan, dated 6/20/22, revealed the resident was at risk for impaired psychosocial well-being due to an episode of inappropriate behavior by another resident. The goal was for the resident to be free from signs and symptoms of stress, changes in behavior, or changes in mood, as evidenced by presenting with a calm appearance through the next review. Interventions included observing for changes in the resident's mood and/or behavior and notifying the resident's physician as indicated; allowing the resident to express feelings related to the situation; and visiting with the resident regularly. Review of the physician's verbal orders for R#58 dated 6/20/22 revealed the resident was to be referred for behavioral psychiatry services and to have line of sight supervision at all times. The physician ordered line of sight supervision was also added to the care plan; however, the intervention was for line-of-sight supervision for 72 hours. The physician's order did not indicate the increased supervision could be discontinued after 72 hours. Review of a Room Change Notification, dated 6/20/22, revealed R#58 was moved from his room on the 400 Hall to a room on the 300 Hall. Review of a revision dated 6/20/22 to R#58's care plan revealed the resident had an episode of sexually inappropriate behavior toward a resident of the opposite sex. The goal was for the resident not to display any more sexually inappropriate or disruptive behaviors through the next review. Interventions included monitoring and documenting the resident's behavior, diverting the resident when behavior was disruptive and unacceptable, and changing the resident's room. Continued review of R#58's care plan revisions dated 6/20/22 revealed the revisions included the resident's behaviors of wandering and intruding on other residents' privacy. The goal was for R#58 not to intrude on other residents' privacy. Interventions included placing R#58 in an area where frequent observation was possible; alerting staff of the resident's wandering behavior and documenting the behavior; redirecting the resident when wandering into other residents' rooms; reminding the resident's visitors of the need to inform staff if they were leaving the designated area with the resident; instructing staff to stay with the resident if he was wandering away from the unit and to converse and gently persuade the resident to walk back to a designated area with them; and assigning staff to account for the resident's whereabouts throughout the day. A review of an in-service document dated 6/20/22 revealed staff education was provided on Line of Sight Supervision for Wandering and Inappropriate Conduct for [R#58]. The training document indicated, The purpose of this in service is to educate the staff on how to manage residents requiring line of sight supervision per physician order. [R#58] will need to remain in staff visual field at all times due to inappropriate conduct toward female residents. It is very important to protect the resident from harm by complying to the LOS [level of supervision] order. Clinical staff must immediately intervene if a resident is [sic] identified has a risk of unsafe wandering to oneself or others. The ultimate goal is to strive to prevent any harm while maintaining the least restrictive environment for the resident. The clinical team will assess and review plan or [sic] care daily to ensure the needs of the residents reflect individualized medical and safety goals. The care plans has been updated to include strategies and interventions to maintain safety. A review of a behavioral health note dated 6/23/22, revealed an initial psychiatric evaluation of R#58 for refusal of care, wandering, and hypersexual behaviors. The note indicated staff had reported that the resident had been in and out of female resident rooms and that the resident had a recent incident where he/she was seen putting his/her hand in another resident's blouse. Staff reported the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a significant change MDS, dated [DATE], revealed R#58 had a BIMS score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident did not exhibit any behavioral symptoms during the seven-day assessment period; however, the MDS indicated the resident's current behavior status, care rejection, or wandering had worsened, as compared to the previous assessment. The MDS revealed R#58 continued to be independent with bed mobility, transfers, walking in the room and corridor, and locomotion on and off the unit, and utilized a walker for ambulation. A review of a behavioral health note dated 7/21/22 revealed R#58's hypersexual tendencies appeared to be improved with the addition of [MEDICATION(S)] and that the plan of care would continue. Recommendations included encouraging activity participation and redirecting and reorienting the resident as needed. On 8/15/22 at 10:20 a.m., R#58 was observed in a facility courtyard, seated with a group of residents. There were no staff present in the courtyard at the time of the observation. Two staff members were standing at a door to the courtyard. On 8/15/22 at approximately 1:00 p.m., R#58 was observed ambulating from the dining area toward the 400 Hall. R#58 no longer lived on the 400 Hall, but R#62 and R#86 continued to reside there. Staff was present in the hallway but did not approach R#58. Licensed Practical Nurse (LPN) MMM was standing by a medication cart on the hall but had her back to R#58. During an interview at this time, LPN MMM stated she did not see R#58 in the hallway while she was at her medication cart. On 8/15/22 at 1:10 p.m., R#58 was observed in his room on the 300 Hall. During an interview on 8/15/22 at 1:21 p.m., CNA CCC revealed there was a book located at the nurse's station that listed the residents