Every finding on record at Resthaven Living Center

Based on record reviews and interviews, the facility failed to inform the resident's responsible party (RP) of a resident's change in condition for 1 (#1) of 3 sampled residents. The facility failed to notify Resident #1's RP when Resident #1 was transferred to the hospital. Review of the facility's policy titled Change in a Resident's Condition or Status with a revision date of May 2017, revealed the following, in part:Policy StatementOur facility shall promptly notify the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:b. There is a significant change in the resident's physical, mental, or psychosocial status; e. It is necessary to transfer the resident to a hospital. Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Cerebral Infarct and Cognitive Communication Deficit. Further review revealed her son was listed as her RP. Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 02/09/2026 revealed a Brief Interview for Mental Status of 8, which indicated the resident was moderately cognitively impaired. Review of the facility's Emergency Transfer Log revealed Resident #1 was transferred to the hospital on [DATE] for having a change in status. Review of Resident #1's Nurse's Notes dated January 2026 revealed no documentation of Resident #1 being transferred to the hospital. Further review revealed no documentation Resident #1's RP had been notified. On 04/06/2026 at 11:30 a.m., an interview was conducted with Resident #1's RP. He stated Resident #1 was discharged from the hospital sometime in February 2026. He stated no one from the facility notified him Resident #1 had been sent to the hospital or why. He stated he found out Resident #1 was at the hospital when the hospital called to update him. On 04/08/2026 at 10:15 a.m., an interview was conducted with S2LPN. S2LPN verified she was assigned to Resident #1 on 01/28/2026. She stated on 01/28/2026, Resident #1 had increased confusion and was transferred to the hospital. She reviewed the nurse's notes from 01/28/2026 and confirmed there was no documentation of the transfer or notification made to the RP. S2LPN confirmed she did not notify Resident #1's RP of the hospital transfer and stated she should have. On 04/08/2026 at 1:30 p.m., an interview was conducted with S1DON. He stated Resident #1 was transferred to the hospital on [DATE] due to increased confusion. He confirmed S2LPN should have notified Resident #1's RP of the transfer.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% by failing to give medications as ordered for 2 (#67 and #85) of 5 residents observed during medication administration. A total of 25 opportunities were observed with 3 medication errors, which resulted in a medication error rate of 12.00%. Findings: Review of the facility's policy titled, Administering Medications with revision date April 2019 revealed the following, in part:Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3. Medications are administered in accordance with prescriber orders, including any required time frame. 9. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication Resident #67On 01/13/2026 at 10:37 a.m., an observation was made of S4LPN during medication pass for Resident #67. S4LPN prepared and administered Sertraline HCL 25 mg 1 tablet by mouth. Review of the current physician orders for Resident #67 revealed the following medication orders:Sertraline HCL 50 mg. Give 1 tablet by mouth one time a day. Order date 10/29/2025. 01/13/2026 at 1:00 p.m., an interview was conducted with S4LPN. She reviewed Resident #67's physician orders and confirmed the order for Sertraline was for 50 mg by mouth. She reviewed the Sertraline medications card and confirmed she administered Sertraline 25 mg by mouth and this was incorrect. She stated she should have checked the dosage prior to administering the medication and did not. Resident #85On 01/13/2026 at 10:50 a.m., an observation was made of S5LPN during medication pass for Resident #85. S5LPN prepared and administered Zinc 50 mg, 1 capsule by mouth and Vitamin D3 10 mcg, 1 tablet by mouth.Review of the current physician orders for Resident #85 revealed the following medication orders:Zinc Sulfate Capsule 220 mg. Give 1 capsule by mouth one time a day. Order date: 08/23/2023.Vitamin D3 Oral Capsule. Give 1250 mcg by mouth in the morning, every Tuesday and Saturday. Order date: 08/09/2024. On 01/13/2026 at 1:28 p.m., an interview was conducted with S5LPN. She reviewed Resident #85's physician orders and confirmed the order for Zinc was for 220 mg by mouth. She observed the bottle of Zinc and confirmed she administered Zinc 50 mg by mouth and this was incorrect. She further confirmed the physician order for Vitamin D3 was for 1250 mcg by mouth. She observed the bottle of Vitamin D3 and confirmed she administered Vitamin D3 10 mcg and this was incorrect. She stated she should have checked the medication dosages prior to administering the medications and did not. On 01/13/2026 at 3:11 p.m., an interview was conducted with S2DON. He was made aware of the above-mentioned medication errors. He stated he expected staff to check medications with the physician's order prior to administering. He confirmed medications administered to residents should be the correct dosage ordered by the physician.

