Every finding on record at PruittHealth - Macon

Based on record review, staff interviews, and review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure resident (R) (R209) was free from abuse when R200 engaged in nonconsensual sexual contact with R209 by grabbing and kissing him on the mouth out of four residents investigated for abuse. This deficient practice had the potential to place cognitively impaired residents at risk for nonconsensual sexual contact and further incidents of abuse. The facility census was 171.Findings include:Record review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised on 10/21/2025, documented, It is the policy of the facility and its affiliated entities .to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property .The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. The policy defined Sexual abuse as non-consensual sexual contact of any type with a resident.1.Review of R209's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia without behavioral disturbance, bipolar disorder with current episode manic severe with psychotic features, and generalized atherosclerosis.Review of R209's Minimum Data Set (MDS) dated [DATE], documented Section C Cognitive Patterns, Brief Interview for Mental Status (BIMS), as 03 - Severe Impairment. Section N-Medications documented R209 as receiving Antipsychotic, Antianxiety, and Antidepressant medications.Review of R209's care plan dated 07/23/2025, documented, problems, titled, Potential for side effects/adverse reactions related to (r/t) psychotropic Drug Use r/t bipolar disorder, insomnia, Dementia with behaviors, Anxiety, and Presence of Behavioral Symptoms includes Wanders Unsafely, Resists Care.2.Review of R200's EHR revealed she was admitted to the facility's Memory Support Unit (MSU) on 10/22/2025 with diagnoses including, but not limited to, Alzheimer's disease, dementia in other diseases classified elsewhere severe with psychotic disturbance, anxiety disorder, and depression.Review of R200's discharge, return anticipated MDS assessment dated , 10/23/2025, documented Section C Cognitive Patterns as, (BIMS), interview not performed, and Section E Behaviors revealed physical behavioral symptoms directed toward others, including grabbing and abusing others sexually, occurred 1 to 3 days, and other behavioral symptoms not directed toward others, including public sexual acts and disrobing in public, occurred 1 to 3 days. Section N Medications documented R200 as receiving Antipsychotic, Antianxiety, Antidepressant, and Anticonvulsant medications.Review of R200's care plan dated, 10/22/2025, documented, problems, titled, Psychotropic Drug Use, and Presence of Behavioral Symptoms, identifying R200 as physically aggressive as evidenced by disrobing and wandering in and out of others' rooms.Review of the Facility's Incident Report Form (FRI), revealed the incident date and time as 10/23/2025 in the evening, and documented, On the evening of October 23, 2025, R200 was observed by nursing staff engaging in inappropriate physical contact, including kissing another resident and making unsolicited physical advances toward male residents. Multiple redirection attempts were unsuccessful. The form documented immediate actions taken including verbal redirection, notification of the Medical Director and Director of Nursing, an updated care plan, a Medical Director order for transfer to an external facility for a behavioral health evaluation, and family notification. The form identified the reportable categories as inappropriate sexual contact between residents, a behavioral health crisis requiring transfer, and a potential risk to the safety and well-being of other residents.Record review of R200's nursing progress notes dated 10/23/2025 at 5:42 PM revealed R200 was very agitated, pulling on other residents' clothing, touching and agitating another resident, hitting and cursing at staff, moving chairs, stripping tablecloths, and making sexual gestures with her breast. The note documented R200 grabbed a male resident and kissed him in the mouth in the dining room, and that R200 sat on top of the dining table and would not get down, nearly falling before being caught by staff.Review of the facility's Situation, Background, Assessment, Recommendation (SBAR) Communication Form, dated, 10/23/2025, revealed the situation was documented as Uncontrolled Behavior, beginning on 10/23/2025, with primary diagnoses listed as dementia, fighting, and disrobing. The nursing notes section of the form reiterated that R200 was noted touching other residents, was noted making sexual gestures with her breast, and grabbed a male resident and kissed him in the mouth. The form documented the primary care clinician, was notified on 10/23/2025 at 8:38 PM, and R200's family/health care agent was notified the same day at 8:40 PM.Record review of the facility's Skilled Nursing Facility / Nursing Facility (SNF/NF) to Hospital Transfer Form dated 10/23/2025 revealed R200 was sent to the hospital, with the reason for transfer documented as Combative, Disrobing, Abnormal Sexual Behavior. The form documented a risk alert for Agitation with risk to harm self or others.Interview conducted on 07/16/26 at 11:49 AM with the Certified Nursing Assistant (CNA) AA revealed she had been in the dining room at the time of the incident. She stated she was tasked with providing one-on-one supervision for R200 because R200 would go around and attempt to kiss other residents. CNA AA stated R200 was in a wheelchair, got up, kissed R209, though she does not recall where on his body. She stated she immediately redirected R200 and escorted her out of the dining room, then informed the nurse.Interview conducted on 07/16/26 at 9:19 AM with the Director of Health Services (DHS) revealed that on the day of the incident, R200 was acting hypersexual in the dining room, rubbing herself and attempting to move around the building. She stated staff were constantly redirecting R200 in the dining room, and staff would routinely sit in the dining room to keep an eye on her. She stated the CNA reported that R200 was especially erratic that day and attempted to stand on the table. She stated the charge nurse called and informed her that R200 was acting erratic, and a short time later, after R200 was transferred out, the nurse told her that R200 had kissed R209. She stated staff notified the Administrator of the incident, who then reported it. She stated interventions included one-on-one supervision, and staff initiated transferring R200 to the medical center and attempted to administer medication to help calm her. She stated the facility concluded their investigation and the allegations were substantiated.Interview conducted on 07/16/26 at 11:10 AM with the Administrator revealed she was not the Administrator at the time of the incident but confirmed the incident did occur. She stated she was told R200 was not at the facility very long, as R200 had significant behavioral issues. She stated staff were concerned about those behavioral issues, and R200 was ultimately discharged .

Based on observations, record review, staff interviews, and review of the facility policy titled, Compliance Rounds, the facility failed to ensure a hazard-free environment for one of six residents (R) (R182)reviewed for accident hazards when six disposable razors and one hair trimmer were observed unsecured on the resident's bedside table and accessible within the resident environment. This deficient practice had the potential to place residents at risk for lacerations or other injuries from unsecured sharp objects. The facility census was 171.Findings include:Review of the facility's policy titled, Compliance Rounds, revised on July 1, 2026, revealed, The Organization is implementing compliance rounds to attain and maintain consistency in providing quality patient/resident care. The policy stated compliance rounds are to be made once per shift by the House Supervisor, Unit Manager, Charge Nurse, Department Head, or designee, utilizing the Compliance Rounds Form, and stated staff should correct identified concerns when possible and if not possible document concerns in the comments column. The associated Compliance Rounds Form included, under Patient/Resident Bathrooms, an item requiring staff to verify no medication or chemicals or sharp items (i.e. cream powder and air freshener) were present in resident rooms.Review of R182's Electronic Health Record (EHR) documented he was admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle weakness, unsteadiness on feet, anxiety disorder, depression, and mood disorder due to known physiological condition.Review of R182's quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Section C Cognitive Patterns, Brief Interview for Mental Status (BIMS), as 14, indicating intact cognition. Section N Medications documented R182 as receiving Antianxiety, and Antidepressant.Review of R182's care plan revealed a problem, dated 06/25/2025, documented R182 was at risk for injury related to hoarding items, keeping all items and belongings out in room and around bed.Observations on 07/13/2026 at 12:31 PM, 07/14/2026 at 9:54 AM, and 07/14/2026 at 12:09 PM revealed six blue disposable razors and a hair trimmer at R182's bedside table.Interview and observation conducted on 07/15/2026 at 10:16 AM with the Certified Nursing Assistant (CNA) BB, revealed that during R182's room checks, she had found items not allowed at bedside as these items could be used by residents to harm themselves. She stated every time staff enter a room, they should scan the room for any accident hazardous item. She stated if she found a hazardous item, she would notify the nurse, who then would talk to the residents to explain why the item must be removed. She stated residents are not allowed to have razors at their bedside table because they could easily hurt themselves. Observation of the room confirmed the presence of razors and a hair trimmer. CNA BB stated a potential negative outcome would be the resident harming himself or another wandering resident gaining access to the items.Interview and observation conducted on 07/15/2026 at 10:25 AM with the Licensed Practical Nurse (LPN) CC revealed that all staff are expected to look out for hazardous items in resident rooms. Observation confirmed six razors and a hair trimmer at the bedside. LPN BB stated a potential negative outcome would be someone coming into the room and using the items to harm themselves or others. She stated the expectation is for anyone entering a resident's room to observe for any hazardous items.Interview conducted on 07/16/2026 at 9:19 AM with the Director of Health Services (DHS) revealed she completed inservice training with staff on which items can and cannot be kept at bedside. She stated they try to conduct room rounds daily, and CNAs are expected to look for any hazardous items during their shift. DHS stated the potential negative outcome of hazardous items being present is that a resident could cut themselves.Interview conducted on 07/16/2026 at 11:10 AM with the Administrator revealed the expectation is that staff follow facility policy and remove hazardous items and educate residents on potential hazardous items. She stated that even if the item is care planned, the item should not be visible. She confirmed R182 is not supposed to have the items at bedside. She stated the potential negative outcome is that another resident could gain access to the razor and use it inappropriately.

Based on observations, staff interviews, record review, and review of the facility's policy titled Patients/Resident Rights, Accommodation of Needs, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one of 50 sampled residents (R) (R73). This deficient practice had the potential to diminish R73's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of the facility's policy titled, Patients/Resident Rights, Accommodation of Needs, dated 12/1/2023, documented under Policy Statement: It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. Under Procedure: .B. Privacy: 1. Patients/residents will be provided full visual privacy during routine care and treatment by means of privacy curtains and closed doors. Review of R73's Annual Minimum Data Set (MDS) assessment, dated 2/2/2025, documented Section GG (Functional Abilities and Goals) documented R73 was dependent on staff for assisting with toileting. Review of R73's care plan dated 4/8/2025 documented that R73 required skills training in toileting/toilet transfer with an approach to assist the resident to the bathroom throughout the day to reduce the risk of falls when taking self to the bathroom. Observation on 5/12/2025 at 2:16 pm revealed Activities Assistant II assisting R73 with her briefs while the door was open, and no privacy curtain was pulled. In an interview on 5/12/2025 at 2:23 pm, the Activities Assistant II confirmed that the door should be closed. In an interview on 5/15/2025 at 8:56 am, the Director of Health Services (DHS) stated that staff tried their best to keep the resident doors shut during care, but that couldn't always be maintained. The expectation was for staff to close the doors while providing care.

Based on observations, resident and staff interviews, and review of the facility's policy titled Infection Control-Housekeeping Services, the facility failed to maintain a safe, clean, comfortable, and homelike environment in four of 97 resident rooms (Room F11, Room F13, Room F15, and Room F21). Specifically, buildup of food on a television, stained and sticky floors, and dust-covered ceilings and wall vents were observed. Findings include: Review of the facility's policy titled Infection Control- Housekeeping Services, revised 10/16/2023, revealed under Friction Cleaning: 1. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in patient/resident care areas. A deep cleaning will be performed for each patient/resident room monthly and at discharge. Under Routine Cleaning of Horizontal Surfaces: 1. In patient/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently if spillage or visible soiling occurs. Observations made on 5/12/2025 at 11:00 am revealed that resident room F11's ceiling and wall vent filter had approximately two inches of thick dust and particle buildup. The floor had sticky substances along with discoloration. Observations made on 5/12/2025 at 11:15 am revealed that resident room F13 had sticky and brown substances on the floor, and the ceiling and wall vents were covered in dust and particle buildup. Observations made on 5/12/2025 at 11:25 am and on 5/13/2025 at 2:00 pm revealed that resident room F15 had a television with food particles built up on the top and sides. Observations made on 5/12/2025 at 11:40 am revealed that resident room F21's ceiling and wall vent filter had approximately two inches of thick dust and particle buildup. During an observation and interview on 5/14/2025 at 12:06 pm with the Housekeeping Supervisor and Maintenance Director, both confirmed all the findings. The Housekeeping Supervisor stated that she used a calendar that the facility goes by to select rooms slated for deep cleaning, and if a room was not selected, needed extra cleaning, that room would be chosen instead. The Housekeeping Supervisor also stated that the housekeeper on the F hall was a regular scheduled staff member and was aware of the issues in room F15 and that it required extra attention daily. The Maintenance Director stated that he understood that there was a lot to be done in the facility. The Maintenance Director admitted that none of the wall or ceiling vents had been opened, pulled down, or cleaned since she had been working in the facility, and added that to be truthful, I don't think it has been done in years. The Maintenance Director also confirmed that the filters in the ductwork had not been changed either, but were on the list of things to do. He stated that this was an old building and needed a lot of work. During an interview on 5/14/2025 at 4:47 pm, the Administrator stated her expectation was that each department had adequate staff and that they were adequately trained, and the managers were going back and doing quality checks to make sure that whatever they delegated was being done.

Based on staff interviews and record review, the facility failed to ensure two of 20 sampled residents (R) (R112 and R10) were referred to the appropriate state-designated authority for a review for a Preadmission Screening and Resident Review (PASRR) Level II. This failure had the potential to place R112 and R10 at risk of not receiving specialized services. Findings include: 1. Review of R112's electronic medical record (EMR) revealed R112 was admitted to the facility on [DATE] with diagnoses including, but not limited to, bipolar disorder, major depressive disorder, and anxiety. Review of R112's Admission Minimum Data Set (MDS) assessment, dated 9/22/2023, revealed Section A (Identification Information) documented R10 had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Section I (Active Diagnoses) documented diagnoses included psychiatric/mood disorder and depression, other than bipolar. Review of R112's Quarterly MDS assessment, dated 3/26/2025, revealed Section I (Active Diagnoses) documented diagnoses included psychiatric/mood disorder and depression, other than bipolar. Review of R112's care plan, dated 10/2/2023, revealed a Problem area of signs and symptoms of mood distress related to a diagnosis of bipolar disorder. Review of R112's EMR revealed there was no PASRR Level II. In an interview on 5/15/2025 at 1:30 pm, the Director of Health Services (DHS) confirmed R112 did not have a PASRR Level II and stated she could not explain why it was not completed. 38154 2. Review of R10's Quarterly MDS assessment dated [DATE] revealed Section N (Medications) revealed R10 received antipsychotic, antianxiety, and antidepressant medications. Review of R10's care plan revealed Problem areas of behavioral symptoms; psychotropic drug use related to antipsychotic, antianxiety, and antidepressant medications; elopement risk; and cognitive loss/dementia. Review of R10's EMR revealed diagnoses including, but not limited to, schizoaffective disorder and bipolar disorder. Review of R10's EMR revealed there was no PASRR Level II. In an interview on 5/1/2025 at 4:00 pm, the Social Worker confirmed R10 should have been submitted for a PASRR Level II based on her diagnoses.