who were known to wander in the facility, but she was not aware of any specific residents who wandered. The CNA stated she was not aware of any concerns with R#58 and indicated the resident did not require any additional supervision when wandering throughout the facility. During an interview on 8/15/22 at 1:30 p.m., LPN DDD revealed there were no residents she was aware of who wandered throughout the facility, but if there were, they would be listed in a book located at the nurse's station that identified residents who wandered. According to LPN DDD, R#58 did not require any additional supervision when wandering throughout the facility, and any resident who did would be moved to the secure unit. During an interview on 8/15/22 between 1:45 p.m. and 2:30 p.m., R#101 stated he/she had witnessed R#58 entering R#62 and R#86's room and had yelled at R#58 to get out of there. R#101 had also observed R#58 leaving the room and had told R#58 to stay out. R#101 further stated she had seen R#58 stand in the hallway and stare into R#62 and R#86's room. R#101 stated she had not told staff about these observations. Review of a quarterly MDS dated [DATE] revealed R#101 scored 14 on a BIMS, indicating the resident was cognitively intact. During an interview on 8/15/22 at 1:46 p.m., CNA QQ revealed she was not aware of any resident-to-resident incidents that had occurred in the last six months or any residents who wandered throughout the facility. She stated if there were wandering residents, they would be listed in a book located at the nurse's station, or staff would be notified during the shift-to-shift report. CNA QQ recalled that R#58 was moved from the 400 Hall but did not know why. She stated R#58 could walk freely on any of the halls throughout the facility and did not require any additional supervision. CNA QQ stated staff did not have to keep R#58 in line of sight when the resident was out of the room, and she was not aware of any residents who required additional supervision when they were out of their room. During an interview on 8/15/22 at 1:58 p.m., Supervisor/LPN EEE recalled R#58 was involved in a resident-to-resident incident and was moved to a different hall because the resident did something inappropriate, but she was not sure what occurred. LPN EEE indicated staff were supposed to be mindful of Resident #58's whereabouts when the resident was out of the room, but R#58 did not require one-on-one supervision. LPN EEE stated R#58 walked around the facility and went to the courtyard or activities and could also walk the 100 and 400 Halls without any restrictions or additional supervision. During an interview on 8/15/22 at 2:08 p.m., CNA KK revealed she was not aware of any issues with resident-to-resident abuse in the last six months or of any residents who wandered throughout the facility. She stated staff should observe and redirect wandering residents. CNA KK stated R#58 did his own thing and liked to walk in the courtyard or down other halls. Sometimes, R#58 would sit by the nurse's station or watch TV. CNA KK stated she was not aware of any specific instructions related to the supervision of R#58 when the resident was out the room, and she was not aware of any concerns related to R#58. During an interview on 8/15/22 at 2:29 p.m., Social Services Staff CC revealed she was aware there was a prior incident of R#58 touching a female resident inappropriately after wandering into the resident's room. Staff CC stated after the incident, there was a department head meeting to discuss how to address the incident. Staff CC indicated the previous Social Services employee spoke with R#58 and expressed no concerns, but that employee no longer worked for the facility. Staff CC stated she did not know if the prior employee spoke with R#62, or any other residents and Staff CC had not followed-up with those residents. Staff CC stated there was a referral for behavioral health services for R#58. Staff CC stated R#58 was allowed to wander throughout the facility and that staff did not follow or keep constant sight of the resident, but staff checked on the resident periodically. On 8/15/22 at 2:30 p.m., R#58 was observed sitting on the side of his bed. The surveyor attempted to conduct an interview with the resident but was unable to understand R#58 due to the resident's [CONDITION(S)]. During an interview on 8/15/22 at 5:00 p.m., the Behavioral Health Nurse Practitioner (NP) stated that a consult was conducted on 6/23/22 following the incident on 6/20/22, and she received a report from nursing staff that R#58 had demonstrated hypersexual behaviors, masturbating in front of staff. The NP stated she did not recall which nurse had told her about the hypersexual behaviors. She ordered [MEDICATION(S)] to treat the hypersexual behaviors. Her plan was to see how the [MEDICATION(S)] worked for the resident and adjust the dose if needed. The NP stated the staff were to keep R#58 in line of sight, which meant knowing where the resident is at all times, knowing what the resident is doing. The NP stated the resident was always in line of sight when she conducted her evaluations. The NP stated she could not say for certain if R#58 would be inappropriate with another resident again, but there had been no further incidents since 6/20/22. The NP stated she did not feel R#58 needed to remain in line-of-sight supervision at this point. However, during an interview on 8/17/22 at 4:20 p.m., R#58's medical doctor (MD) stated it was his expectation that staff continue line-of-sight supervision, at all times. According to the MD, the order for line-of-sight supervision was never discontinued. During an interview on 8/17/22 at 3:08 p.m., CNA NNN revealed she had observed R#58 going into other resident rooms too much. She stated she would