Based on observations and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure:1. The ice machine was maintained in safe operating and sanitary condition; and2. Pots and pans were sanitized.This deficient practice had the potential to affect all 81 residents who ate from the kitchen. Findings: 1. On 01/11/2026 at 8:30 a.m., an observation was made of the ice machine in the kitchen with a low level of ice mixed with pink sludge. Further observation revealed pink sludge in the right front corner. On 01/11/2026 at 8:34 a.m., an interview was conducted with S3DM. She stated the ice machine was serviced and cleaned on 01/09/2026. She observed and confirmed the pink sludge in the ice machine and confirmed this was not sanitary. 2. On 01/11/2026 at 8:45 a.m., an observation was made of S8CK washing pots in the 3 compartment sink. She stated pots and pan were washed and sanitized in the 3 compartment sink. She showed her method while stating she washed, sanitized, and rinsed. Further observation was made of the sanitation dispenser in the second sink labeled, rinse. On 01/11/2026 at 8:46 a.m., an observation and interview was conducted with S3DM. She confirmed the sanitation dispenser should be in the third sink to ensure proper sanitation and was not. She further confirmed the proper method was to wash, rinse, and sanitize. On 01/11/2026 at 10:00 a.m., an interview was conducted with S1ADM. He confirmed the ice machine should be in good working condition and not have pink sludge in the ice. He further confirmed to ensure proper sanitation, the 3 compartment sink should be used in the sequence of wash, rinse, sanitize.

Based on observation and interviews, the facility failed to ensure refuse containers were in good condition and waste was properly contained. This deficient practice had the potential to affect 82 residents residing in the facility. Findings: On 01/11/2026 at 9:15 a.m., an observation was made of a large open bulk grease disposal container outside, next to the facility wall, behind the kitchen with the lid open. A further observation was made of a large amount of black grease on top of the container and on the surrounding concrete area with leaves mixed in. On 01/11/2026 at 9:16 a.m., an interview was conducted with S3DM. She stated the bulk grease disposal container was in poor condition. She confirmed the lid was open and had grease on top and on the surrounding concreate area since September 2025. She confirmed this was unsanitary. On 01/11/2026 at 10:00 a.m., an interview was conducted with S1ADM. He stated he was aware of the bulk grease disposal container located behind the kitchen. He stated the lid had been left open and when it rained the grease spilled over onto the surrounding concrete area. He confirmed the container had been in poor condition for some time and needed to be removed.