Based on observations, staff interviews, record review, and review of the facility's policy titled Care Plan, the facility failed to implement the individualized care plan for one of 50 sampled residents (R) (R52) related to high fall risk. The deficient practice had the potential to place R52 at risk for safety and injuries, which could lead to hospitalization and a diminished quality of life. Findings include: Review of the facility's policy titled Care Plan Policy, revised 7/27/2023, revealed under Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. The policy also revealed under Admission Comprehensive Plan of Care: .4.The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal(s), and should include any PASSAR Level II intervention as needed. Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members. When approaches that involve the certified nursing assistant (CNA) have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. Review of R52's care plan, last revised on 4/28/2025, for R52 revealed the resident is at risk for falls related to impaired mobility, cerebral vascular accident (CVA) with hemiparesis, behaviors, and a witnessed fall with major injury fracture to the right distal femur on 2/5/2025. Approaches include placing frequently used items within reach, placing the right leg knee immobilizer to maintain alignment of the right leg until follow up with Ortho (orthopedic), assist resident with getting out of bed when agitated, non-skid socks, fall mats and encourage resident to use call light for assistance. It was noted that the resident refuses to wear the immobilizer. Observation on 5/12/2025 at 12:09 pm revealed R52 was observed in private room, lying in bed. There were no fall mats on the floor next to the bed. Observation on 5/14/2025 at 9:03 am revealed R52 sitting up in bed eating breakfast. Non-skid socks were not on R52. Fall mats were not in place. On 5/14/2025 at 1:28 pm, R52 was observed lying in bed. The bed was in a low position. Non-skid socks were not on R52's feet. Fall mats were not in place next to the bed. Licensed Practical Nurse (LPN) EE entered the room and confirmed that R52 was at high risk for falls due to a recent fall. LPN EE also revealed that high fall risk residents should have their beds in a low position, and items should be in reach. Residents should be encouraged to use their call light for assistance. He also confirmed that the resident did not have fall mats on the floor nor non-skid socks on. Interview on 5/15/2025 at 1:39 pm with the Director of Health Services (DHS) revealed that any interventions related to fall risk would be on the care assist dashboard for the Certified Nursing Assistants (CNA) to view the activities of daily living (ADL) profile, nurses would provide the information in report, and that fall risk would also be on the resident's face sheet. The DHS also confirmed that she expected the CNAs to follow the interventions. Interview on 5/15/2025 at 1:48 pm with CNA HH confirmed that she would know if a resident were on fall precautions because it would be in the ADL care area of the Care Assist record, but was not sure if interventions were listed. CNA HH also revealed that no shift report was done, but if there was a change with the resident, her nurse would tell her.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure services for hearing were provided for one of 50 sampled residents (R) (R106). The deficient practice had the potential to cause a decrease in R106's quality of life. Findings include: Review of the admission record revealed that R106 was admitted to the facility with diagnoses that include, but are not limited to, paraplegia, acquired absence of the left leg below the knee, shigellosis, methicillin-susceptible Staphylococcus aureus infection, osteomyelitis, and other lesions of the oral mucosa. Review of R106's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status score of 15 (indicating little to no cognitive impairment). Section B (Hearing, Speech, and Vision) documented moderate difficulty with hearing. Review of R106's care plan, dated 1/14/2025, revealed a Problem of Resident is noted to be hear [sic] of hearing. Speaker may have to adjust his/her tone in which resident is able to hear. And a goal stating Resident will makes his needs known thru next review. Interventions include Face the resident when speaking. Provide with materials for written communication. Repeat phrases as needed. Rephrase if necessary. Speak clearly and adjust tone as needed. Speaker to adjust his/her tone in which resident is able to hear. Review of R106's Physician's Orders revealed no referral to audiology from the time of admission, nor any order for further assessment or evaluations. In a concurrent observation and interview on 5/12/2025 at 11:43 am, R106 revealed that he did not have a hearing aid and requested a repeat of the question or statement multiple times. R106 stated he didn't hear well and asked the surveyor to speak louder. R106 also requested that staff remove their mask so he could read their lips during conversation. He stated he had not been evaluated for a hearing device or the cause of his impairment and that no one at the facility had spoken to him about his hearing loss. In an interview on 5/14/2025 at 2:11 pm, the Social Services Director (SSD) confirmed that R106 was not on her current referral list for audiology consultation and revealed that R106 had not been seen by an audiologist that she was aware of. The SSD confirmed a note in R106's electronic medical record (EMR) that referred him to audiology in January, and confirmed there was no follow-up or visit to the audiologist. In an interview on 5/14/2025 at 2:59 pm, the Director of Health Services (DHS) stated the facility provided audiology services and that R106 should have been evaluated on admission and all necessary referrals made. The DHS confirmed there had been no audiology referrals made for R106 since admission and confirmed that his care plan and MDS both indicated that he was hard of hearing with no interventions of referral to audiology.

Based on observations, staff and resident interviews, and record review, the facility failed to ensure one of 50 sampled residents (R) (R127) received restorative nursing as ordered by the physician. This deficient practice had the potential to place R127 at risk for medical complications, such as decreased range of motion of her left hand. Findings include: Review of the R127's Quarterly Minimum Data Set (MDS) assessment, dated 2/17/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented upper extremity impairment on one side. Section O (Special Treatments, Procedures, and Programs) documented that the resident did not receive Restorative Nursing or splint/brace assistance. Review of R127's electronic medical record (EMR) revealed diagnoses including, but not limited to, cerebrovascular accident (CVA), hemiplegia, and hemiparesis. Review of R127's Physician's Orders revealed an order dated 4/24/2024 for LUE (left upper extremity) hand orthodic three to four hours daily as tolerated. Observation on 5/13/2025 at 10:00 am revealed R127 had a contracted left hand. Further observation revealed that R127 did not have a brace on her left hand. Observation on 5/14/2025 4:50 pm revealed R127 did not have a hand brace on her left hand. In an interview, R127 stated she rarely wore the brace and had not worn it in a couple of weeks. Observation on 5/15/2025 at 10:42 am revealed R127 did not have a brace on her left hand. In an interview on 5/14/2025 at 1:45 pm, Certified Nursing Assistant (CNA) NN stated R127 received restorative care for her lower body and did not receive restorative care for her upper body. In an interview on 5/14/2025 at 2:10 pm, Licensed Practical Nurse (LPN) JJ confirmed R127 had a physician's order for a splint for her LUE. She further stated she was unsure if the resident ever wore the splint. In an interview on 5/15/2025 at 12:05 pm, the Director of Health Services (DHS) confirmed R127's physician's order for a left hand splint and stated her expectation was for staff to ensure the splint was applied as ordered.

Based on observations, staff interviews, record review, and review of the facility's policy titled Smoke Free Policy, the facility failed to ensure three of seven residents (R) (R19, R20, and R49) who smoked had complete and accurate smoking assessments. In addition, the facility failed to ensure one of seven R (R19) who smoked had a care plan related to smoking. These deficient practices had the potential to place R19, R20, and R49 at an increased risk of accident hazards related to smoking. Findings include: Review of the facility's policy titled Smoke Free Policy, revised date 12/12/2023, revealed the Assessment and Care Planning section included, . 2. Grandfathered patients/residents will be assessed, utilizing the Smoking Observation Form in the Electronic Health Record (EHR), by a Licensed Nurse upon admission, re-admission, and/or with a significant change. A re-admission smoking care plan shall be developed by the licensed nurse on the Admission Interim Care Plan Form, or electronically. 3. An assessment utilizing The Smoking Observation Form in the EHR is completed at least quarterly thereafter if the answer to either of the first two (2) questions indicates the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident's care plan. 1. Review of R19's Face Sheet revealed an admitted [DATE] with diagnoses including, but not limited to, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of R19's Annual Minimum Data Set (MDS) assessment, dated 4/11/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 11 (indicating moderate cognitive impairment). Section J (Health Conditions) documented no tobacco use. Review of R19's care plan revealed no care plan related to smoking. Review of R19's clinical record revealed no smoking assessments. Review of the facility-provided smoking list revealed R19 was identified as a tobacco user. Observation on 5/12/2025 at 2:30 pm revealed R19 was in the designated smoking area smoking a cigarette. 2. Review of R20's Face Sheet revealed an admitted [DATE] with diagnoses including, but not limited to, major depression disorder, generalized anxiety disorder, delusional disorder, and nicotine dependence. Review of R20's Quarterly MDS assessment, dated 3/3/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 7 (indicating severe cognitive impairment). Section J (Health Conditions) documented no tobacco use. Review of R20's care plan revealed R20 was at risk for injury related to going outside for supervised smoke breaks. Review of the facility-provided smoking list revealed R20 was identified as a smoker. Review of R20's Smoking Observation Form, dated 4/23/2024, revealed the assessment was incomplete and marked as in process. 38154 3. Review of R49's revealed diagnoses including, but not limited to, unspecified dementia, schizophrenia, major depressive disorder, peripheral vascular disease, unspecified glaucoma, heart failure, unspecified, chronic obstructive pulmonary disease (COPD), drug induced subacute dyskinesia, major depressive disorder, mild cognitive impairment, intermittent explosive disorder, Alzheimer's disease with early onset, and major depressive disorder. Review of R49's Quarterly MDS assessment, dated 5/1/2025, revealed Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 3 (indicating severe cognitive impairment). Review of R49's Annual MDS assessment, dated 3 19/2024, revealed Section J (Health Conditions) documented tobacco use. Review of R49's care plan revealed a Problem area of The resident is noted to be at risk for injury related to the resident is a smoker. The resident requires supervised smoke breaks. Last Reviewed/Revised: 04/22/2025. The Long Term Goal Target Date 07/22/2025 revealed The resident will not have any injuries related to smoking thru [sic] the next review. Interventions included 5/14/2019 cigarettes and lighters in the activities office, educate the resident of the smoke breaks, notify the md [sic] (medical doctor) as needed, provide the resident with a smoking apron to prevent injury. Review of R49's Quarterly Observation dated 2/10/2025 revealed the resident had a past history of smoking, but currently not smoking. Observation of R49 on 5/12/2025 at 2:30 pm revealed R49 in the designated smoking area, smoking a cigarette. Observation of R49 on 5/13/2025 at 2:05 pm revealed him smoking in the designated area. During an interview on 5/15/2025 at 10:15 am, the Director of Health Services (DHS) confirmed R19 did not have a smoking assessment or an area for smoking on the care plan, R20 did not have a completed and updated quarterly assessment, and confirmed that R49's quarterly assessment related to smoking was not accurate. The DHS continued to state that smoking assessments were completed by the nursing staff and should be done quarterly and annually. She revealed that if a resident was not assessed or accurately assessed, and if care plan interventions were not in place, staff would not know what to monitor.

Based on observations, staff interviews, and record reviews, the facility failed to ensure oxygen (O2) was administered as prescribed by the physician for two of 20 residents (R) (R22 and R95) receiving O2. This deficient practice had the potential to place R22 and R95 at risk of respiratory complications and a diminished quality of life. Findings include: 1. Review of R22's electronic medical record (EMR) revealed diagnoses including, but not limited to, sarcoidosis, shortness of breath, and eosinophilic asthma. Review of R 22's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) revealed R22 received O2 therapy. Review of R22's care plan, last reviewed/revised 4/29/2025, revealed Problem area stating the resident was at risk for respiratory complications related to diagnosis of asthma and shortness of breath. The Approach revealed O2 has an ordered flow rate. Review of R22's Physician's Orders included an order dated 1/16/2024 for O2 at 3 liters per minute (LPM) via a NC as needed (PRN). Observation on 5/13/25 at 9:33 am revealed R22 in her bed, wearing oxygen via a NC. Observation revealed that the flow rate of the O2 was set between 1.5 and 2 LPM. R22 stated she could not feel the O2 flowing through the NC and called for a nurse. 2. Review of R95's EMR revealed diagnosis, including but not limited to, acute respiratory failure with hypoxia. Review of R95's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section O (Special Treatments, Procedures, and Programs) revealed R95 received O2 therapy. Review of R95's Physician's Orders revealed an order dated 4/30/2025 for O2 at 3 LPM continuous. Observation on 5/12/2025 at 1:06 pm revealed R95 lying in bed with an NC not in place in his nostrils, and the flow meter was set on 2.5 LPM. Observation on 5/13/2025 at 9:41 am observed R95 lying in bed, appeared asleep, and with the O2 not in place. Observation on 5/14/2025 at 8:52 am revealed R95 lying in bed with O2 in place, and the flowmeter was set on 1 LPM. In an interview on 5/14/2025 at 9:15 am, Licensed Practical Nurse/Unit Manager (LPN/UM) EE reviewed O2 orders for R22 and R95 and confirmed the physician's orders were for O2 at 3 LPM continuous for both residents. LPN/UM EE stated that it was his expectation for nursing staff to review the physician orders and ensure the O2 settings were correct each shift. In an interview on 5/15/2025 at 11:54 am, the Director of Health Services (DHS) revealed that she expected nursing staff to review and monitor O2 orders each day.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Infection Prevention and Control Plan, the facility failed to ensure staff followed infection control practices during wound care for one of 18 residents (R) (R106) with pressure ulcers. In addition, the facility failed to properly store personal care supplies in one of 11 resident restrooms observed. These deficient practices had the potential to place R106 at increased risk of infection related to cross-contamination, and had the potential to increase the risk of cross-contamination to the residents residing in room A1. Findings include: Review of the facility's policy titled Infection Prevention and Control Plan, revised 6/21/2024, revealed the Procedure section included A. Infection Control Administrative Structure . 10. Partners are responsible for implementing the Infection Prevention and Control Policy and Procedures. 1. Review of R106's Quarterly Minimum Data Set (MDS) assessment, dated 3/20/2025, revealed Section M (Skin Conditions) documented the resident had three stage four pressure ulcers, and received pressure ulcer care, applications of nonsurgical dressings, and application of ointments/medications. Review of R106's care plan revealed a Problem area for impaired skin integrity and has pressure ulcers to the sacrum, right buttock, left hip/buttock, right leg, and right foot. Approach included treatment and wound care per the provider's orders. Review of R106's diagnoses included, but not limited to, pressure ulcer of the sacral region, unspecified open wound, and osteomyelitis. Observation of wound care on 5/14/2025 at 11:21 am with Licensed Practical Nurse (LPN) AA revealed that she prepared supplies on a lined bedside table. LPN AA washed her hands and donned her gown and gloves. She cleaned the right ischial wound, removed her gloves, and donned (put on) another pair of gloves without performing hand hygiene. She then applied the dressing, removed her gloves, and work surface. LPN AA went on to perform a dressing change to the sacral wound. She donned gloves and did not perform hand hygiene between removing the previous gloves and donning the new gloves. After cleaning the wound, LPN AA removed her gloves and used sanitizer before donning clean gloves. She then assisted with removing fecal matter from the bed with a gloved hand, removed the glove from that hand, did not perform hand hygiene, and donned a new glove before continuing the wound care. In an interview on 5/14/2025 at 1:40 pm, the Infection Preventionist (IP) and the Director of Health Services (DHS) stated that all staff have been educated on several occasions on the importance of infection control and hand hygiene. The DHS stated that it is her expectation that all nursing staff follow infection control practices. 50944 2. Observations on 5/12/2025 at 9:55 am, 5/14/2025 at 2:55 pm, and 5/15/2025 at 12:10 pm revealed one wash basin and one urinal in the restroom of room A1, unlabeled, uncovered, and exposed to the environment. In a concurrent observation and interview on 5/15/2025 at 12:39 pm, the DHS confirmed that the basin and urinal should be covered and labeled. She stated they would be thrown away.