find R#58 behind a curtain messing with R#62, and she would have to take R#58 out of the room. CNA NNN stated she had reported this behavior to the nurses and her supervisor. CNA NNN stated there was no way to keep an eye on R#58 and take care of other residents. CNA NNN revealed after R#58 was moved to the 300 Hall, the resident continued to come and go as he pleased. R#58 knew the code to the 300 Hall door and to the door to get into the room where the snack machine was located. CNA NNN stated other staff had also seen the resident wander. During an interview on 8/18/22 at 4:08 p.m., Registered Nurse (RN) TTT revealed R#58 was quiet and non-verbal. She stated the resident walked around the entire shift, was very sneaky, and was aware and knew what he was doing. According to RN TTT, R#58 had gotten door codes by walking up behind staff while they were entering the codes. She stated the resident stopped outside female residents' rooms and stared into the room, and residents had complained to staff that R#58 made them feel uncomfortable. According to RN TTT, the resident was moved to the 300 Hall and did not have access to the 100, 200, or 400 Halls; however, redirection was the only intervention in place and was not effective long-term. 2. Review of a Face Sheet revealed R#86 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS, dated [DATE], revealed R#86 had a BIMS score of four, which indicated severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for bed mobility. According to the MDS, the resident had highly impaired vision. Review of Nurse's Notes, for R#86 dated 8/16/22 at 10:05 p.m., revealed a CNA (not identified) reported another resident was found in R#86's room. The resident was redirected to the correct room without difficulty. A full head-to-toe assessment was completed for R#86, with no abnormal findings. R#86 had no complaints of pain or discomfort. Review of R#58's medical record revealed a Nurses Note dated 8/16/22 at 10:00 PM and signed by the Assistant Director of Nursing (ADON), which indicated R#58 was in another resident's room. According to the note, R#58 was redirected back to his room without difficulty and one-to-one monitoring was initiated along with ongoing line-of-sight supervision Review of physician's Progress Notes, dated 8/17/22, revealed the facility contacted the Medical Director to review an incident involving R#58. The note indicated a CNA found the resident uninvited in another resident's room. R#58 was reported to be standing next to a sleeping resident who was unaware of R#58's presence. R#58 was partially dressed and there was no appearance or evidence that any personal contact had occurred. Staff escorted R#58 back to his room, and a one-on-one sitter was assigned until further discussion and a plan was formulated. The note revealed the Medical Director met with the nursing management team and discussed the incident with the resident's primary care physician. The decision was made to transfer R#58 to a more appropriate level of care due to the behavior. During an interview on 8/17/22 at 3:08 p.m., CNA NNN revealed that on 8/16/22, she finished showering a resident, went back to the linen cart, and walked to the room shared by R#86 and R#62. CNA NNN stated she observed R#58 with his right leg on R#86's bed and R#58's pants were down. CNA NNN stated that R#86 was lying in the bed with her mouth open. CNA NNN stated R#58 was in an obvious state of sexual arousal, he had knee up on the bed, and was positioned close to R#86's face. R#58 was making a stroking motion up and down by his genitals. CNA NNN stated she called two nurses to come to the room and asked R#58 what was going on. At that point, R#58 pulled up his pants. The nurses asked the resident what was happening, and R#58 stated, I don't know. According to CNA NNN, she believed R#58 was aware that R#62 and R#86 were unable to talk and that is why R#58 preyed on those two residents. During an interview on 8/17/22 at 4:01 p.m., the DON revealed following the 6/20/22 incident involving R#58 and R#62, she instructed the nurse that R#58 needed to be always within someone's sight. The line-of-sight supervision was to allow the resident to have freedom to walk around the facility but to make sure there was no threat to any residents. According to the DON, nursing may have put a time limit of 72 hours for supervision on the care plan, but after the 72 hours, the facility made the decision for supervision to continue and believed there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/19/22 at 3:23 p.m., LPN GG stated that R#58 would get up during the night and staff would redirect the resident. LPN GG stated she tried to know R#58's whereabouts, but if she was doing rounds, she may not see the resident and it was possible for the resident to get past her without being noticed. LPN GG stated she worked the night of 8/16/22. When she arrived for the shift, she was told there had been an incident on the previous shift involving R#58 and that the resident was to have one-to-one monitoring. LPN GG stated if the prior shift nurse was in another room, R#58 could have gotten into the other resident's room without being noticed. During a follow-up interview on 8/20/22 at 11:43 a.m., the DON revealed she was called to the facility on [DATE] when R#58 was found in R#86's room. The DON stated on the evening of the incident, she met with Assistant Director of Nursing (ADON) EE, the Administrator, and the Director. The DON stated the decision was made to place R#58 on one-to-one observation. During an interview on 8/20/22 at 1:12 p.m., the Administrator stated it was her expectation for staff to follow the processes already in place. The goal was to ensure the residents were in a safe environment and kept safe.