Based on observations and interviews the facility failed to ensure a safe, sanitary and comfortable environment. The facility failed to ensure the residents' Shower Room A was comfortable and sanitary. Findings: On 01/13/2026 at 3:00 p.m., an observation was made of Shower Room A. The observation revealed a black, fuzzy substance on the tile below the shower head where the wall tile met the floor. On 01/13/2026 at 3:03 p.m., an interview was conducted with S6CNA. She confirmed the above observation. She stated Shower Room A was not a comfortable and sanitary environment. She stated the black fuzzy substance had been present for a long time and was an ongoing problem. She stated S7MNT and S1ADM were both aware of Shower Room A's condition. On 01/13/2026 at 3:30 p.m., an interview was conducted with S7MNT. He stated he was aware Shower Room A used by residents had a black fuzzy substance on the tile below the shower head where the wall met the floor. He stated the substance had been present for months. He confirmed Shower Room A was not maintained in a comfortable and sanitary manner. On 01/13/2026 at 4:03 p.m., an interview was conducted with S1ADM. He stated he was aware residents' Shower Room A had a black fuzzy substance. He confirmed this substance should not have been present. He confirmed Shower Room A should have been maintained in a comfortable and sanitary manner.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (#2 and #51) of 22 residents reviewed for accommodation of needs. Review of the facility's policy, Resident Call Light System, revised 06/2023, revealed the following, in part:Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guideline: 4. Ensure that the call light is easily reachable by the resident. Resident #2Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Bilateral Primary Osteoarthritis of Hip, Mild Neurocognitive Disorder with Behavioral Disturbance, Wedge Compression Fracture of T9-T10 Vertebra, Intellectual Disabilities, Schizophrenia, and Cerebral Infarction. Review of Resident #2's MDS with an ARD of 12/03/2025, revealed a BIMS score of 11, which indicated she was moderately cognitively impaired. Review of Resident #2's current Care Plan revealed resident was to have a working and reachable call light and encouraged to use it for assistance as needed. On 01/12/2026 at 9:40 a.m., an observation was made of Resident #2's call light located on the floor and not within Resident #2's reach. On 01/12/2026 at 9:50 a.m., an interview was conducted with S13CNA. S13CNA confirmed Resident #2 was able to use the call light. S13CNA further confirmed Resident #2's call light was not within the resident's reach. Resident #51Review of Resident #51's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Difficulty in Walking, Other Lack of Coordination, Primary Generalized Osteoarthritis, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Muscle Wasting and Atrophy.Review of Resident #51's MDS with an ARD of 11/14/2025 revealed a BIMS score of 07, which indicated she was severely cognitively impaired. Review of Resident #51's current Care Plan revealed she required assistance from staff for ADLs, a working, reachable call light, and to encourage resident to use call light for assistance. On 01/12/2026 at 9:01 a.m., an observation was made of Resident #51 sitting in a geri-chair with her call light rolled up on the bedside table not within her reach. On 01/12/2026 at 9:20 a.m., an interview was conducted with S12SUP. S12SUP confirmed Resident #51's call light was not within resident's reach and should have been. S12SUP further confirmed Resident #51 was capable of using call light to call for assistance. On 01/14/2026 at 10:25 a.m., an interview was conducted with S2DON. S2DON stated he was aware of the call lights being found out of the reach of Resident #2 and Resident #51. S2DON stated it is the facility's process to place the call lights within the resident's reach prior to exiting a resident's room. S2DON stated he expected the staff ensure all call lights were within reach for each resident at all times.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#92) of 3 residents reviewed for closed records.Review of Resident #92's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/10/2025 revealed Resident #92 was discharged to a Short-Term General Hospital. Review of Resident #92's Nurse's Notes revealed the following, in part:12/10/2025 at 11:20 a.m. Resident #92 left facility via wheelchair accompanied by his own transportation. On 01/14/2026 at 5:00 p.m., an interview was conducted with S9MDS. S9MDS confirmed Resident #92 left the facility against medical advice. She reviewed Resident #92's Discharge MDS with an ARD of 12/10/2025 and confirmed it indicated he discharged to a Short-Term General Hospital. S9MDS confirmed Resident #92's discharge status was not coded accurately and should have been coded as discharged to home/community. On 01/14/2026 at 5:20 p.m., an interview was conducted with S2DON. S2DON stated he expected MDS nurses to complete all assessments to accurately reflect each residents' discharge status.

Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation with accurate mental health diagnoses for 1 (#67) of 2 sampled residents' records reviewed for PASRR.Review of Resident #67's Clinical Record revealed Resident #67 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Bipolar Disorder, Depression, and Anxiety Disorder. Review of Resident #67's PASRR Level 1 Form dated 07/30/2025 revealed mental health diagnoses which included Major Depression and Anxiety Disorder. Further review revealed Bipolar Disorder diagnosis was not listed. An interview was conducted on 01/14/2026 at 5:25 p.m. with S10LPNADM. S10LPNADM stated she completed Resident #67's PASRR Level 1 Form, dated 07/30/2025. S10LPNADM stated she reviewed Resident #67's clinical records from the referring Hospice Agency, and the clinical records did not include the Bipolar Disorder diagnosis. She stated she did not review Resident #67's initial admission clinical records, dated 10/03/2024, because she did not have access at that time. After review of the above mentioned clinical records, she confirmed the Bipolar Disorder diagnosis should have been included in the PASRR Level 1 Form and was not. An interview was conducted on 01/14/2026 at 5:15 p.m. with S11QI. S11QI reviewed the above Resident #67's Clinical Records and confirmed the Bipolar Disorder diagnosis should have been included on Resident #67's PASRR Level 1 Form, dated 07/30/2025, and was not.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#95) of 3 residents reviewed for infection control. The facility failed to ensure staff wore proper PPE while providing direct care to Resident #95, who was on Enhanced Barrier Precautions.Findings: Review of the facility's policy titled Implementation of Standard and Transmission-Based Precautions with a revision date of 03/2024, revealed the following, in part:3. Enhanced Barrier Precautions - Expand the use of PPE and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. I. Examples of EBP residents:-Indwelling Medical Devices- Include central linesII. EBP are indicated during:-Device care or use: central lineb. PPE:-Gowns and glove.-PPE for EBP is only necessary when performing high-contact care activities. Review of Resident #95's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #95's current Physician Orders revealed the following:Nursing Intervention: Implement and maintain EBP when performing high contact care, start date 11/19/2025.May access port, Order. Date: 08/24/2023.Vancomycin HCl Intravenous Solution, use 1.75 gram intravenously one time a day for sacral wound infection, Order date: 01/02/2026. On 01/13/2026 at 1:00 p.m., an observation was made of Resident # 95's door with an EBP sign and PPE in a bin outside of the door. The EBP sign read in part, the following:Enhanced Barrier Precautions: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use . On 01/13/2026 at 1:02 p.m., an observation was made of S4LPN administer Vancomycin to Resident #95 via port to the right chest. S4LPN was observed with no gown in place while administering the IV antibiotic. On 01/13/2026 at 1:10 p.m., an interview was conducted with S4LPN. She confirmed Resident #95 was on EBP due to his port and wounds. She confirmed she should have worn a gown while providing direct resident care and did not. On 01/13/2026 at 3:11 p.m., an interview was conducted with S2DON. He stated when a resident was on EBP he expected staff to wear the appropriate PPE when providing direct resident care. He confirmed EBP was initiated when a resident had indwelling medical devices such as a port. He further confirmed appropriate PPE should be worn during IV medication administration through a port.