Based on observations, staff interviews, and review of the facility policies titled Labeling, Dating, and Storage, Leftovers, Food Ordering, Receiving, and Storage, Dishwashing, and Pot/Pan Washing and Sanitation, the facility failed to label, date, and securely wrap opened food items; failed to remove dented cans from general can storage; failed to prevent wet nesting in staked pans to eliminate potential of bacteria growth; and failed to sanitize dishware to prevent cross-contamination. This deficient practice affected 136 of 153 residents receiving an oral diet. Findings include: 1. A review of the facility policy titled Labeling, Dating, and Storage, revised 11/11/2022, revealed the Procedure section lines numbered 1. Food and beverage items will have an identifying label as well as a received date and opening date. 2. Foods will be stored in their original or approved container and if opened shall be wrapped tightly with film, foil, etc. A review of the facility policy titled Leftovers, dated September 2001, revealed the Guidelines section line numbered 5. Non-perishable leftovers need to be stored in a dry cool area and be dated and labeled after being opened. Observation on 1/12/2024 at 8:45 am of the dry storage area revealed a five-pound bag of grits that had been opened with no date, an opened package of square cheese crackers with no date, and an opened one-pound bag of potato chips with no date. During an interview on 1/12/2024 at 8:45 am, the Assistant Dietary Manager (ADM) confirmed that the bag of grits, cheese crackers, and potato chips had been opened and had no open date on them. The ADM revealed that dietary staff should have placed an open date on the items before storing them. Observation on 1/12/2024 at 9:15 am of the freezer located outside in a rented trailer revealed an opened case of sliced pepperoni that was not covered, the inside contents were completely exposed. Further observation revealed an open bag of steak fries that was not securely wrapped or dated. During an interview on 1/12/2024 at 9:15 am, the ADM confirmed that the case of sliced pepperoni was open to the air and the opened bag of steak fries was not securely wrapped and dated. The ADM revealed that dietary staff should have closed the case of sliced pepperoni after use and should have wrapped and dated the opened bag of steak fries. 2. A review of the facility policy titled Food Ordering, Receiving, and Storage, revised 6/14/2016, revealed the Procedure section line numbered 9. Dented cans should be kept in a separate designated area, with a dented can sign, and away from regular stock. Observation on 1/12/2024 at 8:45 am of the dry storage area revealed a large can storage rack. Continued observation revealed a 105-ounce can of mandarin oranges with a large dent to the side stored on the rack within general cans. During an interview on 1/12/2024 at 8:45 am, the ADM confirmed that the can of mandarin oranges had a large dent to the side and had not been placed in the dented can area. The ADM revealed that staff should have noted the large dent and placed the can in a separate area in the dry storage area specifically for dented cans. Observation on 1/14/2024 at 9:05 am of the dry storage area revealed another 105-ounce can of mandarin oranges with a large dent to the side and on the can rack. During an interview on 1/12/2024 at 9:05 am, the ADM confirmed that there was another can of mandarin oranges with a large dent to the side. The ADM revealed that she had gone through the cans after the initial kitchen tour on 1/12/2024 and she missed this can. The ADM revealed that the dented can should have been placed in the dented can location. 3. A review of the facility policy titled Dishwashing, revised 3/23/2016, revealed the Procedure section line numbered 8. Allow all items to thoroughly air dry before unloading racks or storing items. A review of the facility policy titled Pot/Pan Washing and Sanitation, revised 4/11/2016, revealed the Procedure section line numbered 1 contained: Air dry pots and pans on the drainboard. Inspect for cleanliness and store pots and pans, inverted in a clean, dry, protected area. Observation on 1/12/2024 at 9:30 am of the pot and pan rack revealed stacks of steam table pans. A stack of four medium-sized rectangle steam table pans were pulled apart and the top three pans had moisture inside. A stack of two medium-sized rectangle steam table pans were pulled apart and the top pan had moisture inside as well and had four areas inside with a white substance. The white substance was on each side of the pan, each about two to three inches in length and one-quarter inch in width. During an interview on 1/12/2024 at 9:30 am, the ADM confirmed that the stacked steam table pans were stored stacked and wet. The ADM confirmed that the one steam table pan was not cleaned properly and had a white substance inside. She revealed that staff should allow pans to completely dry before stacking and should check the inside of the pan to ensure the pans were clean before stacking. Observation on 1/14/2024 at 9:15 am of the pot and pan rack revealed a stack of seven square steam table pans. The top five pans were pulled apart and all five pans had moisture inside. One of the steam table pans was tipped to the side and water ran from the edge of the pan to the floor. During an interview on 1/14/2024 at 9:15 am, the ADM confirmed that all five square steam table pans were stacked and stored with moisture on the inside of the pans. The ADM revealed that dietary staff should have allowed the pans to completely dry before stacking. 4. A review of the facility policy titled Pot/Pan Washing and Sanitation, revised 4/11/2016, revealed the Procedure section line numbered 1. A three-compartment sink is used for manual washing, rinsing, and sanitizing of utensils, pots, pans, and all other items to be hand washed. Pots, pans, and utensils must be sanitized in the sanitizer sink according to one of the following methods: heat sanitizer or chemical sanitizer. Observation on 1/13/2024 at 11:50 am of Dietary Staff JJ using the three-compartment sink to wash a steam table pan and lid revealed she washed the items with soapy water and rinsed them under running water then placed them in the drying area. Dietary Staff JJ did not sanitize the steam table pan before drying. Further observation of the three-compartment sink revealed the sanitizing sink had not been set up with a sanitizing solution for usage at the time Dietary Aide JJ was washing dishware. During an interview on 1/13/2024 at 11:50 am, Dietary Aide JJ confirmed that she did not sanitize the steam table pan or lid with a sanitizing solution. Dietary Aide JJ confirmed that the sanitizing sink had not been properly set up with a solution for usage. Dietary Aide JJ revealed that she did not properly sanitize the pan or lid due to the sanitizing sink having no solution. Dietary Aide JJ could not explain why she did not fill the sanitizing sink with a sanitizing solution. During an interview on 1/13/2024 at 11:50 am, the Dietary Manager (DM) revealed that she expects the dietary staff to properly wash and sanitize dishes when using the three-compartment sink. The DM revealed that staff should have filled the sanitizing sink with a sanitizing solution if washing dishes using the three-compartment sink.

Based on record review, staff interviews, and review of facility policy titled Care Plans, the facility failed to develop or implement a care plan for seven of 37 sampled residents (R) (R81, R17, R9, R130, R133, R64, and R26). Findings include: A review of the facility policy titled Care Plans revised 7/27/2017, revealed the section titled Admission Comprehensive Plan of Care line numbered 3: The comprehensive person-centered care plan is developed to include measurable goals and timeframe to meet a resident's medical, nursing, and psychosocial needs, the services that are furnished to attain or maintain the resident's highest practicable physical, mental psychosocial needs that are identified in the comprehensive assessment. The section titled Care Plan Review and Update line numbered 4: Care plans will be updated by nurses, Case Mix Directors, or any other interdisciplinary team member so that the care plan will reflect the resident's needs at any given moment. 1. A review of the clinical record revealed that R81 was admitted to the facility with diagnoses including, but not limited to, anxiety disorder and suicidal ideations. A review of a Psychotherapy Comprehensive Clinical assessment dated [DATE] revealed a treating diagnosis of chronic Post Traumatic Stress Disorder (PTSD). A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section I - Active Diagnoses revealed a diagnosis of post-traumatic stress disorder. A review of the care plan last updated on 12/19/2023 revealed a care plan had not been developed for R81 for PTSD. During an interview on 1/12/2024 at 2:20 pm with the Social Worker, she revealed that she was not aware of R81 presenting with the diagnosis of PTSD. During an interview on 1/14/2024 at 8:35 am the Director of Health Services (DHS) revealed if a resident has a diagnosis of PTSD, there should have been a care plan developed for PTSD. During an interview on 1/14/2024 at 11:30 am the Social Worker revealed that she missed the PTSD diagnosis on the psychotherapy assessment. The Social Worker revealed that she was not responsible for developing a care plan for any resident with PTSD and stated the care planning team/MDS was responsible for developing the PTSD care plan. During an interview on 1/14/2024 at 12:05 pm, MDS Coordinator MM confirmed that R81 did not have a care plan for PTSD. MDS Coordinator MM revealed that MDS was responsible for care planning PTSD, and R81's diagnosis of PTSD was missed by staff. 37739 2. A review of the clinical record revealed that R17's current funding source was Medicaid GA. A review of the Annual MDS assessment dated [DATE] Section L - Oral/Dental Status revealed that the resident was assessed to have obvious or like cavities or broken natural teeth. A review of the comprehensive care plan for R17 revealed there was not a care plan for dental services or care. During an interview on 1/14/24 at 3:27 pm with the MDS Director GG, she stated that R17 should have a dental care plan. She stated sometimes it was put under the care plan for nutrition. After reviewing the care plan, she confirmed that R17 did not have a dental care plan. During an interview on 1/14/24 at 3:40 pm, the MDS Director GG stated that she only signs off that the MDS is complete, and she does not check for accuracy. She stated that the MDS Coordinator LL completed the dental section and MDS Coordinator LL signed off that it was accurate. During an interview on 1/14/24 at 3:45 pm, the MDS Coordinator LL stated there should be a care plan for dental services and further stated she would complete one. 3. A review of R9's Quarterly MDS dated [DATE] revealed that she had a BIMS score of 99, which indicates severe cognitive impairment. Section I - Active diagnosis revealed a diagnosis of dementia. A review of R9's care plans revealed that there was not a care plan area for dementia, nor interventions to address dementia. During an interview with Registered Nurse (RN) GG on 1/14/2024 at 7:55 am, RN GG confirmed that there was not a dementia care plan for R9. She stated that care plans were developed by the Interdisciplinary Team (IDT). She stated that the person who identifies a problem is the person who develops a care plan for it. RN GG stated that care plans are updated quarterly and as needed. 41165 4. A review of R130's Quarterly MDS dated [DATE] Section M revealed that R130 had one unhealed stage 3 pressure ulcer. A review of R130's care plans revealed that there was not a care plan area for pressure ulcers, nor interventions to address pressure ulcers. An interview with RN GG on 1/13/2024 at 7:55 am revealed RN GG stated that she is the MDS Director. She stated that care plans are developed by the IDT. RN GG confirmed that there was not a care plan area to address R130's pressure ulcer. An interview with Licensed Practical Nurse (LPN) FF on 1/13/2024 at 2:33 pm confirmed that there was not a pressure ulcer care plan to address R130's pressure ulcer. She stated one of the treatment nurses should have developed a care plan to address R130's pressure ulcer. 5. A review of R133's Significant Change MDS dated [DATE] Section O - Special Treatments and Programs revealed she received hospice care while a resident. A review of R133's care plan revealed that there was not a care plan area for hospice/palliative care, nor interventions to address hospice/palliative care. An interview with RN GG on 1/14/2024 at 7:55 am confirmed that there was not a care plan area to address hospice/palliative for R133. She stated that care plans were developed by the IDT. She stated that the person who identifies a problem is the person who develops a care plan for it. RN GG stated that care plans are updated quarterly and as needed. RN GG stated that there is no individual care plan for hospice/palliative care. An interview with the DHS on 1/14/2024 at 8:26 am revealed the DHS stated that the nurses were responsible for the baseline 48-hour care plan upon admission. The DHS stated that she follows up to ensure care plans are in. An interview with Senior Nurse Consultant (SNC) II on 1/14/2024 at 8:43 am revealed the process for care plans was for the nurse to initiate the baseline care plan on admission. She stated that MDS makes sure that care plans are initiated. SNC II stated that a resident who is receiving hospice or palliative care should have a hospice or palliative care plan. SNC II stated that it should have been caught by MDS. She stated that consultants and MDS consultants come in annually and do care plan audits. She stated that she has not conducted a care plan audit because she acquired this facility on 12/1/2023. An interview with LPN HH on 1/14/2024 at 11:33 am revealed that R133 was no longer on hospice services. She stated that R133 is now receiving palliative care services. She stated that palliative care has a Nurse, CNA, Social Worker, and a Chaplain. LPN HH stated that palliative care is like hospice care, but they do not receive as many visits. LPN HH stated that R133 should have a palliative care plan. 45813 6. A review of Active Orders for R64 revealed an order dated 7/20/2022 for Glucerna 1.5 at 60 milliliters (ml) per hour for 20 hours (1200 ml 1800 kilocalories) and water flush at 200 ml every 4 hours for 20 hrs. A review of the care plan for R64 revealed resident had an alteration in nutrition and hydration related to the resident receiving all nutrition and hydration via a G-tube (a tube placed into a patient's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate). The approaches in the care plan included: Flushes as ordered and tube feeding as ordered. Observations on 1/12/2024 at 8:48 am, 1/13/2024 at 7:54 am, 9:52 am, and 10:27 am revealed the setting on the feeding tube pump to indicate the water flush was infusing at 250 ml every 4 hours. During an interview and walking observation on 1/13/2024 at 10:41 am with LPN BB, she confirmed the water flush was being delivered at an incorrect rate and should be at 200 ml every 4 hours. During an interview on 1/13/2024 at 10:56 am with the DHS, she verified that the staff was not following/ implementing R64's plan of care for tube feeding. 7. A review of R26's clinical record revealed a Consultant Pharmacist Communication to Physician document revealed the facility's Nurse Practitioner (NP) wrote an order for a trial dose reduction to decrease Abilify (a medication used to treat schizophrenia) to 5 milligrams (mg). This order was dated 7/28/2023. A review of the Electronic Medication Administration Record for July 2023 through January 13, 2024, revealed R26 received aripiprazole (the generic name for Abilify)10 mg tablet once daily at 9:00 am every day. A review of the care plan revealed that R26 was at risk for alteration in behavior due to schizophrenia. The approaches on the care plan included administering the resident's medication as ordered by the physician. During an interview on 1/14/2024 at 9:25 am the DHS revealed that the staff was not following or implementing R26's plan of care.

Based on observation, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure one resident (R) (R48) reviewed for self-administration of medications did not have medications stored at the bedside. This deficient practice had the potential to allow R48 to administer the medications in an unsafe manner. The sample size was 37 residents. Findings include: A review of the facility policy titled Self-Administration of Medications by Patients/Residents, with a revision date of 1/28/2020, revealed the Policy Statement: 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 the patient/resident and other patients/residents of the healthcare center. The Procedure section revealed: 1. The opportunity to self-administer medications is reviewed during routine assessment by the healthcare center's interdisciplinary team utilizing the Electronic Health Record Observation tool, Medication Self-Administration Observation. 5. Bedside storage of medications is permitted only when it does not present a risk to confused patients/residents who wander into the rooms of, or room with patients/residents who self-administer. The following conditions are met for bedside storage to occur: The Electronic Health Record form is printed and maintained at the bedside and is reviewed on each nursing shift, and the administration information is transferred to the electronic medication record. Attending physician enters an order into the electronic health record for bedside storage. 6. All nurses and aides are required to report to the Charge Nurse on duty any medications found at bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. Observations on 1/12/2024 at 8:59 am and 12:01 pm, and on 1/13/2024 at 8:19 am revealed a container of medicated chest rub and a pack of cough and throat relief drops within R48's reach on the bedside table. A review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed section C - Cognitive Patterns: Brief interview for Mental Status (BIMS) score of 13, indicating little to no cognitive impairment. A review of R48's electronic medical record (EMR) under the Order tab revealed that R48 did not have a current order for the cough drops, the chest rub, or an order for self-administration of medications. Further review of the EMR under the Observation tab revealed a self-administration of medication observation dated 9/8/2023 which indicated R48 did not want to self-administer medications. The facility will administer medications. There also was a self-administration of medication observation dated 10/27/2023 which indicated R48 did not want to self-administer medications and resident had a history of noncompliance with medication and other treatments. The observation also indicated that based on the answers, it was not appropriate for R48 to self-administer medications. This determination was reached due to a history of noncompliance. The resident will not be self-administering medications. During an interview on 1/13/2024 at 8:19 am, R48 revealed that his wife brought him the chest rub and the cough drops to the facility over a week ago. R48 also stated he uses the cough drops and places the chest rub above his top lip. R48 informed the surveyor that both over-the-counter medications had remained on his bedside table since his wife brought them to him, and no one informed him that he was not allowed to have them. During an interview and walking rounds on 1/13/2024 at 9:18 am, Licensed Practical Nurse (LPN) Unit Manager BB revealed that R48 should not have any medications at the bedside. LPN BB stated that she was in R48's room earlier this morning and she did not notice any medications in his room. LPN BB verified medications were on the resident's bedside table and with R48's permission, she removed the medications. LPN BB verified R48's Self-Medication Observation indicated he would not have medications at the bedside and R48 did not have current physician orders for the medications. During an interview on 1/13/2024 at 9:36 am with the Director of Health Services (DHS), she stated there were no residents residing in the facility who had been assessed and deemed appropriate to self-administer medications. DHS confirmed that R48 did not have a physician order for the medications that were located at his bedside. DHS further stated that she would educate her staff to make them aware that over-the-counter medications are not allowed in residents' rooms unless that resident has been assessed and deemed appropriate to self-medicate. DHS confirmed R48's self-administration observation dated 10/27/2023 indicated he was inappropriate to self-administer medications.