Based on clinical record review, interviews, and facility policy review, the facility failed to ensure a safe discharge for one of three residents (R) (R#125) reviewed for discharge. R#125 was discharged from the facility to home on 10/28/22 without a confirmation that home health services were in place and that there was a capable family member at home to assist with the resident's continued care needs following discharge. Findings included: A review of the facility policy, titled, Discharge Summary and Plan of Care, dated 3/1/19, revealed the following: Policy: It is the policy of this facility to ensure that a discharge planning process is in place which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. Policy Explanation and Compliance Guidelines: 1. The discharge planning process will begin at admission and include a discharge plan based on the resident's assessment and goals for care, desire to be discharged , and the resident's capacity for discharge. 2. The Discharge Plan should include: d. To ensure the needs of the resident will be met after discharge from the facility, the social service or designee should identify and arrange for post-discharge needs such as nursing and therapy services, medical equipment for discharge home or to an alternate care setting. e. Referrals to local contact agencies, the local ombudsman, or other appropriate entities; f. Documentation of the referrals and response to the referrals. A review of R#125's admission Minimum Data Set (MDS), dated [DATE], revealed R#125 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance with bed mobility, dressing, personal hygiene, and bathing; and was dependent on staff for toilet use. R#125 received all three disciplines of therapy while at the facility: physical therapy (PT), occupational therapy (OT) and speech therapy (ST). A review of R#125's comprehensive care plan, dated 10/07/21, indicated: Problem/Need: Resident admitted for short-term rehabilitation. Resident and Family desire resident to be discharged back home w (with) son after rehab (rehabilitation). Resident will have in-home supportive services (caregiver, home health, etc.) Approaches: Monitor resident's progress in therapies. As the tentative discharge date approaches, discuss the need for continued therapy with the rehab department. If continued services are necessary in the home environment and arrange home health services. Arrange appropriate home care services as needed including medical equipment and home health services. A review of Social Progress Notes revealed the social worker met with R#125 one time on 10/15/21 and indicated that the resident's goal was to return home and that there was already medical equipment in the home. The social worker indicated that a referral to home health services would be provided at discharge. A review of R#125's PT - Therapist Progress & Discharge Summary, evaluation, dated 10/27/21, revealed: The patient had been living at an apartment w (with) son - had [CONDITION(S)] (TBI) in 2011 - able to assist with some home care such as cooking and cleaning the apartment], tub shower unit, standard toilet/grab bars, ambulatory w/o (without) AD (assistive device) cooking, cleaning, driving. However, over the past two months the patient reports a decline in all functional skills - patient hired a PCS [patient care assistant] to help bathe and move around the house - due to decline in functional skills, this patient requires skilled PT [physical therapy] to regain decrease burden of care. A review of the physician's discharge order, dated 10/28/21, revealed an order to discharge the resident to home with home health on 10/28/21, with orders to evaluate for OT, PT, ST, nursing, and social worker. A review of a facsimile (fax) to a home health agency, dated 10/28/21, revealed a request for home health to evaluate R#125 upon discharge. The reviewed fax contained a receipt confirmation of 10/28/21 at 12:20 p.m. The directive handwritten at the bottom of the fax, signed by social services, revealed: Pt (patient) scheduled to d/c (discharge) 10/28/21 at 11:00 a.m. Will need eval (evaluation) for OT, PT, ST, Nursing, Social Worker. A review of Skilled Daily Nurses Note for R#125, dated 10/28/21 at 2:23 p.m., indicated: Resident is anxious about going home. Resident given PRN (as needed) [MEDICATION(S)] (a narcotic pain medication) for discomfort. Signed by Licensed Practical Nurse (LPN) AA. A review of Nurse's Notes for R#125, dated 10/28/21 at 2:57 p.m., indicated: Resident discharged with (name of transportation service) at 2:57 p.m. All belongings with resident. Stated PRN (as needed) medication given for discomfort was effective. Resident transported via stretcher. Signed by LPN AA. A review of R#125's discharge instructions revealed that an evaluation had been sent to a home health agency for OT, PT, nursing, and a social worker. There were no nursing concerns identified and that a Hoyer (mechanical lift for transferring) lift with sling had been ordered from a medical equipment company. During an interview on 8/17/22 at 12:23 p.m., LPN AA stated when preparing to discharge a resident she would assess the resident's progress and discuss ambulation and activities of daily living (ADLS) with therapy. LPN AA further stated that the resident's ability with self-care was considered, and that nursing ensures any necessary follow up medical appointments were in place and the resident was educated on any specific needs such as indwelling urinary catheter care. LPN AA stated that if she thought it was an unsafe discharge, based on her assessments, she would notify her supervisor. She did not recall the circumstances of R#125's discharge. During an interview on 8/18/22 at 9:20 a.m., LPN BB, the nursing supervisor, stated she was responsible for conducting a follow me home page that was submitted to the pharmacy requesting a seven-day supply of medications for the resident to have once home. LPN BB further stated that she would review the discharge medications with the resident and/or family prior to discharge and any upcoming appointments were provided. LPN BB stated that social services was responsible for arranging community services for when the resident