Based on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 84 residents who consumed food from the kitchen. Findings: On 12/09/2024 at 9:06 a.m., an interview was conducted with S3DA. S3DA stated the Dietary manager was fired 2-3 weeks ago and he has been acting manager until the facility was hired a new dietary manager. He stated he did not have certification in food service or dietary management. On 12/09/2024 at 11:22 a.m., an interview was conducted with S1ADM. S1ADM further confirm him nor did any other staff in the facility have a certificate in food service or dietary management.

Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 84 residents who were served meals from the kitchen. Findings: On [DATE] at 8:40 a.m., observations were conducted of the kitchen food preparation area, the following items were found to be expired: ,d+[DATE]oz opened container of cayenne pepper with open date of [DATE] and manufacture expiration date of [DATE]. ,d+[DATE]oz opened container of Italian seasoning with open date of [DATE] and manufacture expiration date of [DATE]. ,d+[DATE]oz opened container of crushed red pepper with open date of [DATE] and manufacture expiration date of [DATE]. ,d+[DATE]oz opened container of sage rub with open date of [DATE] and manufacture expiration date of [DATE]. Review of the facility's policy, titled Food Receiving and Storage, revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. Revised 2014. On [DATE] at 8:55 a.m., an interview was conducted with S1ADM. S1ADM confirmed 84 residents eat from the kitchen. He confirmed the above observations, and also confirmed the above expired items should have been discarded and were not.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#19) of 19 sampled residents reviewed for MDS. Findings: Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #19 was diagnosed with Glaucoma. Review of Resident #19's quarterly MDS with an ARD of 11/06/2024 revealed in part, the following: B0600: Speech Clarity: Clear Speech checked B1000: Vision: Adequate checked Review of Resident #19's therapy progress notes revealed treatment diagnoses of Dysarthria and Anarthria with Low Vision Precautions in place. An interview was conducted on 12/10/2024 at 9:45 a.m. with Resident #19. Resident #19 had slurred speech throughout the interview, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:40 p.m. with S10PT. S10PT stated Resident #19 did not have adequate vision, had slurred speech, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:41 p.m. with S11OT. S11OT stated Resident #19 did not have adequate vision, had slurred speech, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:42 p.m. with S12ST. S12ST stated Resident #19 did not have adequate vision, had slurred speech, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:52 p.m. with S8ADON. S8ADON stated Resident #19 had slurred speech and had some vision loss. S8ADON stated all MDS assessments should be accurately coded for each resident.