Based on record review, resident responsible party interview, staff interviews, review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, and review of the website titled Agency of Healthcare Research and Quality (AHRQ), the facility failed to notify the physician and family of an allegation of abuse for one resident (R) (R9). The sample size was 37 residents. Findings include: A review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, review date of 1/11/2024 indicated: Policy line numbered 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. A review of the Agency of Healthcare Research and Quality (AHRQ) website states that an SBAR document is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue the team needs to address. https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/sbar.html A review of the Grievance/Complaint Form: Health Centers dated 1/8/2023{sic} revealed the Speech Licensed Therapist (SLP) and Certified Occupational Therapy Assistant (COTA) entered R9's room at 11:54 am. The resident was notably upset and asked that the police be called. When asked why R9 responded that she had been beaten. The resident was asked by the SLP and COTA did the incident happened prior to her admission to the facility. The resident stated no that the incident took place the night before and last night. The SLP asked R9 where it occurred and the resident responded, I have been beaten, assaulted, and raped. The SLP informed the resident the incident would be reported. A review of the Facility Incident Report Form dated 1/8/2024 revealed the facility Administrator reported an allegation of abuse via the State Survey Agency (SSA) online website. The box other was checked on the reportable. The date and time of the incident was documented as 1/6/2024. Details of the incident stated: Resident reported to staff member that the night before last she was beaten and raped. When interviewed further she stated that it happened when she got off the train and it was a tall black man who hit her on the gut and raped her. Steps taken by the facility to prevent further incidents: Nurse to complete full body assessment. MD and family notified. Police were notified, waiting for them to come out. Investigation initiated. Review of the Nursing Progress Notes recorded a note dated 1/8/2024 at 4:14 pm and edited on 1/9/2024 at 9:19 am: Head-toe assessment performed by Registered Nurse (RN) ZZ. There was no documentation that the resident's groin, vaginal area, or anal area was assessed. There was no documentation in the Electronic Medical Record (EMR) that the physician, family, and/or responsible party (RP) was notified. An interview on 1/13/2024 at 10:54 am with the Social Service Director (SSD) stated she is aware of R9's allegation of sexual abuse. She stated she did not notify anyone regarding R9's allegation. The SSD stated it is not her responsibility to notify the family and/or RP. An interview on 1/13/2024 at 11:54 am with the Administrator stated the physician, family/RP should be notified of a resident's change in condition notification and documented in the resident's EMR. The Administrator stated the physician was notified of R9's allegation on the day the incident was reported to the SSA. She stated the physician did not want the resident sent out to the hospital. The Administrated stated she was not sure of the time the family was notified of the incident. An interview on 1/13/2024 at 1:59 pm with RN ZZ stated a skin assessment was completed on R9 after the allegation of sexual assault was reported. The RN stated the resident had no vaginal or rectal redness or skin tears. The RN stated she did not notify the physician, family, and/or the RP of the incident. She stated The Director of Health Services (DHS) is the person to ask regarding R9's family and physician notification. An interview on 1/13/2024 at 3:55 pm with the DHS stated the speech therapist was the person who reported to the Administrator R9's allegation. She stated she is not sure if the physician, family, and/or RP was notified. She stated she would check and get back to the surveyor. The DHS never returned with the information. A telephone interview on 1/13/2024 at 5:20 pm with R9's family/RP stated the facility notified the family today (1/13/2024) of the incident that was reported by R9 on 1/8/2024. The family stated they had no prior notification of the incident. The family stated that R9 has a history of being assaulted at the age of 14 or 15. The family stated it is difficult for her to talk about but as she has gotten older, she tells the family fragments of the assault which is upsetting to her (R9). The family stated that R9 is re-experiencing trauma from that incident that happened to her as a young girl. During an interview on 1/14/2024 at 10:15 am with the Administrator and DHS, the Administrator stated that when the initial report was sent to the SSA, she did document that the physician and family were notified. The Administrator and DHS confirmed that the physician or the family were not notified on 1/8/2024 of R9's allegation of sexual abuse. The DHS stated she expects her staff to document in the progress notes, complete the SBAR, document a complete skin assessment, and for the physician and responsible party to be notified. The Administrator stated she did not think it through, and further stated that going forward she will communicate clearly with the team to ensure that the physician and families are notified of a resident change in condition or allegation of abuse/neglect.

Based on record review, observations, staff interviews, and review of the facility policies titled Infection Control - Housekeeping Services and Infection Control - Maintenance Department, the facility failed to ensure that there was a safe, clean, and homelike environment for two of seven Units (F Unit and D Unit) as evidenced by housekeeping and maintenance concerns identified. The census was 153 residents. Findings included: A review of the facility policy titled Infection Control - Housekeeping Services, last revised 10/16/2023 revealed the Policy Statement: It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure orderly, sanitary, and comfortable environment. The Procedure section included: Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. A deep cleaning will be performed for each resident's room monthly and at discharge. In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently if spillage or visible soiling occurs. A review of the facility policy titled Infection Control - Maintenance Department, last revised 12/1/2023 revealed the Procedures section line numbered 3 stated: Routine monitoring of the facility will be completed, and repairs or maintenance needs will be reported to the Administrator. 1. On 1/12/2024 at 10:14 am, the following was observed in Room F (F Unit) room [ROOM NUMBER]: [NAME] substance in the bathroom on the floor around the toilet, uneven tiles exposing area under the tiles and presenting a non-cleanable surface, two opened and unlabeled bars of soap, an opened and unlabeled bottle of personal cleansing shampoo, brown stains/substance inside the sink, a bagged plunger with a brown substance on the bag, an unbagged basin and bedpan, the room wall had scraped and unpainted areas, the paint was peeling on the wall, and opened bags of briefs were sitting around the room. On 1/12/2024 at 10:40 am, the following was observed in Room F-06: The bathroom light was not working, an opened and unlabeled bottle of body wash; a used cup, glove, and paper towels were on the sink; four unbagged basins, the area around the bottom of the toilet was discolored and the floor was dirty. On 1/12/2024 at 11:08 am, the following was observed in Room F-12: Two opened and unlabeled bottles of personal cleanser and lotion on the sink, an opened and unlabeled bar of soap on the sink, one unbagged bedpan and three unbagged stacked basins, a call light cord was missing in the bathroom, the tile was broken in the room, the floor was dirty, the walls had scratches, and the over the bed light fixtures for bed A and B were missing pull cords. On 1/12/2024 at 11:19 am, the following was observed in Room F-17: The room reeked of urine odor, there was a large yellow puddle of liquid on the floor with the edges of the liquid dried on the floor, the floor was sticky, and shoes adhered to the floor when walking in the room, there was a discolored and lifting floor tile, multiple unbagged personal items were in the bathroom above the sink, an unbagged urine graduate in the bathroom, the wall behind the toilet was damaged and the floor tile behind the toilet was stained and dirty, and the tile behind the toilet had missing area presented an uncleanable surface. On 1/12/2024 at 6:08 pm, the following was observed in Room F-17: A puddle of yellow liquid remained on the floor behind the head of the bed. The edges of the puddle were dried, and a strong ammonia-like smell was present in the room radiating out into the hall. During an interview on 1/13/2024 at 9:20 am, Housekeeper TT stated that the housekeeping staff are assigned a set area. She stated she was assigned room F-29 on the F Unit. She stated that on her set, there are five hot rooms that she cleans multiple times a day. She identified those rooms as Room F-17, F-8, F-7, F-20, and F-14. She stated that she would hit those rooms first thing and then again after lunch. She clarified that she cleans the hot rooms three times during her shift. For the other rooms, she cleans once. She stated that cleaning the rooms included sweeping and mopping. She stated that she used an odor eliminator chemical in Room F-17 to clean the floor, and further stated she ran out of the chemical and her supervisor had to order more. She stated that the resident in Room F-17 urinates on the floor throughout the day, so they must clean that room often. On 1/13/2024 at 9:28 am, the following was observed in Room F-17: The yellow pooled liquid was still on the floor and the edges were dried up. The yellow liquid was pooled behind the bed and seeping from under the nightstand. The resident's bed was the only bed in the room and there were no chairs or room decor to make the room homelike. During a comprehensive environmental tour of the F Unit on 1/13/2024, the following was observed: At 9:31 am the shared bathroom for Room F-3 and F-4 had a urinal hanging on the towel holder (labeled with R58 but R58 was not a resident assigned to either room sharing this bathroom), two unbagged bedpans on the floor, two unbagged basins on the floor, and a can of shaving cream sitting on the sink. At 9:34 am the shared bathroom for Rooms F-5 and F-6 had four unbagged basins, stains around the bottom of the toilet, a bottle of soap, an empty cup, and used paper towels sitting above the sink. At 9:37 am the shared bathroom for Rooms F-7 and F-8 had two unbagged bars of soap and personal cleanser, and an unbagged basin. In room F-8, the tube feeding pump had a brown substance on both sides and the side rail of Bed B had a brown substance on it. At 9:41 am Room F-10 observation revealed the floor was stained with dirt build-up and the drywall had scratched and damaged areas. At 9:44 am the shared bathroom in Rooms F-11 and F-12 had an unbagged and unlabeled bar of soap and a container of lotion sitting on the sink, three unbagged basins, one unbagged bedpan, and the call light was without a string. Room F-12 had scrapes on the wall. At 9:49 am the shared bathroom for Room F-13 and F-14 had an unbagged basin, a broken piece of a metal toilet paper holder sitting on the sink, the sink was stained with rust, the call light cover was not attached to the wall and was hanging on the call light cord. Room F-13 walls had scratches and discolored areas. There was no chair or decor in the room. At 9:54 am the shared bathroom for Rooms F-15 and F-16 had a hand bar near the toilet with rust and discoloration, the floor and wall were dirty, and there were two unbagged basins, an unbagged bedpan, and an unbagged urine graduate. Room F-16 had a hole in the wall next to the outlet plug, the paint and drywall had scratches on them, the wall was scratched and discolored, and there was damaged drywall (the wall had an opening near the floor molding). At 10:04 am Room F-17 had a yellow puddle of liquid on the floor, and the room reeked of an ammonia-like urine smell. Standing outside the room, the surveyor's eyes watered and the scent of ammonia burned the surveyor's eyes and nasal area. At 10:06 am the shared bathroom for Rooms F-19 and F-20 had an unbagged basin on the floor and an unbagged bedpan on the shelf. room [ROOM NUMBER] walls were scraped, and an in-wall dresser had peeling paint. During a tour of the F Unit with the Maintenance Director, the Assistant Administrator, and the Housekeeping Supervisor on 1/13/2024 from 10:22 am to 10:50 am, all areas of concern were verified. During the tour, when observing Room F-5 and Room F-6, the Maintenance Director stated that the tile was clean but needed to be pulled up. He further stated that the housekeeping staff should have scrapers on their carts and should scrape the floors where there was dirt buildup. The Assistant Administrator stated that the housekeeping staff should be cleaning the side rails on the beds and that the nursing staff should be keeping the tube feeding pumps clean. She further confirmed that personal items should be in a basin, labeled and bagged and personal items such as briefs should not be sitting out on dressers and nightstands. She confirmed that some resident rooms had sitting chairs and decor but not all resident rooms. The Housekeeping Supervisor stated that he went out to replace the odor-eliminating chemical for room F-17 and that the housekeeping staff had to go into the room multiple times a day to ensure urine was not on the floor because the resident urinated on the floor. The Assistant Administrator stated that they have tried multiple interventions, but it was the resident's behavior to urinate on the floor. She stated housekeeping may need to go in more often or have the resident on a 30-minute to hourly check. The Maintenance Director stated that they must pull up the tile in the room to clean underneath the tile in Room F-17. On 1/14/2024 at 10:07 am, Resident in F-16B was observed sitting in a geriatric chair. The armrests on the chair were cracked and exposed, presenting a non-cleanable surface, and a hazard for skin tears. This was confirmed by LPN SS at this time. During an interview with the Maintenance Director on 1/14/2024 at 12:57 pm, he stated that all management staff completes compliance rounds, and his assigned rooms were Rooms F-13 through F-18. He stated they were supposed to go in daily and check to make sure that everything was working, and that the room was home-like. He stated they use a check-off list to look at all areas of the room and give the completed checklist to the Administrator. He further stated the maintenance department did not conduct any routine maintenance-specific compliance rounds. During an interview with the Administrator on 1/14/2024 at 1:23 pm, she stated that she expected management to complete compliance rounds, but with the holidays and people outside, she had not been strict on them completing the forms. She stated she would like them to do the rounds at least twice a week. 41165 2. Initial observation tour on D Unit on 1/12/2024 at 9:18 am of Room D-3 revealed a 30 cubic centimeter (cc) syringe on the floor next to a trash can that had no liner. The trash can was observed with trash stuck in the bottom of the can along with a brown liquid substance. There was dried formula observed on a tube feeding pump and pole. A dried formula was observed on the left bed rail. Observation revealed the floor was dirty with trash. The nightstand had flaky particles and stains next to a suction machine with the suction tubing hanging from the left side of the nightstand. The floor on the right side of Bed B had a fall mat partially rolled up with trash on top of it. Observations from 1/12/2024 through 1/14/2024 revealed all environmental concerns listed above remained unchanged. Observation and interview on 1/13/2024 at 8:45 am with Licensed Practical Nurse (LPN) HH confirmed the dirty tube feeding pump, dirty floor, dirty trash can, dirty bed rail, and trash on the floor. LPN HH stated that it is the responsibility of the housekeepers to make sure the feeding pump is clean. She stated that it is also the housekeeper's responsibility to clean the nightstand and the floors. LPN HH stated that she guessed that the nurses could clean the formula from the feeding pump and the bed rail. During an interview with the Director of Health Services (DHS) on 1/14/2024 at 8:54 am, the DHS stated that the nurse taking care of the resident should make sure that the feeding pump is clean. Interview with the Housekeeping Supervisor on 1/14/2024 at 1:58 pm, s/he stated that the nursing department is responsible for making sure the feeding pumps and feeding tubes are clean. S/he stated that housekeeping staff is responsible for cleaning the beds and floors. S/he stated that Housekeepers clean all rooms daily and that they have a deep cleaning schedule that they go by to deep clean the rooms. S/he stated that the Housekeeping Supervisor makes sure that the rooms are cleaned daily. The Housekeeping Supervisor viewed pictures of the environmental issues in D Unit room [ROOM NUMBER]. The Housekeeping Supervisor stated that should not have happened. In an interview with the Administrator on 1/14/2024 at 3:00 pm, the Administrator stated that she met with her staff on 1/13/2024 and discussed the environmental issues.

Based on record review, staff interviews, and review of facility policy titled Care Plans, the facility failed to develop a baseline care plan regarding dementia and hospice care for one resident (R) (R206) of 13 newly admitted residents in the past 30 days. Findings include: A review of the facility policy titled Care Plans, revised 7/27/2023, revealed the Definitions section to state: Baseline Care Plan - must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. The Procedure section stated: New Admission Baseline Plan of Care: 1. Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT, the patient/resident, and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Resident 206 was admitted to the facility on [DATE]. Her diagnosis included but was not limited to, chronic obstructive pulmonary disease (COPD) and dementia with anxiety. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R206 had an active diagnosis of dementia and was receiving hospice services while in the facility. A review of the medical record revealed a hospice contract signed by R206 Power of Attorney (POA) dated 12/27/2023 for R206 to receive hospice services due to COPD. A review of the care plan dated 12/28/2023 revealed there was no care plan developed for dementia or hospice services. During an interview on 1/14/2024 at 8:25 am, the Director of Health Services (DHS) revealed that the nurse admitting new residents to the facility is responsible for developing the baseline care plan. The DHS revealed that a resident with a diagnosis of dementia or who is receiving hospice service should have a care plan. During an interview on 1/14/2024 at 12:10 pm the Minimum Data Set (MDS) Coordinator confirmed that there was no baseline care plan developed for dementia or hospice services. MDS LL revealed the nurse admitting R206 was responsible for developing the baseline care plan for dementia and hospice care.