got home. LPN BB stated she did not remember the resident (R#125). During an interview on 8/18/22 at 9:26 a.m., Social Worker (SW) CC stated that she was not working at the facility during the time that R#125 was admitted and discharged and was unable to speak to the circumstances of the discharge at that time. The SW during the time that R#125 was at the facility was no longer employed at the facility and unavailable for interview. SW CC stated that when requesting home health, she would keep a copy of the referral and if there were questions related to the availability of home health, she would follow up to make sure that the services ordered were in place following discharge. SW CC stated that she tried to touch base with nursing and therapy to ensure that everything was okay with a potential discharge. During a phone interview on 8/18/22 at 12:28 p.m., R#125 stated that he was aware of being sent home, but did not receive any discharge instructions. R#125 further stated that he had to return home by stretcher because he could not walk and once home, the resident did not have any home health services. R#125 stated that the home health agency contacted the resident and stated that they were unable to provide services as they did not have staff availability. R#125 stated that there were several calls made to the social worker at the facility, but the calls were not returned, the resident had to hire a caregiver to come into the home to help with ADLs and indwelling urinary catheter care as the resident was unable to perform these tasks without help. During an interview on 8/18/22 at 3:48 p.m., Therapy Department Coordinator (TDC) DD stated that she did not recall R#125 or the circumstances of the resident's discharge. TDC DD reviewed the resident's closed clinical record and stated that R#125 was discharged requiring assistance with self-care and transfers and that therapy did not recommend the resident being discharged , and that the discharge was due to a payor limitation. During an interview on 8/19/22 at 3:41 p.m., the Director of Nursing (DON) stated that typically the nursing staff was notified by social services approximately 48 hours in advance that a resident was going home and whether the patient needed home health or durable medical equipment (DME). Nursing would write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Depending on the resident, education may need to take place. The DON did not start working for the facility until November 2021 and was unable to discuss R#125's discharge. The DON stated that her expectation was that staff discussed discharge with social services and the physician to ensure a safe discharge. The DON further stated social services should have reached out to home health to ensure they could meet the needs of the patient. During an interview on 8/20/22 at 12:33 p.m., the Administrator stated that ideally the home health referral should occur at least three days prior to the discharge to allow the home health company time to get the physician order, the insurance verification, and to line up the staff needed to provide the expected services. The Administrator stated that she was unaware of the situation with R#125 and was very disheartened to hear that this had occurred. She stated her expectation was that the staff provided the best care, and that the resident was discharged with their goals in mind and ensure a safe discharge.

Base on observation, interview, and the facility policies titled Food and Supply Storage Procedures and Cleaning Vents the facility failed to store, label, date, discard of expired food items, and to prepare food in a sanitary manner to prevent food contamination by ensuring that one ceiling vent over a preparation counter was clean. This had the potential to effect 136 oral fed residents of a total of 139 residents. Findings include: 1. Record review of policy titled Food and Supply Storage Procedures read Foods past the use by, sell by best-by, or enjoy by date should be discarded. Foods that are stored on ladder/speed racks must be fully covered to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart, or cover each tray individually An observation with the Dietary Manager (DM) on [DATE] at 10:46 a.m. of one of two Reach in Refrigerators designated for dairy items labeled as the milk cooler revealed three, one quart containers of half and half with an expiration date of [DATE]. An observation with the DM on [DATE] at 10:47 a.m. revealed the following food items: one box of mushroom not completely sealed or covered with no open date, An observation with the DM on [DATE] at 10:49 a.m. of the pantry revealed an open bag of rice in a large plastic bag with no open date and no expiration date. Interview with DM on [DATE] at 10:35 a.m. reported that her expectations are for staff to label, date, discard of expired food, and store food properly to prevent contamination. 2. Record review of policy titled Cleaning of Vent the policy stated that the Maintenance Department is responsible for cleaning the vent, An observation with the DM on [DATE] at 10:58 p.m. of one of three ceiling vents revealed one ceiling vent covered with thick dark brown and dark greyish substances located directly above one preparation counter that contained a toaster. The DM confirmed at the time of the observation that the substance was dust mixed with dirt and debris. She further stated the counter is used to prepare toast and sandwiches. The DM stated that the Maintenance Supervisor is responsible for cleaning the vents in the kitchen. An interview on [DATE] at 1:25 p.m. with the DM and the Maintenance Director (MD) revealed that it is the MD duty to clean the vent. He last cleaned the vent last year and could not recall the exact date. The Maintenance Director was asked to provide a copy of the cleaning log although it was not provided during the survey. An interview with the Administrator on [DATE] at 8:56 a.m. revealed that the DM had made her aware of the problems in the kitchen and her expectations are for the dietary staff to clean the vents in the kitchen. She further stated that her expectations are for all food items to be labeled, dated, and expired food items to be discarded.