Based on record review, observation, and interviews, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#3) of 1 (#3) resident reviewed for respiratory services. The facility failed to change Resident #3's oxygen tubing and humidifier bottle out weekly. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma. Review of Resident #3's current Physician Orders revealed the following, in part: Oxygen: change oxygen tubing and water bottle every night shift every Sunday and as needed for contamination. On 12/09/2024 at 8:25 a.m., an observation was made of Resident #3's oxygen tubing and humidifier bottle. Both the oxygen tubing and humidifier bottle were labeled 12/01/2024. On 12/09/2024 at 8:43 a.m., an interview was conducted with S5LPN. She stated she was assigned to Resident #3. She stated oxygen tubing and humidifier bottles were changed weekly on Sunday nights. At that time, an observation was made of Resident #3's oxygen tubing and humidifier bottle with S5LPN. S5LPN confirmed Resident #3's oxygen tubing and humidifier bottle were dated 12/01/2024. She confirmed Resident #3's oxygen tubing and humidifier bottle should have been changed on Sunday night, 12/08/2024, and was not. On 12/09/2024 at 8:57 a.m., an interview was conducted with S2DON. She stated S5LPN notified her Resident #3's oxygen tubing and humidifier bottle were not changed Sunday night, 12/08/2024. She confirmed all resident's oxygen tubing and humidifier bottles were to be changed every Sunday night, and Resident #3's should have been.

Based on record reviews and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 2 (#3 and #290) of 19 residents reviewed in the final sample. Findings: Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma. Review of Resident #3's current Physician Orders revealed the following, in part: Oxygen: change oxygen tubing and water bottle every night shift every Sunday and as needed for contamination. Review of Resident #3's December 2024 Medication Administration Record (MAR) revealed S7LPN documented Resident #3's oxygen tubing and humidifier bottle were changed on Sunday, 12/08/2024. On 12/09/2024 at 8:25 a.m., an observation was made of Resident #3's oxygen tubing and humidifier bottle. Both the oxygen tubing and humidifier bottle were labeled 12/01/2024. On 12/09/2024 at 8:43 a.m., an observation was made of Resident #3's oxygen tubing and humidifier bottle with S5LPN. S5LPN confirmed Resident #3's oxygen tubing and humidifier bottle were dated 12/01/2024. She confirmed Resident #3's oxygen tubing and humidifier bottle should have been changed on Sunday night, 12/08/2024, and was not. On 12/11/2024 at 1:47 p.m., an interview was conducted with S7LPN. She verified she worked Sunday 12/08/2024. She stated oxygen tubing and humidifier bottles were to be changed weekly on Sundays. She reviewed Resident #3's December 2024 MAR and verified she documented she changed Resident #3's oxygen tubing and humidifier bottle on Sunday 12/08/2024. She was notified of the observation of Resident #3's oxygen tubing and humidifier bottle on 12/09/2024, which were dated 12/01/2024. She confirmed she should not have documented Resident #3's oxygen tubing and humidifier bottles were changed if they were not. On 12/11/2024 at 1:53 p.m., an interview was conducted with S2DON. She reviewed Resident #3's December 2024 MAR and verified S7LPN documented she changed the oxygen tubing and humidifier bottle on 12/08/2024. She confirmed S7LPN should not have documented Resident #3's oxygen tubing and humidifier bottle were changed on 12/08/2024 if she did not change them. Resident #290 Review of Resident #290's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Long Term Use of Anticoagulants. Review of Resident #290's Physician Orders revealed the following, in part: Lab: PT/INR weekly every Wednesday. Start date 10/09/2024. Review of Resident #290's October 2024 MAR revealed S15LPN documented Resident #290's PT/INR was collected on Wednesday, 10/16/2024. Review of Resident #290's lab results dated October 2024 revealed no PT/INR results for 10/16/2024. On 12/11/2024 at 10:28 a.m., an interview was conducted with S15LPN. S15LPN stated if her initials were documented on the MAR in the PT/INR section, it meant the task was collected and completed. She stated if labs were refused by Resident #290 the MAR should have accurately reflected a refusal and should not have been signed off as completed. She stated she was unaware if the PT/INR was collected on 10/16/2024. On 12/11/2024 at 11:53 a.m., an interview was conducted with the facilities laboratory representative. The laboratory representative confirmed the only dates of services provided to Resident #290 were on 10/09/24 and 10/23/2024. She stated there was no record of labs being collected on 10/16/2024. On 12/11/2024 at 10:52 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #290's October 2024 MAR and confirmed S15LPN documented the PT/INR was collected on 10/16/2024. S2DON stated she was unable to provide documentation to confirm Resident #290's PT/INR was collected on 10/16/2024. S2DON confirmed all residents MARs should accurately reflect services provided. 47191