Based on observations, resident interviews, staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care related to showers and shaving for four of 38 sampled residents (R) dependent on staff for ADL care, (R17, R18, R58, and R123.) This failure had the potential to negatively impact R17, R18, R58, and R123's quality of life. Findings included: 1. On 1/12/2024 at 11:22 am and 6:08 pm and on 1/13/2024 at 10:48 pm, R17 was observed in bed, not shaven with a full and uneven beard. A review of the clinical record revealed that R17 had diagnoses including, but not limited to, cerebral palsy, lack of coordination abnormal posture; convulsions; mild cognitive impairment; and anoxic brain damage. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R17 was dependent on staff for personal hygiene. A review of the clinical record for R17 revealed no recent documentation that the resident refused to be shaved. 2. On 1/12/2024 at 10:35 am and on 1/14/2024 at 1:11 pm, R18 was observed in bed with a hospital gown on and not shaven. A review of the clinical record revealed that R18 had diagnoses including, but not limited to, polyneuropathy, Alzheimer's disease, obesity, muscle spasm, and muscle weakness. A review of the Quarterly MDS assessment dated [DATE] revealed that R18 was dependent on staff for showering and bathing. The assessment further noted that R18 required partial to moderate assistance with dressing and personal hygiene. A review of the care plan with the last revision date of 12/13/2023 revealed that R18 had a self-care deficit related to ADL care due to impaired physical status, vision, and muscle weakness (generalized) and that R18 required extensive to total assistance with ADL's, transfers, and bathing. 3. In an interview on 1/12/2024 at 12:25 pm, R58 stated he had not had a shower since he had been at the facility. When asked if he had been shaved, R58 stated that the staff did not shave him. He stated that he would like to be shaved and for all his facial hair to be shaved off. At that time, Certified Nursing Assistant (CNA) UU came into R58's room to bring him his lunch. He asked CNA UU if she could shave him, and she replied that she didn't have her clippers today but would bring them tomorrow. A review of the clinical record revealed that R58 was admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle weakness, anemia, unsteadiness on feet, diabetic neuropathy, and weakness. A review of the Quarterly MDS assessment dated [DATE] revealed that R58 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, and required partial to moderate assistance with showering and hygiene. A review of the care plan with the last revision date of 1/4/2024 revealed that R58 presented with a self-care deficit for ADL care due to impaired mobility and weakness and that R58 required limited to extensive assistance with ADLs care and transfers. In an interview on 1/13/2024 at 2:20 pm, the F Unit Manager (UM) stated that all showers had been done for the day for the first shift. She stated that the shower sheets were being worked on at this time. 4. During an observation and interview with R123 on 1/12/2024 at 11:35 am, he stated that the staff does wash his face and wipe him down a little bit, but they don't do a full cleaning. He stated that he can't walk so they don't get him into the shower room. He was asked if he wanted a shower and he stated he would want that. When asked when the last time he was taken to the shower room was, he stated he had never been to the shower room. Observation revealed his nails were dirty and uncut and he was unshaven. When asked if he would like a shave, he stated that he would and he would like all the hair on his face shaven. He stated that he also needed a haircut. He was observed to have a short afro that was uneven and untrimmed. During an interview on 1/13/2024 at 2:22 pm, CNA UU confirmed that it was R123's shower day but she gave the resident a bed bath, not a shower. Observation of the resident at this time verified he was not shaved. A review of the clinical record revealed that R123 was admitted to the facility on [DATE] with diagnoses including, but not limited to, difficulty in walking, muscle weakness, abnormal posture, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility, muscle wasting and atrophy, type 2 diabetes mellitus with diabetic neuropathy, and overweight. A review of the Quarterly MDS dated [DATE] revealed that R123 presented with a BIMS score of 15, indicating that the resident was cognitively intact. The assessment further noted that R123 required partial moderate staff assistance with bathing and hygiene. A review of the care plan with the last revision date of 12/14/2023 revealed that R123 presented with a self-care deficit related to ADL care due to impaired physical mobility. The care plan noted that R123 will be assisted with daily grooming, oral hair, and skin care. During an interview on 1/13/2024 at 2:22 pm, CNA UU confirmed that it was R123's shower day but she gave the resident a bed bath, not a shower. Observation of the resident at this time verified he was not shaved.

Based on observations, staff interviews, record review, and review of the policy titled Restorative Nursing Program, the facility failed to ensure Occupational Therapy recommendations were implemented for two of 17 residents (R) (R56 and R127). This deficient practice had the potential to cause a negative outcome to the resident's physical, mental and psychosocial health, or well-being. The sample size was 37 residents. Findings include: A review of the policy titled Restorative Nursing Program, revised 11/04/2021, revealed the Policy Statement: It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and well-being of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN) and a License Practical Nurse (LPN), and restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff. Nursing assistants/aids must be trained in the techniques that promote resident involvement in the activity. 1. A review of R56's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section GG - Functional Abilities and Goals: dependent on staff for eating, oral hygiene, toileting hygiene, shower/bath, and upper and lower body dressing. Section O - Special Treatments and Programs: Did not receive Restorative Nursing. A review of the diagnoses included, but was not limited to, contracture right and left hand, muscle weakness. A review of the care plan revealed a Problem start date of 10/17/2023: Resident requires passive range of motion and orthotic management to bilateral upper extremities daily. Approaches included: Provide passive range of motion (PROM) to bilateral upper extremity digits in extension followed by hand hygiene, followed by orthotic application, once a day. Review of discharge information from Occupational Therapy (OT) included: Patient has reached maximal functional potential currently, necessitating discharge from OT services. The patient was placed on the Restorative Nursing Program (RNP) for bilateral upper extremity hands PROM, hand hygiene, and orthotic management to reduce the risk of further contracture and development and skin breakdown. Observation of R56 on 1/14/2024 at 8:59 am revealed she was unable to open her hands and she can move the right hand but not the left. 2. Review R127's Quarterly MDS dated [DATE] revealed: Section GG - Functional Abilities and Goals: dependent on staff for oral hygiene, shower/bath, and lower body dressing and required partial/moderate assistance with eating, toileting hygiene, and upper body dressing. Section O - Special Treatments and Programs: Did not receive Restorative Nursing. A review of the diagnoses included, but was not limited to, contracture left hand and muscle weakness. A review of the care plan revealed a Problem start date of 3/23/2023: Resident requires splint/brace assistance to left hand seven times per week. Approaches included: Place resident in the restorative nursing program: Patient will wear left resting hand splint one time per day for 2-3 hours, seven times per week to prevent further contractures and improve wrist stiffness, and overall maintain joint integrity. Review of OT discharge information included: OT discharge. Caregivers were educated on splinting schedule and assessment of skin with good understanding. Skilled services provided since the start of care included splinting management, progressive stretching, grooming/hygiene tasks, and PROM which improved the patient's abilities to tolerate the splint for a longer duration and decrease stiffness in the wrist. An observation on 01/13/24 at 9:08 am of R127 revealed she was able to move her right hand but not her left. During an interview with LPN SS on 1/14/2024 at 9:00 am, it was revealed there is no Restorative Nursing Program at this facility and there is nothing on the Medication Administration Record (MAR) about Range of Motion (ROM). During an interview with RN NN on 1/14/2024 at 9:10 am, it was revealed the R56 cannot feed herself or wash her face, nor can she open her hands. RN NN reviewed the MAR and verified there was nothing on it for a splint. She verified there was a statement on the care plan for ROM. During an interview on 1/14/2024 at 9:20 am with CNA PP, it was revealed that R56 had a ball that she puts in her hand, and she stated it may be in the laundry and not in the room. During an interview on 1/14/2024 at 9:30 am with CNA CC, it was revealed that R56 was getting a bath and CNA CC found the resident's splint at the bedside. She stated it was supposed to be put on every day, but usually, it was not on. During an interview on 1/14/2024 at 9:33 am with Physical Therapy Assistant (PTA) QQ, it was revealed that R56 was seen by OT in October 2023, and she was discharged from OT because skill services were not needed. She stated ROM can be maintained with a splint. She further stated that R127 was last seen by OT in March 2023. She verified OT discharge instructions for R127 included increased ROM left hand and left resting hand splint to be used four hours at a time daily. During an interview on 1/14/2024 at 10:15 am with LPN Unit Manager (UM) OO, it was revealed that R127 cannot wash her face, requires total care assistance, she can move her hands but with no coordination. LPN OO stated if a resident has an order for a splint, the nursing staff would be the ones who would put the splint on. LPN OO verified R127's care plan stated: splint/brace assistance to the left hand. During an interview on 1/14/2024 at 10:50 am with the RN MDS Director, it was revealed that any updates to the care plans are done by the Interdisciplinary Team. The RN MDS Director stated if therapy added a splint to the treatment plan, they would update the information on the care plan. The RN MDS Director stated there was not a Restorative Nursing Team at the facility, and further stated that CNAs were trained to provide Restorative Care. During an interview on 1/14/2024 at 11:30 am with the Director of Nursing (DON), it was revealed that resident care information is discussed in the morning meetings. The DON stated OT would recommend information for the care plan during the meetings, and the Infection Control Nurse would put the information in the computer. The nurse who takes care of the resident will notify the physician for an order. The DON further stated that CNAs are taught how to provide Restorative Nursing Care by the Staff Educator. The books the CNAs use for training are Nursing Rehabilitation/Restorative Program and Restorative Nursing Educational Response. The DON did not have the sign-in sheets for this program. The DON stated CNAs document ADL care in the computer including information about ROM and Restorative Care. The DON verified there was no documented Restorative Nursing care for R56 or R127. During an interview on 1/14/2024 at 1:00 pm with Senior CNA RR, it was revealed the CNAs document Restorative Care on the computer. CNA RR stated he did work in the Restorative Nursing Program before it was discontinued. He stated he believes it was discontinued due to low staffing schedules. During an interview on 1/14/2024 at 1:00 pm with Senior CNA RR, it was revealed the CNAs document Restorative Nursing Care on the computer. He stated he previously worked in the Restorative Program, but they do not have it now. He stated that R127 had not had a splint on today or yesterday. He could not show the surveyor documentation of when R127 had the splint on.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration: Enteral Tubes, the facility failed to provide enteral nutrition and hydration according to current physician orders for one of twenty-one residents (R) (R64) receiving tube feeding via a gastrostomy tube (G-tube) (a tube placed into a patient's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate). The sample size was 37 residents. Findings include: A review of the facility's policy titled, Medication Administration: Enteral Tubes, revised 1/30/2020 revealed a Policy Statement: The healthcare center provides safe and effective administration of enteral formula and medications. Enteral formulas will be administered via feeding tube by physician order following nursing assessment of the patient/resident's condition and in consultation with the dietician and consultant pharmacist. The Procedure section line numbered 1 stated: Choice of enteral formula, route of administration, and rate of flow will be selected and administered on physician's order following assessments by nursing and dietician. Record review for R64 revealed diagnoses including dysphagia following cerebral infarction, gastro-esophageal reflux disease without esophagitis, and dysphagia (oropharyngeal phase). A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R64 revealed Section G - Functional Abilities: resident was dependent on staff for assistance with activities of daily living (ADL), and Section K - Swallowing/Nutrition Status: received 51 percent or more of total calories through a tube feeding. A review of Active Orders for R64 revealed an order dated 7/20/2022 for Glucerna 1.5 at 60 milliliters (ml) per hour for 20 hours (1200 ml 1800 kilocalories) and water flush at 200 ml every 4 hours for 20 hrs. Turn feeding off 4 hours daily from 7:00 am until 11:00 am. A review of a Progress Note by the Registered Dietician (RD) dated 12/12/2023 at 4:21 pm revealed R64 was being followed by the RD due to nothing by mouth (NPO) with percutaneous endoscopic gastrostomy (PEG) tube in place. Glucerna 1.5 was ordered via PEG at 60ml per hour for 20 hours and 200ml flushes in place every 4 hours. No RD recommendations at this time. Observation on 1/12/2024 at 12:19 pm of R64 revealed Glucerna 1.5 infusing at 60 ml per hour via a feeding pump. The water flush bag was also attached, and the feeding pump was set to deliver 250 milliliters of water every 4 hours. Observation 1/13/2024 at 7:54 am revealed Glucerna 1.5 infusing at 60 ml per hour. The pump was programmed to deliver 250 ml of water every 4 hours. Observation 1/13/2024 at 9:52 am and 10:27 am revealed Glucerna 1.5 infusing at 60 ml per hour and water flush at 250 ml every 4 hours. During an interview and walking observation on 1/13/2024 at 10:41 am with Licensed Practical Nurse (LPN) BB and Registered Nurse (RN) AA, they verified R64's G-tube feeding was infusing at 60ml per hour and the water flush was infusing at 250 ml every 4 hours. RN AA stated the night nurse usually turns the feeding off before leaving her shift. LPN BB confirmed the water flush was being delivered at an incorrect rate and should be at 200 ml every 4 hours. LPN BB further stated that she had no idea how the pump got programmed incorrectly or how long R64 had been receiving the incorrect water flush. During an interview on 1/13/2024 at 10:56 am with the Director of Health Services (DHS), she indicated she would expect the nurses to check the feeding pump settings every shift. DHS stated that the night nurse should have turned the feeding off before leaving and the day nurse is responsible for resuming the feeding as ordered. Cross-reference F656.