Based on observation, interviews, and the facility policy titled Dignity and Quality of Life Policy, the facility failed to maintain dignity to one resident (R), R#126, who has a biliary bag of 44 sampled residents. Findings include: Record review of policy titled Dignity and Quality of Life Policy stated the following: To promote care of residents in a manner and in an environment, that maintains or enhance each resident 's dignity and respect and full recognition of his or hers individuality. The resident has the right to -be treated with dignity, respect and consideration at all times; privacy in the treatment and care of your personal needs. Record review of the resident's medical record revealed [REDACTED]. Review of the Admission Nursing Assessment, dated 4/16/19, revealed that resident was assessed as being cognitve and oriented times three. and that the resident was admitted for rehabilitation purposes only. Review of Nurse's note dated 4/26/19 at 7:15 a.m. stated that resident was seen at a local hospital for a special procedure and returned to the facility on the same day at 12:00 p.m. with biliary drainage tube. An observation on 4/30/19 at 10:22 a.m. revealed the resident sitting in his wheelchair in the rehab therapy room with six other residents. The resident's catheter bag, that included a cholecystectomy tube (biliary drainage tube), was not covered exposing dark yellow bile and urine in the catheter bag. An interview with the resident on 4/30/19 at 4:01 p.m. revealed that he was unaware and received no education from staff that his catheter and biliary bag should be covered. The resident stated that he would had like for staff to provide covering so no one will see his business. An interview on 5/2/19 at 11:55 a.m. with Licensed Practical Nurse (LPN) HH revealed her expectations are for residents to always have attached bags covered to ensure privacy. She further stated that at one time staff used a pillow case for the resident's biliary bag. An interview with on the Director of Nursing (DON) on 5/1/19 at 2:58 p.m. revealed that she expects the biliary tube bag to be covered. She further stated that she was not sure if her staff had received any in-service training on ensuring dignity care for residents who have a catheter/ biliary bag.

Based on observations, staff interviews, and review of the facility policy titled To Provide Direction /Guidance in Reference to Change of Conditions and the Hospice contract agreement policy titled Nursing Facility Agreement dated 1/2/19 the facility failed to provide notification to the Physician and Hospice staff about one Resident (R) W draping a call light around his neck and across his shoulders of 44 sampled residents. Findings include: Review of policy titled To provide direction/guidance in reference to changes of conditions revealed, It is the policy of the facility to notify the MD/NO/PA (Medical Director/Nurse Practitioner/Physician Assistant) of any change of condition regarding the patient. When a change of condition or change from baseline is observed and reported, the licensed nurse is responsible to evaluate the resident 's condition. The nursing supervisor on duty is also notified regarding the change in condition. The SBAR (Situation Background Assessment Recommendation) is then completed and sent to the provider for review. Record review of R W revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of Physician Orders (POF) and the Medication Administration Record [REDACTED]. The resident was receiving [MEDICATION NAME] 100 milligrams (mg) in the morning and 200 mg at HS (hour of sleep). Review of the Quarterly Minimum Data Set (MDS) assessment that was completed on 10/23/18 revealed a Brief Interview Mental Status (BIMS) score of two, with no behaviors assessed. Review of the Quarterly MDS completed on 1/17/19 indicates a BIMS score of four, with no behaviors assessed. A BIMS score of two or four out of 15 indicates severe cognitive impairment. Record review of Hospice record revealed that R W was admitted to Hospice on 1/13/18. The Hospice primary admitting [DIAGNOSES REDACTED]. Record review of Nurse Notes dated 9/16/18 (no specific time given), 10/7/18 at 2:00 a.m., 10/7/18 at 4:00 p.m., 10/7/18 at 8:00 p.m., and 10/15/18 at 11:00 p.m. revealed separate incidents of RW wrapping call light around his neck. There was no documentation evidence, in the record, to indicate that Hospice and/ or the Physician were notified of the incidents. An observation on 4/29/19 at 1:10 p.m. and on 4/30/19 at 4:52 p.m., revealed R W lying in bed, with his eyes closed with the call light attached and within reach. An observation on 5/1/19 at 10:40 a.m., revealed R W to be alert and lying in bed with the call light attached to the bed and within reach. Family was present in room visiting at that time. An observation on 5/2/19 at 8:10 a.m., revealed R W to be alert, call light removed and bell within reach. Also, observed R W lying in bed, HOB (head of bed) elevated with a Certified Nursing Assistant (CNA) WW, feeding the resident his breakfast. CNA WW reported that he is providing monitoring (as a sitter) and has been authorized by the Administrator to sit with resident for eight hours. After the incident was identified during the survey and brought to the Director of Nursing (DON) attention on 5/1/19 at 2:00 p.m., the DON reported that she was unaware of the incidents. She further stated that the licensed nursing staff who wrote the nurse notes were no longer employed with the facility. Further interview with the DON on 5/1/19 at 2:27 p.m. revealed that R W was only draping the call light around his neck and shoulders. The call light was never observed by staff to encircle his neck. DON reported that information was provided by a Certified Nursing Staff (CNA) UU. She further stated that this was a known habit of this resident. The DON described R W as having periods of confusion. The DON revealed that R W was described as being nonsuicidal and has no history displaying behaviors of trying to hurt himself. During an interview on 5/1/19 at 4:15 p.m., the Family Member of R W revealed that the facility contacted the family today about sending RW out for a psych eval (psychological evaluation) earlier today. The family did not want a psych evaluation and were aware of an incident of R W wrapping call light around his neck and did not view the incident as R W trying to harm himself. The Family Member described the resident's behavior of wrapping the call light around his neck as being scared and fear that he would lose it (meaning the call light) and not wanting his room door closed. She stated that R W would never harm himself and that the resident denied trying to harm himself when she asked him. She was not sure the exact date the incident occurred and felt that it happened in (MONTH) or (MONTH) of (YEAR). An interview with the DON and the Administrator on 5/1/19 at 5:40 p.m. R W draping the call light around his neck on at least three occasions revealed that the Administrator was not aware of these incidents. The Administrator revealed the facility approach to ensure R W safety is to evaluate the resident to see if he could use a hand-held bell to call for assistance, and if so, would remove the call light. The DON revealed there was no evidence that the Physician was notified of the incidents. An interview with CNA UU on 5/1/19 at 5:40 p.m. revealed that she found the resident in his room about four or five months ago, with his call light draped around his neck. She reported that the positioning of the call light did not place the resident at risk/ jeopardy of choking himself although she informed the resident not to drape the call light cord around his neck. She revealed that the resident had been instructed to use his call light if there was an emergency or he needed something. CNA UU revealed that the cord was removed from R W's neck, placed at his bedside and the Licensed Practical Nurse (LPN) was notified. The CNA was unable to remember which LPN was notified and was not aware that the resident had ever done this before. An interview with the Physician on 5/1/19 at 6;00 p.m. revealed that he had not been notified about the incident until 5/1/19. He stated that due to resident 's [DIAGNOSES REDACTED]. He further stated that the resident was wrapping the call light around his neck for placement purpose and to use so he will be able to reach it and have contact with others. He further stated that the call light was never in a loop (a loop would had been a concern). When asked if he would had put any intervention in place of the time of the incident occurrence providing he received notifications? He stated no, because R W has medications to calm him ([MEDICATION NAME]) When asked if he felt the increase in [MEDICATION NAME] made a difference in R W's behavior? He stated no. An interview with the Administrator on 5/1/19 at 7:10 p.m. revealed that she was putting in place the following: a staff( to serve as a sitter) to provide 1:1 throughout the night and ongoing until her team decide on how to ensure safety. Staff will log information on the staff who will be sitting starting tonight She stated that the call light has been removed and R W was given a bell to use. An interview on 5/2/19 at 12:46 p.m., with the Hospice Register Nurse (RN) revealed that notifications in regard to the incidents of R W draping call light around his neck and shoulder was not provided to Hospice until yesterday afternoon by the DON. She stated that the Hospice policy clearly states that certain incidents are mandatory reporting. This incident would had been categorized as critical- and entered in the Triage system. She reported that she has researched the triage and there were no calls recorded from the facility. She further reported that she does not feel that R W is suicidal or want to harm himself. She stated that the resident has a fear of being left alone, want the door be open, becomes afraid at night and use to sleep with his finger on the call light. She stated that his fine motor skills are gone and he view the call light as a safety blanket. On 5/2/19 at 11:00 a.m., the DON presented a physician progress notes [REDACTED]. Record review of physician progress notes [REDACTED]. Patient has always been comfortable.