Based on resident and staff interviews, medical record review, review of the facility policy titled, Prevention of Patient Abuse Policy the facility failed to ensure one resident (R#50) was free from physical, verbal, and emotional abuse. The sample size was 7 residents. On 12/29/16, a determination was made that a situation in which the facility's non-compliance 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, Area Vice President, and the Senior Nurse Consultant were informed of the Immediate Jeopardy (IJ) on 12/29/16 at 3:38 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on 11/30/16. The IJ continued through 12/29/16 and was removed on 12/30/16. The facility implemented an acceptable credible allegation of compliance (AoC) related to the IJ on 12/29/16. The immediate jeopardy is outlined as follows: On 11/30/16 at approximately 5:00 p.m., resident (R#50) told LPN WW that he was not going to take any more insulin that day, however Licensed Practical Nurse (LPN) WW entered the residents room at approximately 9:00 p.m. on 11/30/16 snatched the sheet off of his head, held the residents left arm/hand behind the residents back and administered the insulin. R#50 reported the alleged abuse, on 11/30/16; however, the facility failed to protect residents and the facility continued to allow LPN WW to work until 12/28/16. The facility failed to investigate the event, the facility failed to notify the state agency as required, and the facility failed to follow their own policy titled, Abuse Prevention Program (and) Reporting Policy. The IJ was related to the facility's non-compliance with the program requirement at 42 CFR 483.13(b), 483.13(c)(1)(i) Free from Abuse/Involuntary Seclusion (F223 S/S:J); 42 CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigate/report Allegations/individuals (F225 S/S:J), and: 42CFR. 483.13(c) Develop/implement/Abuse/neglect, ETC policies. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from Abuse/Involuntary Seclusion (F223 S/S:J); 42 CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigate/report Allegations/individuals (F225 S/S:J), and: 42CFR. 483.13(c) Develop/implement/Abuse/neglect, ETC policies (F226 S/S:J. A Credible Allegation of Compliance was received on 12/29/16. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/30/16. The facility remained out of compliance at the following lower scope and severity of F223:D, F225:D, F226:D while the facility continued management level staff oversight. This oversight process included the analysis of the facility staffs' conformance with the facility's Policies and Procedures including Abuse Prevention Program and Reporting Policy. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to Abuse. Findings include: Review of the facility's policy titled, Abuse Prevention Program and Reporting Policy revised on 11/21/16 revealed, in pertinent part: Provide for the immediate safety of the resident/patient upon identification of suspected abuse, and initiate behavior crisis management interventions, as applicable. Review of medical revealed R#50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed that R#50 was understood by others; and able to understand others with a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact, this MDS also documents that R#50 used a wheelchair for locomotion and required one (1) staff member assistance to complete activities of daily living. Section E, Behaviors E0100, of this same MDS, documents that R#50 did not exhibit any behaviors such as hallucinations or delusion. E0200 documents that the resident did not experience any physical or verbal behaviors. Section E0800 documents that the resident had not rejected evaluation or care. Review of the care plan dated 11/20/13 last reviewed 9/13/16, revealed that R#50 is a diabetic and receives medication as ordered. Review of November 2016 Medication Administration Record [REDACTED]. The November 2016 MAR indicated [REDACTED]. Review of the Daily Nursing Assignments dated 11/30/16 through 12/27/16 revealed that LPN WW was the nurse scheduled and assigned to R#50. Interview on 12/28/16 at 12:45 p.m. with R#50 revealed, that on 11/30/16, LPN WW entered the resident's room around 5:00p.m. and administered his insulin. R#50 stated that he told LPN WW, at that time, that he would not be taking any more insulin on that day. R#50 further stated that LPN WW returned to his room at approximately 9:00 p.m. on 11/30/16, and snatched the sheet, that was covering his head, and then held his left arm behind his back and injected him with insulin. R#50 stated he felt helpless. R#50 revealed that he had surgery on his back a few years ago and that the surgery crippled his right arm. Further interview revealed that R#50 reported the incident to Certified Nurse Assistant (CNA) RR - on 11/30/16. R#50 revealed that CNA RR stated she would report what LPN WW had done. R#50 stated that the next day the short boss lady, the DHS, entered his room and spoke with him and that R#50 explained to DHS, in detail, what LPN WW had done and that DHS had stated okay. Resident stated that the DHS told him that she had fired the employee and that she had to hire him back. Resident stated that he called Adult Protective Services to report the incident. Interview on 12/28/16 at 2:00 p.m. with the Director of Health Service (DHS) revealed that the facility did not thoroughly investigate the abuse of R#50 and that measures were not implemented to keep the resident from being abused. Interview on 12/28/16 at 4:00 p.m. with the Staffing Coordinator (SC) revealed that she had received a text from CNA RR at about 10:25 p.m. on 11/30/16 informing her that LPN WW, the Charge Nurse for R#50, had twisted R#50's arm and administered his insulin and that R#50 was very upset. The SC instructed CNA RR to write a statement and place the statement under the door of the DHS office. SC revealed that she immediately called the DHS and told her what CNA RR had sent her via text. SC revealed that the DHS told her to call the nursing supervisor and have LPN WW to write a statement about the allegation and to instruct LPN WW not to go back in to R#50's room. SC revealed that the DHS instructed LPN WW returned to work the next day, on 12/1/17. The SC revealed that LPN WW remained assigned to the same area and remained assigned as the nurse for R#50 because the SC never changed his assignment. Interview on 12/28/16 4:30 p.m. with R#50 revealed that when the boss lady (the DHS) came in and talked with him, on 12/1/16, about what happened with LPN WW, on 11/30/16, that he told the DHS boss lady everything the Charge Nurse did to him. R#50 revealed that he told DHS about LPN WW holding his left arm behind his back, pulling the sheet off his head and giving him insulin, which he had previously refused earlier that evening. Interview on 12/28/16 at 5:39 p.m. with Registered Nurse (RN) QQ revealed that R#50 told her the morning of 12/1/16, that LPN WW had twisted his arm and administered insulin. RN QQ revealed that she wrote up the incident on a Situation, Background, Assessment, Recommendation (SBAR) sheet, on 12/1/16, and left it in a folder, that the staff leaves for the SCP, for it to be followed up on the next day. Interview on 12/29/16 at 10:00 a.m. with CNA RR revealed that R#50 had put on his call light 11/30/16 at approximately 10:00 p.m., and that when she responded R#50 was cursing and told her that LPN WW had come into his room and held his arm down and had administered his insulin and that this was against his rights. CNA RR told R#50 that she would call someone. CNA RR revealed that she immediately called the Staffing Coordinator, who stated that she would call the DHS and the nursing supervisor. CNA revealed that she was told by the Staffing Coordinator (SC) to write a statement and put the statement under the DHS's door. CNA RR revealed that she wrote her statement and that she placed her statement under the door to the DHS office. Surveyor attempted to contact LPN WW but was not able to leave a message and the call was not returned. Review of a nursing note dated, 12/28/16, at 2:30 p.m., documented by the Director of Health Services (DHS) revealed that R#50 complained about abuse by a Licensed Practical Nurse (LPN WW). There was no further documentation regarding this incident found in the resident's record. Interview on 2/1/17 at 2:30 p.m. with R#50 revealed that the resident was able to restate the allegation of abuse exactly as he had relayed it to the surveyor previously on 12/28/16. R#50 revealed that on 11/30/16 that LPN WW entered his room, snatched the sheet off of his head, held his left arm behind his back and administered insulin that he had previously refused earlier that day. Interview on 2/2/17 at 9:47 a.m. with the RN, Senior Nurse Consultant (SNC) revealed that R#50 is a [MEDICAL TREATMENT] patient and that he did not like his medication at 9 p.m. and that his doctor changed his insulin to be administered at 6:30 p.m. The SNC revealed that if a resident refused a medication and a nurse administered the medication anyway then that is abuse. Further interview revealed that LPN WW should have been suspended pending investigation and then terminated when the incident occurred on 11/30/16. Interview on 2/2/17 at 10:38 a.m. with the Area Vice President (AVP) revealed that if R#50 had his cover pulled off his head and administered the insulin in the manner that R#50 described then he considered that to be abuse. Interview on 2/2/17 at 12:02 p.m. with the DHS revealed that if R#50 received insulin that he had refused earlier, had the sheet pulled off his head, and his arm held behind him then that is abuse. Interview on 2/2/17 at 2:04 p.m. with the Medical Director (MD) revealed that the incident that occurred with R#50 having the sheet pulled off his head, given insulin he had refused and had his arm held behind him is abuse. The MD further revealed that this incident would be physical, mental and psychological abuse. She also revealed that the employee (LPN WW) should have been suspended, pending an investigation, and then terminated. She stated the abuse was reviewed in Quality Assurance and Performance Improvement (QAPI) in January. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Nurse in question was immediately suspended pending the investigation on December 28, 2016 when Administrator was informed of abuse allegation. 2. Administrator conducted an internal investigation related to this event. Investigation was started on 12/28/16 and is on-going. 3. 24 hour report was completed and submitted to state on December 28, 2016. 4. On December 28, 2016 residents with BIMS score above 10 were interviewed on the unit where the accused nurse worked by Nurse Management and social worker. No findings of any further allegations of abuse with the exception of this 1 same allegation. 5. On December 29, 2016 a 100% skin assessment and observation of weekly skin assessment was initiated to rule any injury of unknown origin and/or abuse on the unit the accused Nurse has worked. All findings will be reported to the Administrator and ADHS for additional follow up. There were no abnormalities findings from the audit completed on December 29 2016. 6. Education began on December 28, 2016 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. The center will have 80% of staff in-service completed by 12/29/2016. As of 6pm on 12/29/16 the facility is at 80% compliance with education (200 out of 250 completed). The remainder of in-services will be completed by 12/31/2016. Any staff not receiving the in-service related to FMLA, PRN status, or paid time off will be educated before the next schedule shift. Education on abuse is reviewed in new partner orientation by the Clinical Competency Coordinator. Any staff members not receiving the in-service will be unable to return to work until they have completed the in-service. 7. On 12/29/2016 the Administrator educated the Director of Health Services and the Senior Care partner on the grievance and abuse policy and procedure including timely reporting, investigation, and reporting to the state agency. 8. On December 29, 2016 Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council. 9. Administrator will review all grievances in morning meeting to identify allegations of abuse or neglect. 10. Administrator will notify the Area Vice President immediately of any alleged reports of abuse or neglect. 11. Administrator and Area Vice President will review all allegations of abuse and neglect. To ensure accurate investigation were completed and reporting is completed per current policy. Abuse policy is reviewed yearly by the compliance officer at the corporate office and was updated on [DATE] to include the new requirements of participation. The State Survey Agency (SSA) validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Interview on 12/30/16 at 8:10 a.m. with the Staffing Coordinator revealed the nurse in question, LPN WW, was suspended on 12/28/16. Review of the daily staffing sheets from December 28-30, 2016 did not indicate that LPN WW was on the schedule to work. 2. Interview on 12/30/16 at 2:00 p.m. with the Administrator and the Director of Health Services (DHS) revealed the facility began an internal investigation on 12/28/16 of the alleged abuse that occurred on 11/30/16. The Administrator provided a Facility Incident Report Form dated 12/28/16 for review. The investigation is ongoing at this time. 3. Interview on 12/30/16 at 2:00 p.m. with the Administrator and the DHS revealed the facility reported the alleged abuse that occurred on 11/30/16 to the State Agency on 12/28/16. This was verified by review of the entity self-reported complaint, Intake # GA 039. The intake date is 12/29/16. 4. On 12/30/16 at 2:45 p.m. review of the Census List dated 12/29/16 indicated 32 residents on the F-Hall with Brief Interview for Mental Status (BIMS) scores of 10 and above, were interviewed on 12/28 and 12/29/16. The interviews were conducted by LPN NN and RN UU. The residents were asked if they were ever treated roughly by staff, if staff had ever injured them on purpose, had they ever had an injury for which they could not account, and do they ever feel afraid for themselves or other residents because of the manner in which they are treated by staff. The interview responses revealed that all interviewed residents had no concerns except for R#50, the complainant of the incident that occurred on 11/30/16. 5. On 12/30/16 at 3:34 p.m. review of the Census List dated 12/29/16 indicated there were 52 residents on the F-Hall. 52 Body Audit Forms were reviewed and indicated completion on 12/29/16. No abnormalities were identified. 6. On 12/30/16 at 4:00 p.m. the sign-in sheet and in-service course content was reviewed. The in-service was titled Abuse Investigation and Reporting and Resident Rights and began on 12/28/16. On 12/28/16, 80% of staff (200 f 250) had been in attendance of the in-service. By the time of this review on 12/30/16, 97% of staff (243 of 250) had signed that they had attended the in-service. Four staff members had not yet returned to work and three staff members were on FMLA. The following staff members were interviewed on 12/30/16: CNA UUU at 11:05 a.m., LPN LLL at 11:07 a.m., LPN BB at 11:10 a.m., Social Service Director at 11:15 a.m., Laundry Aide XXX at 11:17 a.m., Laundry Aide YYY at 11:20 a.m., RN CC at 11:20 a.m., Laundry Aide AAAA at 11:24 a.m., CNA DD at 11:25 a.m., Occupational Therapist at 11:28 a.m., LPN NNN at 11:30 a.m., CNA FF at 11:30 a.m., LPN NN at 11:30 a.m., LPN OO at 11:37 a.m., RN UU at 11:40 a.m., CNA II at 11:42 a.m., LPN OOO at 11:35 a.m., LPN SS at 11:47 a.m., Maintenance Staff at 11:50 a.m., Social Service Worker GG at 11:50 a.m., CNA JJJJ at 11:50 a.m., Housekeeping Aide TT at 11:53 a.m., Respiratory Therapist WWW at 11:55 a.m., Housekeeping Aide VV at 11:56 a.m., Financial Counselor HHHH at 11:57 a.m., Dietary Aide HH at 12:00 p.m., CNA TT at 12:00 p.m., RN YY at 12:02 p.m., CNA MM at 12:09 p.m., CNA II at 12:10 p.m., LPN XX at 12:12 p.m., Housekeeping Aide ZZ at 12:14 p.m., CNA JJ at 12:15 p.m., Transporter JJ at 12:22 p.m., LPN AAA at 12:24 p.m., CNA BBB at 12:27 p.m., CNA CCC at 12:33 p.m., RN DDD at 12:36 p.m., Respiratory Therapist KK at 12:40 p.m., LPN MMM at 12:52 p.m., Dietary Aide GGG at 12:55 p.m., CNA SSS at 12:55 p.m., Dietary Aide HHH at 12:59 p.m., Central Supply Assistant EEEE at 1:01 p.m., CNA III at 1:05 p.m. and LPN JJJ at 1:07 p.m. these multidisciplinary staff members were interviewed by three state surveyors. All staff stated they had attended an in-service related to abuse since 12/28/16. The staff was able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Observations on 12/30/16: at 11:30 a.m. of housekeeping to resident interaction, at 11:45 a.m. of a staff member passing snacks to residents in the A hall, at 12:20 p.m. of multiple staff to resident interactions in the B hall hallway, at 12:45 p.m. in the main dining room with six staff members assisting with lunch, at 1:30 p.m. of CNA to resident interaction, at 1:40 p.m. in the F hall dining room with six staff members assisting with lunch. These observations of staff to resident interactions revealed no identified concerns. 7. On 12/30/16 at 4:00 p.m. review of the in-service titled Abuse Investigation and Reporting and Resident Rights dated 12/29/16 revealed the signature of the DHS on the sign-in sheet. The educational topics included residents' rights, abuse policy and procedures, abuse definitions, prevention, reporting, and protection during investigation. In an interview on 12/30/16 at 2:00 p.m. with the DHS confirmed that she had received this re-education form the Administrator. 8. An interview on 12/30/16 at 1:10 p.m. with the Resident Council President (RCP) revealed that the facility's Administrator held a meeting with the resident council on 12/29/16. During that meeting, the Administrator talked to the residents about abuse and informed them to immediately report any incidents to the staff or if they wanted to, the RCP. The RCP should report all incidents immediately to the Administrator. The RCP stated no reports of abuse were made by the residents during the time of the meeting. The resident council meeting minutes dated 12/29/16 was reviewed. Topics included Abuse and Resident Rights. The document indicated that 31 residents were in attendance. 9. An interview on 12/30/16 at 2:00 p.m. with the Administrator revealed there was one grievance reviewed during morning meeting on 12/30/16. This was reported to the state on 12/30/16. This grievance is currently under investigation. Review of the complaint revealed the complaint was reported. Additionally, the Administrator provided the Reportable Occurrence Log Form for review. The new grievances on 12/30/16 was identified on this log. This report was verified. No concerns noted. 10. Interview on 12/30/16 at 4:20 p.m. with the Administrator revealed that he did report the new incident relate to a resident's missing money on 12/30/16 to the Area Vice President. 11. Interview on 12/30/16 at 4:20 p.m. with the Administrator revealed that(NAME)Health reviews the abuse policy annually. He and the Area Vice President reviewed the abuse policy and no changes were made at this time. The policy had just recently been revised on 11/21/16. The state surveyor reviewed the policy titled The Prevention of Abuse/Neglect at this time. No concerns with the policy.

Based on resident, staff interviews, clinical record review, and review of the facility policy titled, Abuse Prevention the facility failed to report to the State Agency for one resident (R) #50, who alleged that he was abused by Licensed Practical Nurse (LPN) WW on 11/30/16. The sample size was 7 residents. On 12/29/16, a determination was made that a situation in which the facility's non-compliance 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, Area Vice President, and the Senior Nurse Consultant were informed of the Immediate Jeopardy (IJ) on 12/29/16 at 3:38 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on 11/30/16. The IJ continued through 12/29/16 and was removed on 12/30/16. The facility implemented an acceptable credible allegation of compliance (AoC) related to the IJ on 12/29/16. The immediate jeopardy is outlined as follows: On 11/30/16 at approximately 5:00 p.m., resident (R#50) told LPN WW that he was not going to take any more insulin that day, however Licensed Practical Nurse (LPN) WW entered the residents room at approximately 9:00 p.m. on 11/30/16 snatched the sheet off of his head, held the residents left arm/hand behind the residents back and administered the insulin. R#50 reported the alleged abuse, on 11/30/16; however, the facility failed to protect residents and the facility continued to allow LPN WW to work until 12/28/16. The facility failed to investigate the event, the facility failed to notify the state agency as required, and the facility failed to follow their own policy titled, Abuse Prevention Program (and) Reporting Policy. The IJ was related to the facility's non-compliance with the program requirement at 42 CFR 483.13(b), 483.13(c)(1)(i) Free from Abuse/Involuntary Seclusion (F223 S/S:J); 42 CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigate/report Allegations/individuals (F225 S/S:J), and: 42CFR. 483.13(c) Develop/implement/Abuse/neglect, ETC policies. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from Abuse/Involuntary Seclusion (F223 S/S:J); 42 CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigate/report Allegations/individuals (F225 S/S:J), and: 42CFR. 483.13(c) Develop/implement/Abuse/neglect, ETC policies (F226 S/S:J. A Credible Allegation of Compliance was received on 12/29/16. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/30/16. The facility remained out of compliance at the following lower scope and severity of F223:D, F225:D, F226:D while the facility continued management level staff oversight. This oversight process included the analysis of the facility staffs' conformance with the facility's Policies and Procedures including Abuse Prevention Program and Reporting Policy. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to Abuse. Findings include: Review of the facility's policy titled, Abuse Prevention Program and Reporting Policy revised on 11/21/16 revealed, in pertinent part, The facility is required by their policy to report the allegation to the State Agency. Review of medical revealed R#50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMs score was 15 indicating that he is cognitively intact. Cross refer to F323 for details. Interview on 12/28/16 at 12:45 p.m. with R#50 revealed that R#50 reported to Certified Nurse Assistant (CNA) RR that LPN WW had come in to his room and twisted his left arm and gave him insulin which he had previously refused. R#50 stated the next day the short boss lady DHS came into his room and spoke with him and he told her, in detail, what had happened to him by LPN WW and she stated ok. Interview on 12/28/16 at 2:00 p.m., with the Administrator, Director of Health Services (DHS), and the Senior Care Partner (SCP) revealed the SCP revealed that she was told about the incident by a Registered Nurse (RN) QQ who reported that LPN WW had twisted R#50's hand when he administered the residents insulin. The Administrator revealed that he did not have any knowledge of the allegation of abuse that occurred on 11/30/16, until 12/28/16. The SCP revealed that when she documented the grievance, on 12/1/16, that she did not document anything related to R#50s arm. Interview on 12/29/16 at 10:00 a.m. with CNA RR revealed that she was told by the Staffing Coordinator to write a statement and put the statement under the DHS's door, which she did. Interview on 12/29/16 at 12:18 p.m. with the Administrator and the Area Vice President (AVP) The Administrator revealed that if R#50, or any other resident refused a medication and was given the medication(s), he would classify that as abuse and the employee would be suspended and an investigation started. Interview on 12/29/16 at 12:30 p.m. with the Senior Care Partner (SCP) revealed that she, and the DHS, spoke with R#50 on 12/1/16, about his arm and his insulin dose. SCP further revealed that when she and the DHS left the residents room that they decided that physical abuse had not occurred. Interview on 12/30/16 at 2:00 p.m. with Administrator revealed that the employee LPN WW was suspended on 12/28/16 and an investigation and education of staff were started on 12/28/16. The Administrator further revealed that staff are suspended pending an investigation of abuse and can return or not return, to work for different reasons. The Administrator stated sometimes the resident can recant their complaints, staff can confess to the abuse, the wrong person could have been suspended and other reasons, so the time that the staff is away from work can vary. The Administrator also stated that LPN WW returned to work because he, the Administrator, had not been aware of the allegation of abuse. Interview on 2/2/17 at 9:47 a.m. with Registered Nurse (RN) Senior Nurse Consultant revealed the report of abuse should have been made to the State Agency concerning the allegation of abuse when it occurred on 11/30/16. Interview on 2/2/17 at 10:38 a.m. with Area Vice President (AVP) revealed the incident should have been report on 11/30/16 when the R#50 reported that he was abused. Interview on 2/2/17 at 11:26 a.m. with the facility Administrator revealed that the abuse should have been reported to the State Agency, LPN WW should have been suspended pending the investigation and that he would have informed the AVP of the abuse. He also stated the police should have been notified. Interview on 2/2/17 at 4:20 p.m. with the Medical Director (MD) revealed that the facility should have made a report to the State Agency when R#50 made the allegation of abuse on 11/30/16. Cross refer to F223 The facility implemented the following actions to remove the Immediate Jeopardy: 1. Nurse in question was immediately suspended pending the investigation on December 28, 2016 when Administrator was informed of abuse allegation. 2. Administrator conducted an internal investigation related to this event. Investigation was started on 12/28/16 and is on-going. 3. 24 hour report was completed and submitted to state on December 28, 2016. 4. On December 28, 2016 residents with BIMS score above 10 were interviewed on the unit where the accused nurse worked by Nurse Management and social worker. No findings of any further allegations of abuse with the exception of this 1 same allegation. 5. On December 29, 2016 a 100% skin assessment and observation of weekly skin assessment was initiated to rule any injury of unknown origin and/or abuse on the unit the accused Nurse has worked. All findings will be reported to the Administrator and ADHS for additional follow up. There were no abnormalities findings from the audit completed on December 29 2016. 6. Education began on December 28, 2016 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. The center will have 80% of staff in-service completed by 12/29/2016. As of 6pm on 12/29/16 the facility is at 80% compliance with education (200 out of 250 completed). The remainder of in-services will be completed by 12/31/2016. Any staff not receiving the in-service related to FMLA, PRN status, or paid time off will be educated before the next schedule shift. Education on abuse is reviewed in new partner orientation by the Clinical Competency Coordinator. Any staff members not receiving the in-service will be unable to return to work until they have completed the in-service. 7. On 12/29/2016 the Administrator educated the Director of Health Services and the Senior Care partner on the grievance and abuse policy and procedure including timely reporting, investigation, and reporting to the state agency. 8. On December 29, 2016 Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council. 9. Administrator will review all grievances in morning meeting to identify allegations of abuse or neglect. 10. Administrator will notify the Area Vice President immediately of any alleged reports of abuse or neglect. 11. Administrator and Area Vice President will review all allegations of abuse and neglect. To ensure accurate investigation were completed and reporting is completed per current policy. Abuse policy is reviewed yearly by the compliance officer at the corporate office and was updated on [DATE] to include the new requirements of participation. The State Survey Agency (SSA) validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Interview on 12/30/16 at 8:10 a.m. with the Staffing Coordinator revealed the nurse in question, LPN WW, was suspended on 12/28/16. Review of the daily staffing sheets from December 28-30, 2016 did not indicate that LPN WW was on the schedule to work. 2. Interview on 12/30/16 at 2:00 p.m. with the Administrator and the Director of Health Services (DHS) revealed the facility began an internal investigation on 12/28/16 of the alleged abuse that occurred on 11/30/16. The Administrator provided a Facility Incident Report Form dated 12/28/16 for review. The investigation is ongoing at this time. 3. Interview on 12/30/16 at 2:00 p.m. with the Administrator and the DHS revealed the facility reported the alleged abuse that occurred on 11/30/16 to the State Agency on 12/28/16. This was verified by review of the entity self-reported complaint, Intake # GA 039. The intake date is 12/29/16. 4. On 12/30/16 at 2:45 p.m. review of the Census List dated 12/29/16 indicated 32 residents on the F-Hall with Brief Interview for Mental Status (BIMS) scores of 10 and above, were interviewed on 12/28 and 12/29/16. The interviews were conducted by LPN NN and RN UU. The residents were asked if they were ever treated roughly by staff, if staff had ever injured them on purpose, had they ever had an injury for which they could not account, and do they ever feel afraid for themselves or other residents because of the manner in which they are treated by staff. The interview responses revealed that all interviewed residents had no concerns except for R#50, the complainant of the incident that occurred on 11/30/16. 5. On 12/30/16 at 3:34 p.m. review of the Census List dated 12/29/16 indicated there were 52 residents on the F-Hall. 52 Body Audit Forms were reviewed and indicated completion on 12/29/16. No abnormalities were identified. 6. On 12/30/16 at 4:00 p.m. the sign-in sheet and in-service course content was reviewed. The in-service was titled Abuse Investigation and Reporting and Resident Rights and began on 12/28/16. On 12/28/16, 80% of staff (200 f 250) had been in attendance of the in-service. By the time of this review on 12/30/16, 97% of staff (243 of 250) had signed that they had attended the in-service. Four staff members had not yet returned to work and three staff members were on FMLA. The following staff members were interviewed on 12/30/16: CNA UUU at 11:05 a.m., LPN LLL at 11:07 a.m., LPN BB at 11:10 a.m., Social Service Director at 11:15 a.m., Laundry Aide XXX at 11:17 a.m., Laundry Aide YYY at 11:20 a.m., RN CC at 11:20 a.m., Laundry Aide AAAA at 11:24 a.m., CNA DD at 11:25 a.m., Occupational Therapist at 11:28 a.m., LPN NNN at 11:30 a.m., CNA FF at 11:30 a.m., LPN NN at 11:30 a.m., LPN OO at 11:37 a.m., RN UU at 11:40 a.m., CNA II at 11:42 a.m., LPN OOO at 11:35 a.m., LPN SS at 11:47 a.m., Maintenance Staff at 11:50 a.m., Social Service Worker GG at 11:50 a.m., CNA JJJJ at 11:50 a.m., Housekeeping Aide TT at 11:53 a.m., Respiratory Therapist WWW at 11:55 a.m., Housekeeping Aide VV at 11:56 a.m., Financial Counselor HHHH at 11:57 a.m., Dietary Aide HH at 12:00 p.m., CNA TT at 12:00 p.m., RN YY at 12:02 p.m., CNA MM at 12:09 p.m., CNA II at 12:10 p.m., LPN XX at 12:12 p.m., Housekeeping Aide ZZ at 12:14 p.m., CNA JJ at 12:15 p.m., Transporter JJ at 12:22 p.m., LPN AAA at 12:24 p.m., CNA BBB at 12:27 p.m., CNA CCC at 12:33 p.m., RN DDD at 12:36 p.m., Respiratory Therapist KK at 12:40 p.m., LPN MMM at 12:52 p.m., Dietary Aide GGG at 12:55 p.m., CNA SSS at 12:55 p.m., Dietary Aide HHH at 12:59 p.m., Central Supply Assistant EEEE at 1:01 p.m., CNA III at 1:05 p.m. and LPN JJJ at 1:07 p.m. These multidisciplinary staff members were interviewed by three state surveyors. All staff stated they had attended an in-service related to abuse since 12/28/16. The staff was able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. observations of staff to resident care and/or interactions were conducted by three state surveyors. No concerns were identified. Observation on 12/30/16 at 11:30 a.m. of housekeeping to resident interaction, at 11:45 a.m. of a staff member passing snacks to residents in the A hall, at 12:20 p.m. of multiple staff to resident interactions in the B hall hallway, at 12:45 p.m. in the main dining room with six staff members assisting with lunch, at 1:30 p.m. of CNA to resident interaction, at 1:40 p.m. in the F hall dining room with six staff members assisting with lunch. These observations of staff to resident interactions revealed no identified concerns. 7. On 12/30/16 at 4:00 p.m. review of the in-service titled Abuse Investigation and Reporting and Resident Rights dated 12/29/16 revealed the signature of the DHS on the sign-in sheet. The educational topics included residents' rights, abuse policy and procedures, abuse definitions, prevention, reporting, and protection during investigation. In an interview on 12/30/16 at 2:00 p.m. with the DHS confirmed that she had received this re-education form the Administrator. 8. An interview on 12/30/16 at 1:10 p.m. with the Resident Council President (RCP) revealed that the facility's Administrator held a meeting with the resident council on 12/29/16. During that meeting, the Administrator talked to the residents about abuse and informed them to immediately report any incidents to the staff or if they wanted to, the RCP. The RCP should report all incidents immediately to the Administrator. The RCP stated no reports of abuse were made by the residents during the time of the meeting. The resident council meeting minutes dated 12/29/16 was reviewed. Topics included Abuse and Resident Rights. The document indicated that 31 residents were in attendance. 9. An interview on 12/30/16 at 2:00 p.m. with the Administrator revealed there was one grievance reviewed during morning meeting on 12/30/16. This was reported to the state on 12/30/16. This grievance is currently under investigation. This report was verified. No concerns noted. Review of the complaint revealed that it had been reported. Additionally, the Administrator provided the Reportable Occurrence Log Form for review. The new grievances on 12/30/16 was identified on this log. 10. Interview on 12/30/16 at 4:20 p.m. with the Administrator revealed that he did report the new incident relate to a resident's missing money on 12/30/16 to the Area Vice President. 11. Interview on 12/30/16 at 4:20 p.m. with the Administrator revealed that(NAME)Health reviews the abuse policy annually. He and the Area Vice President reviewed the abuse policy and no changes were made at this time. The policy had just recently been revised on 11/21/16. The state surveyor reviewed the policy titled The Prevention of Abuse/Neglect at this time. No concerns with the policy.