Based on record review, staff interview, facility document review and hospital record review the facility failed to develop a comprehensive plan of care for one (1) , resident #1, who had been assessed as being as totally dependant for care and was at high risk for falls, in a survey sample of five (5) residents. This resulted in the resident experiencing a fall and sustaining a fractured femur. Findings include: Record review for resident #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated that the resident was assessed as being totally dependent and as requiring two plus person physical assistance for transfers, totally dependent for bed mobility, totally dependent for bathing and totally dependent for dressing. Review of the Care Plan dated 1/04/2012 for resident #1, listed as a problem the potential for falls, and for injury due to [MEDICAL CONDITION] activity; however, there was no specific approaches on the Fall Care Plan related to the resident's inability to sit in an upright position due to her debilitated state, and her history of [MEDICAL CONDITION] that had left the resident with residual physical deficits and upper body contractures. Additional review of the record for resident #1 did reveal a problem identified on the Care Plan of 1/04/2012 listing that the resident was totally dependent on staff for all care and needs; however, the approaches for this problem did not include any interventions which would prevent a fall from a shower chair and/or interventions to accommodate this resident's lack of functional ability to sit in a chair, or shower chair without support. Futher, the care plan did not specify the staff support required by this resident who had been assessed as being totally dependant for dressing. Review of resident's #1s Nurse's Note dated 8/30/2012 at 11:00 a.m., revealed documentation that Licensed Nurse "EE" was called to the shower room where she observed resident #1 laying on the wet floor on her back. This same note further documented the right leg appeared to be laying in a different position than normal, Certified Nursing Assistant (CNA) "CC" stated that the resident slid out of the shower chair, with no apparent injuries noted at that time. The physician was notified and resident was sent to the emergency room for evaluation. The resident was admitted to the hospital and subsequently diagnosed with [REDACTED]. During an interview with Administrative Staff "DD" on 10/12/2012 at approximately 1:46 p.m., Staff Member "DD" stated that there had been two CNA staff members present during the bath, but the other CNA had left this area to attend to other residents, leaving CNA "CC" alone to care for (dress) this totally dependent resident who was still in the shower chair. During interview with Administrative Staff "AA" and "DD" on 10/19/2012 at approximately 3:40 p.m. the above findings were confirmed. Cross refer to F323G for failure to have adequate supervision to prevent accidents.

Based on record review, hospital record review, facility document review and staff interview, the facility failed to ensure that a resident received adequate supervision/assistance to prevent accidents, for one (1) resident who was assessed as being totally dependant for care, resident #1, on the survey sample of five (5) residents. This resulted in the resident sustaining a fracture of the right femur. Findings include: Record review for resident #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated that the resident was assessed as being totally dependent and requiring two plus person physical assistance for transfers, totally dependent for bed mobility, totally dependent for bathing and totally dependent for dressing. The Care Plan dated 1/04/2012 documented the resident was totally dependent on staff for all care and needs. One of the approaches listed was to provide a bed bath or shower care per schedule and as needed. A Nursing Home Progress Note from the physician dated 1/26/2012 documented severe dementia, bedfast, severely debilitated, contractures of the upper and lower extremities and multiple strokes for this resident. Additional [DIAGNOSES REDACTED]. A Physician's Medical Statement dated 10/16/2012 documented that the resident had advanced osteoporosis and a history of multiple fractures. Review of a Nurse's Note of 8/30/2012 at 11:00 a.m., revealed documentation that Licensed Nurse "EE" was called to the shower room where resident #1 was observed lying on the wet floor on her back. This same note further documented the right leg appeared to be laying in a different position than normal, certified nursing assistant (CNA) "CC" stated that the resident slid out of the shower chair, with no apparent injuries noted at that time. The physician was notified and the resident was sent to the emergency room for evaluation. The resident was admitted to the hospital and subsequently diagnosed with [REDACTED]. A written statement from CNA "CC" who was caring for the resident on 8/30/2012 when the incident occurred, documented that she was going to put a diaper/brief on the resident after the resident had been bathed, as she leaned the resident up, the resident slid out of the chair and onto the floor. This statement further indicated that CNA "CC" managed to grab the resident under her arms to prevent her from hitting her head, but the resident still landed on her legs, and her legs were under her knees and slightly bent. During an interview with Administrative Staff "DD" on 10/12/2012 at approximately 1:46 p.m., Staff Member "DD" stated that there had been two CNA staff members present during the bath, but the other CNA had left the area to attend to other residents, leaving CNA "CC" alone to care (dress) for this totally dependent resident who was still in the shower chair. During interview with Administrative Staff "AA" and "DD" on 10/19/2012 at approximately 3:40 p.m. the above findings were confirmed.