Based on resident and staff interviews, policy review titled Abuse Prevention Program (and) Reporting Policy and medical record review, the facility failed to implement the policy related to investigation of abuse to resident (R#50). The sample size was 7 residents. On 12/29/16, a determination was made that a situation in which the facility's non-compliance 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, Area Vice President, and the Senior Nurse Consultant were informed of the Immediate Jeopardy (IJ) on 12/29/16 at 3:38 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on 11/30/16. The IJ continued through 12/29/16 and was removed on 12/30/16. The facility implemented an acceptable credible allegation of compliance (AoC) related to the IJ on 12/29/16. The immediate jeopardy is outlined as follows: On 11/30/16 at approximately 5:00 p.m., resident (R#50) told LPN WW that he was not going to take any more insulin that day, however Licensed Practical Nurse (LPN) WW entered the residents room at approximately 9:00 p.m. on 11/30/16 snatched the sheet off of his head, held the residents left arm/hand behind the residents back and administered the insulin. R#50 reported the alleged abuse, on 11/30/16; however, the facility failed to protect residents and the facility continued to allow LPN WW to work until 12/28/16. The facility failed to investigate the event, the facility failed to notify the state agency as required, and the facility failed to follow their own policy titled, Abuse Prevention Program (and) Reporting Policy. The IJ was related to the facility's non-compliance with the program requirement at 42 CFR 483.13(b), 483.13(c)(1)(i) Free from Abuse/Involuntary Seclusion (F223 S/S:J); 42 CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigate/report Allegations/individuals (F225 S/S:J), and: 42CFR. 483.13(c) Develop/implement/Abuse/neglect, ETC policies. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from Abuse/Involuntary Seclusion (F223 S/S:J); 42 CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigate/report Allegations/individuals (F225 S/S:J), and: 42CFR. 483.13(c) Develop/implement/Abuse/neglect, ETC policies (F226 S/S:J. A Credible Allegation of Compliance was received on 12/29/16. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/30/16. The facility remained out of compliance at the following lower scope and severity of F223:D, F225:D, F226:D while the facility continued management level staff oversight. This oversight process included the analysis of the facility staffs' conformance with the facility's Policies and Procedures including Abuse Prevention Program and Reporting Policy. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to Abuse. Findings include: 1. Review of the facility's November 2016 Abuse Prevention Program (and) Reporting Policy revealed, in pertinent part, Notify the Shift Supervisor immediately if suspected abuse, neglect, mistreatment or misappropriation of property occurs; Report the incident immediately to the Administrator, and DON; Notify the appropriate State agency(s) immediately by fax or telephone after identification of alleged/suspected incident; Initiate process according to State specified regulations; Notify the legal guardian, spouse, or responsible family member/significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property immediately; Notify the Physician immediately; The Facility Administrator is responsible to initiate contact with local law enforcement, immediately, when warranted, and as required by State law. Review of medical record on 12/28/16 at 11:30 p.m. revealed R#50 was admitted to the facility on [DATE] with diagnoses, that include, but may not be limited to: end stage [MEDICAL CONDITION], muscle weakness, type 2 diabetes mellitus, unspecified injury at unspecified level of cervical spinal cord. Review of the Quarterly Minimum Data Set (MDS)dated 11/30/16, revealed that R#50 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Interview on 12/28/16 at 12:45 p.m. with R#50 revealed that on 11/30/16 R#50 reported that LPN WW had allegedly abused him by snatching a sheet off of his head, holding his arm down, and administering his insulin that he had previously refused. Cross refer to F223 Interview on 12/28/16 at 2:00 p.m. with the Director of Health Service (DHS) revealed that the facility did not thoroughly investigate the abuse of R#50 and that measures were not implemented to keep the resident from being abused nor was staff educated regarding the facility abuse policy and procedures. The DHS further stated that LPN WW was sent home at the end of his shift on 11/30/16. DHS revealed she instructed the Staffing Coordinator to recall LPN WW back to work on 12/1/16 for the 3:00 p.m. - 11:00 p.my. shift. Interview on 12/28/16 at 4:00 p.m. with the Staffing Coordinator (SC) revealed she received a text from CNA RR at about 10:25 p.m. on 11/30/16 informing her that LPN WW, the Charge Nurse had twisted the arm of R#50 arm and given him insulin and that R#50 was very upset. Further interview revealed that LPN WW returned to work the next day, on 12/1/16, after SC was told by the DHS to have LPN WW to return to work. SC revealed that LPN WW continued to be assigned to the same unit because she was never told to change his assignment. Review of a written statement dated 12/28/16, signed by the SC, revealed in pertinent part . LPN WW returned back to work the next evening after I was told to call him to return back to work. And no, R#50 is not the type to get very upset about anything. Interview on 12/29/16 at 10:00 a.m. with CNA RR revealed that she wrote a statement regarding the allegation of abuse, as she was instructed to do, and slid the statement under the door to the DHS office. Interview on 12/29/16 at 12:30 p.m. with Registered Nurse, Senior Care Partner (SCP) revealed that she and the DHS went into the room on the next day and spoke with R#50 about his arm and his insulin dose. SCP further revealed that when she and the DHS exited the resident's room they both decided that physical abuse was not involved. Interview on 12/29/16 at 12:18 p.m. with the Administrator and the Area Vice President (AVP) revealed he did not have any idea about a physical or mental abuse of the R#50. He also stated that members of his staff knew about the abuse and knew that he was responsible for not taking action. Interview on 12/29/16 at 1:16 p.m. with DHS revealed that if she had known that the resident refused his insulin and was given the medication then that would have been abuse to the resident. DHS stated that the employee would have been suspended and an investigation started when she first learned about the allegation on 11/30/16. The DHS revealed that she did not speak with CNA RR regarding the allegation of abuse. Interview on 2/2/17 at 10:38 a.m. with the AVP revealed the Administrator is responsible for the investigation of the allegation of abuse. The AVP stated the Administrator would report to him by telephone and if there were any questions he would help with them. Interview on 2/2/17 at 12:02 p.m. with DHS revealed that the abuse that occurred to R#50 is physical, emotional and psychological abuse. Interview on 2/2/17 at 2:06 p.m. with the LPN assigned to R#50 revealed the resident is cognitively intact. She stated the resident never complained to her about anything. The LPN stated the resident is pretty quiet. The LPN stated what the nurse did to the resident would be called physical, mental and psychological abuse and should have been reported immediately as the staff are required to do Interview on 2/2/17 at 4:20 p.m. with Medical Director revealed the abuse allegation should have been reported to the State Agency as soon as the complaint was made. She also stated that the employee should have been suspended and then terminated as required by the facility protocol. Record review revealed that the allegation of abuse that had been reported on 11/30/16 was not reported to the State agency until 12/28/16, when surveyors were present in the facility, and the Administrator became aware of the allegation. Additional review, upon return visit on 2/1/17, revealed that LPN WW was terminated from employment on 1/2/17. Record review revealed that there was no evidence of any documentation that the wife of R#50 had been contacted and informed of the allegation of abuse that occurred on 11/30/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Nurse in question was immediately suspended pending the investigation on December 28, 2016 when Administrator was informed of abuse allegation. 2. Administrator conducted an internal investigation related to this event. Investigation was started on 12/28/16 and is on-going. 3. 24 hour report was completed and submitted to state on December 28, 2016. 4. On December 28, 2016 residents with BIMS score above 10 were interviewed on the unit where the accused nurse worked by Nurse Management and social worker. No findings of any further allegations of abuse with the exception of this 1 same allegation. 5. On December 29, 2016 a 100% skin assessment and observation of weekly skin assessment was initiated to rule any injury of unknown origin and/or abuse on the unit the accused Nurse has worked. All findings will be reported to the Administrator and ADHS for additional follow up. There were no abnormalities findings from the audit completed on December 29 2016. 6. Education began on December 28, 2016 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. The center will have 80% of staff in-service completed by 12/29/2016. As of 6pm on 12/29/16 the facility is at 80% compliance with education (200 out of 250 completed). The remainder of in-services will be completed by 12/31/2016. Any staff not receiving the in-service related to FMLA, PRN status, or paid time off will be educated before the next schedule shift. Education on abuse is reviewed in new partner orientation by the Clinical Competency Coordinator. Any staff members not receiving the in-service will be unable to return to work until they have completed the in-service. 7. On 12/29/2016 the Administrator educated the Director of Health Services and the Senior Care partner on the grievance and abuse policy and procedure including timely reporting, investigation, and reporting to the state agency. 8. On December 29, 2016 Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council. 9. Administrator will review all grievances in morning meeting to identify allegations of abuse or neglect. 10. Administrator will notify the Area Vice President immediately of any alleged reports of abuse or neglect. 11. Administrator and Area Vice President will review all allegations of abuse and neglect. To ensure accurate investigation were completed and reporting is completed per current policy. Abuse policy is reviewed yearly by the compliance officer at the corporate office and was updated on [DATE] to include the new requirements of participation. The State Survey Agency (SSA) validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Interview on 12/30/16 at 8:10 a.m. with the Staffing Coordinator revealed the nurse in question, LPN WW, was suspended on 12/28/16. Review of the daily staffing sheets from December 28-30, 2016 did not indicate that LPN WW was on the schedule to work. 2. Interview on 12/30/16 at 2:00 p.m. with the Administrator and the Director of Health Services (DHS) revealed the facility began an internal investigation on 12/28/16 of the alleged abuse that occurred on 11/30/16. The Administrator provided a Facility Incident Report Form dated 12/28/16 for review. The investigation is ongoing at this time. 3. Interview on 12/30/16 at 2:00 p.m. with the Administrator and the DHS revealed the facility reported the alleged abuse that occurred on 11/30/16 to the State Agency on 12/28/16. This was verified by review of the entity self-reported complaint, Intake # GA 039. The intake date is 12/29/16. 4. On 12/30/16 at 2:45 p.m. review of the Census List dated 12/29/16 indicated 32 residents on the F-Hall with Brief Interview for Mental Status (BIMS) scores of 10 and above, were interviewed on 12/28 and 12/29/16. The interviews were conducted by LPN NN and RN UU. The residents were asked if they were ever treated roughly by staff, if staff had ever injured them on purpose, had they ever had an injury for which they could not account, and do they ever feel afraid for themselves or other residents because of the manner in which they are treated by staff. The interview responses revealed that all interviewed residents had no concerns except for R#50, the complainant of the incident that occurred on 11/30/16. 5. On 12/30/16 at 3:34 p.m. review of the Census List dated 12/29/16 indicated there were 52 residents on the F-Hall. 52 Body Audit Forms were reviewed and indicated completion on 12/29/16. No abnormalities were identified. 6. On 12/30/16 at 4:00 p.m. the sign-in sheet and in-service course content was reviewed. The in-service was titled Abuse Investigation and Reporting and Resident Rights and began on 12/28/16. On 12/28/16, 80% of staff (200 f 250) had been in attendance of the in-service. By the time of this review on 12/30/16, 97% of staff (243 of 250) had signed that they had attended the in-service. Four staff members had not yet returned to work and three staff members were on FMLA. The following staff members were interviewed on 12/30/16: CNA UUU at 11:05 a.m., LPN LLL at 11:07 a.m., LPN BB at 11:10 a.m., Social Service Director at 11:15 a.m., Laundry Aide XXX at 11:17 a.m., Laundry Aide YYY at 11:20 a.m., RN CC at 11:20 a.m., Laundry Aide AAAA at 11:24 a.m., CNA DD at 11:25 a.m., Occupational Therapist at 11:28 a.m., LPN NNN at 11:30 a.m., CNA FF at 11:30 a.m., LPN NN at 11:30 a.m., LPN OO at 11:37 a.m., RN UU at 11:40 a.m., CNA II at 11:42 a.m., LPN OOO at 11:35 a.m., LPN SS at 11:47 a.m., Maintenance Staff at 11:50 a.m., Social Service Worker GG at 11:50 a.m., CNA JJJJ at 11:50 a.m., Housekeeping Aide TT at 11:53 a.m., Respiratory Therapist WWW at 11:55 a.m., Housekeeping Aide VV at 11:56 a.m., Financial Counselor HHHH at 11:57 a.m., Dietary Aide HH at 12:00 p.m., CNA TT at 12:00 p.m., RN YY at 12:02 p.m., CNA MM at 12:09 p.m., CNA II at 12:10 p.m., LPN XX at 12:12 p.m., Housekeeping Aide ZZ at 12:14 p.m., CNA JJ at 12:15 p.m., Transporter JJ at 12:22 p.m., LPN AAA at 12:24 p.m., CNA BBB at 12:27 p.m., CNA CCC at 12:33 p.m., RN DDD at 12:36 p.m., Respiratory Therapist KK at 12:40 p.m., LPN MMM at 12:52 p.m., Dietary Aide GGG at 12:55 p.m., CNA SSS at 12:55 p.m., Dietary Aide HHH at 12:59 p.m., Central Supply Assistant EEEE at 1:01 p.m., CNA III at 1:05 p.m. and LPN JJJ at 1:07 p.m., These multidisciplinary staff members were interviewed by three state surveyors. All staff stated they had attended an in-service related to abuse since 12/28/16. The staff was able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. . Observations on 12/30/16 at 11:30 a.m. of housekeeping to resident interaction, at 11:45 a.m. of a staff member passing snacks to residents in the A hall, at 12:20 p.m. of multiple staff to resident interactions in the B hall hallway, at 12:45 p.m. in the main dining room with six staff members assisting with lunch, at 1:30 p.m. of CNA to resident interaction, at 1:40 p.m. in the F hall dining room with six staff members assisting with lunch. These observations of staff to resident interactions revealed no identified concerns. 7. On 12/30/16 at 4:00 p.m. review of the in-service titled Abuse Investigation and Reporting and Resident Rights dated 12/29/16 revealed the signature of the DHS on the sign-in sheet. The educational topics included residents' rights, abuse policy and procedures, abuse definitions, prevention, reporting, and protection during investigation. In an interview on 12/30/16 at 2:00 p.m. with the DHS confirmed that she had received this re-education form the Administrator. 8. An interview on 12/30/16 at 1:10 p.m. with the Resident Council President (RCP) revealed that the facility's Administrator held a meeting with the resident council on 12/29/16. During that meeting, the Administrator talked to the residents about abuse and informed them to immediately report any incidents to the staff or if they wanted to, the RCP. The RCP should report all incidents immediately to the Administrator. The RCP stated no reports of abuse were made by the residents during the time of the meeting. The resident council meeting minutes dated 12/29/16 was reviewed. Topics included Abuse and Resident Rights. The document indicated that 31 residents were in attendance. 9. An interview on 12/30/16 at 2:00 p.m. with the Administrator revealed there was one grievance reviewed during morning meeting on 12/30/16. This was reported to the state on 12/30/16. This grievance is currently under investigation. This report was verified. No concerns noted. Review of the complaint revealed that it had been reported. Additionally, the Administrator provided the Reportable Occurrence Log Form for review. The new grievances on 12/30/16 was identified on this log. 10. Interview on 12/30/16 at 4:20 p.m. with the Administrator revealed that he did report the new incident relate to a resident's missing money on 12/30/16 to the Area Vice President. 11. Interview on 12/30/16 at 4:20 p.m. with the Administrator revealed that(NAME)Health reviews the abuse policy annually. He and the Area Vice President reviewed the abuse policy and no changes were made at this time. The policy had just recently been revised on 11/21/16. The state surveyor reviewed the policy titled The Prevention of Abuse/Neglect at this time. No concerns with the policy.

Based on observation and staff interview, the facility failed to identify a new pressure sore during a dressing change for one(1) resident from a sample of thirty-two (32) residents. This is an additional example to a previously cited deficiency resulting from a complaint investigation of #GA 359 conducted on 1/18/11. The Plan of Correction (PoC) for this survey was 2/18/11, after completion of the Standard Survey. Findings include: Review of the clinical record for resident #255 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed that the resident was re-admitted on [DATE], after a hospital stay, with stage 3 pressure sores to, the right buttock, the right inner knee and the left inner knee. An acquired stage 1 pressure sore to the top of the right foot was identified on 02/14/11. Observation of pressure sore treatment on 02/17/11 at 10:25 a.m. revealed Licensed Practical Nurse (LPN) "II" remove the dressing from the right buttock. There was a fluid filled blister observed on the edge of the dressing on the right mid section of the buttock. The right upper buttock pressure sore had a small area approximately 0.1-0.2 cm of slough. The nurse applied Santyl to a 4 x 4 and placed the 4 X 4 onto the entire wound bed. After completing the dressing changes, the LPN went outside the room to the treatment cart. Interview on 02/17/11 at 10:55 a.m. with LPN "II" revealed that the buttock looked the same. Continued interview revealed that when asked about the blister on the right buttock, the nurse indicated that she was unaware of a blister. The nurse went back into the resident's room and confirmed a new blister to the right buttock and measured the blister as 5 cm long by 1.4 cm wide.

Based on observation, record review, and resident and staff interview, the facility failed to implement recommended interventions in a timely maner for one (1) resident with a high risk for pressure ulcers. from a sample of six (6) resident. This resulted in actual harm for one (1) resident (#1) that was not immediate jeopardy. Findings include: Review of the medical record for this resident revealed that he was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had a gastrostomy tube in place for tube feeding. Review of the admission body audit form dated 12/24/10 revealed no open areas on the sacrum, hips, buttocks, ankles, feet and heels. There was a reddened area on the buttocks but was documented as blanchable. Review of the weekly skin assessment performed on 01/03/1, ten days after admission to the facility, revealed the following: right plantar foot #2 stage II 1.8 centimeter (cm) x 1.1 cm with blister right plantar foot #1 stage ll 3.1 cm x 3.2 cm with blister right heel stage I 6 cm x 6 cm with no drainage left plantar foot stage II 3 cm x 4.5 cm with blister left heel unstageable 4 cm x 4 cm suspected deep tissue injury left heel unstageable 3.5 cm x 3.5 cm suspected deep tissue injury left ankle#1 0.5 cm x 0.5 cm x < 0.1 cm with granulation tissue, light drainage let ankle #2 unstageable 1 cm x 1 cm suspected deep tissue injury left ankle #3 stage II 1.1 cm x 1 cm left third toe stage I 0 .5 cm x 0..5 cm left buttocks stage II 1 cm x 2 cm x less than 0.1 cm left buttocks stage III irregular shape with granulation tissue with slough no drainage right buttocks #1 stage I 3 cm x 1.5 cm x < 0.1 cm granulation tissue and slough right great toe stage I I cm x 1 cm no drainage left third toe stage I 0 .5 cm x 0.5 cm During an interview with the Licensed Practical Nurse (LPN) "AA" on 01/18/11 at 10:00 a.m. and again at 12:30 p.m. she revealed that she had first assessed the resident on 12/24/10 and on 12/29/10 realized that the resident needed a longer bed for a 74 inch body. Continued interview revealed that even when he sat up in bed at a thirty or a forty-five degree angle his feet pressed against the footboard and created pressure against the balls of his feet. She placed heel boots on his feet but this was not enough to relieve the pressure. Further interview revealed that on 12/29/10 during a "ZAP" meeting, when resident needs are addressed, the LPN requested an extra long mattress, as well as, a low air loss mattress for the resident. Upon return to work, on 01/03/11, from scheduled leave time, the LPN assessed the resident's skin and found pressure blisters on the balls of the feet. The resident was still in the same bed as when he was admitted . There was no evidence that a longer mattress or low air loss mattress had been ordered for this resident. These were obtained on 1/03/11. During an interview with the Director Of Nursing (DON) on 01/18/11 at 12:35 p.m. she acknowledged that the LPN had requested the items first during the meeting on 12/29/10 and then again on 01/03/11. She revealed that she had forgotten to place the order. She did add that all residents in the facility are on pressure relief mattresses although not alternating air mattresses. Observation at 9:30 a.m. on 01/18/11 of the resident revealed the upper extremities were contracted and although the resident was diagnosed as a quadriplegic he had enough mobility to use a wedge call button which was close at hand. Interview at 9:30 on 01/18/11 with the resident revealed orientation to time, place, situation, and self. Continued interview revealed that the blistered areas on the feet had occurred because the bed he/she had previously occupied had a mattress that was too short for the resident's 74 inch frame. About a week after admission, the mattress had been ordered and placed on the bed. Further interview revealed that the staff was very good about turning and positioning him/her about every two hours but occasionally would refuse if he had just been positioned after receiving incontinence care and had no complaints about the staff or the care provided. Observation of the resident's wound care on 01/18/2011 at 9:45 a.m., provided by the treatment nurse LPN "AA" revealed treatments were applied to multiple pressure ulcers. There were nonstageable darkened blister areas observed on both balls of the feet as well as eschar areas on outer ankles of both feet. The resident was positioned on an low air loss mattress. Review of the medical record revealed a physician's orders [REDACTED]. Further review revealed assessments for potential risk for pressure ulcers documented as high. Review of the careplan from time of admission and updates though 01/03/11 were found including the identification of high risk for skin breakdown 12 24/10. Interventions included barrier creams, turning and repositioning, and by 01/03/11 nutritional supplements, positioning and use of devices, heel protectors, an extra long bed frame and low air loss mattress. Interview on 1/18/11 at 1:48 p.m. with the administrator revealed that the DON did not order the items due to a corporate memo dated 12/28/10 indicating that items could not be ordered except on the order day as noted for each facility. The facility was not listed on the memo. She indicated that the order had to placed through the corporate office. The DON did not write the order until 01/03/11 because there was no point in writing the order until it could be filled Review of the contract with the Durable Medical Equipment (DME) company revealed that the company agrees to use its reasonable best efforts to deliver product to the facility within four hours. Interview on 1/18/11 at 2:05 p.m. with the clerk at the DME company revealed the order had been placed on 01/03/11 and delivered by the evening of 01/03/11.