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#23) of 5 (#2, #23, #55, #57, and #85) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing direct care for a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Categories of Transmission Based Precautions revised on 09/2022, revealed the following, in part: 5. Appropriate notification is placed on the room entrance door so that personnel are aware of the need for and the type of precautions. a. The signage informs the staff of instructions for the use of PPE. Review of Resident #23's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Paraplegia, Neuromuscular Dysfunction of the Bladder, and Ileostomy Status. An observation was made on 12/11/2024 at 10:02 a.m. of the Enhanced Barrier Precautions sign posted on Resident #23's door which revealed the following, in part: Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, transferring. An observation was made on 12/11/2024 at 10:05 a.m. of S13CNA and S14CNA dressing, emptying urostomy bag, and transferring Resident #23. S13CNA and S14CNA did not wear a gown while performing Resident #23's direct care. An interview was conducted on 12/11/2024 at 10:11 a.m. with S13CNA. S13CNA confirmed when a resident was on EBPs, staff should wear a gown while performing direct care and she did not. An interview was conducted on 12/11/2024 at 10:12 a.m. with S14CNA. S14CNA confirmed when a resident was on EBPs, staff should wear a gown while performing direct care and she did not. An interview was conducted on 12/11/2024 at 11:54 a.m. with S2DON. S2DON confirmed when a resident was on EBPs, staff should wear a gown while performing direct care. An interview was conducted on 12/11/2024 at 11:55 a.m. with S9IP. S9IP confirmed when a resident was on EBPs, staff should wear a gown while performing direct care.

Based on observation, record review, and interviews, the facility failed to ensure the results of the most recent annual survey and complaint surveys were available for resident review. Findings: On 12/08/2024 at 9:17 a.m., an observation was made of the facility's binder titled State Survey Binder located at the nurse's station. Review of the documents included in the state survey binder revealed the annual recertification along with a complaint survey results dated 12/08/2022. Further review revealed no documented evidence of the survey results from the annual recertification survey dated 11/29/2023 or the complaint survey dated 04/23/2024 and 05/31/2024 having been available for resident review. On 12/08/2024 at 9:20 a.m., an interview was conducted with S6CNA. She confirmed all survey results were kept in the State Survey Binder. She reviewed the facility binder State Survey Binder, and confirmed the only survey results located in the binder were dated 12/08/2022. On 12/08/2024 at 9:29 a.m., an interview was conducted with S2DON. She confirmed all survey results were kept in the State Survey Binder. She reviewed the facility binder State Survey Binder, and confirmed the only survey results located in the binder was the annual recertification along with a complaint survey dated 12/08/2022. She confirmed the most recent annual recertification survey and complaint survey results were not posted in the binder and should have been.

Based on observation and interviews, the facility failed to ensure current nurse staffing data was posted daily. This deficient practice had the potential to affect any of the 85 residents residing in the facility. Findings: On 12/09/2024 at 8:45 a.m., an observation was made of the form titled Daily Staffing Report posted on the bulletin board by the nurses' station revealed it was dated 12/08/2024. On 12/09/2024 8:50 a.m., an interview was conducted with S1ADM. He reviewed and confirmed the Daily Staffing Report posted on the bulletin board by the nurses' station was dated 12/08/2024. He confirmed it was not current and should have been. On 12/09/2024 at 9:02 a.m., an interview was conducted with S2DON. She reviewed and confirmed the Daily Staffing Report posted on the bulletin board by the nurses' station was dated 12/08/2024. She confirmed the current Daily Staffing Report had not been posted and should have been.

50093 Based on record reviews and interviews, the facility failed to ensure services were provided to meet quality professional standards for 2 (#1 and #3) of 3 (#1, #2, and #3) residents reviewed for falls. The facility failed to ensure staff documented neurological assessments after unwitnessed falls. Findings: Review of the facility's policy titled Falls-Clinical Protocol revealed the following: 2. In addition, the nurse shall asses and document/report the following as needed: e. Neurological status; Resident #1 Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Repeated Falls, Cerebrovascular Disease, Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Unspecified Osteoarthritis, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Other Lack of Coordination. Review of the facility's Fall Investigation Reports for Resident #1 revealed he had unwitnessed falls on 12/25/2023, 01/09/2024 and 02/04/2024. Review of Resident #1's clinical record revealed there was no documented neurological assessments following the unwitnessed falls on 12/25/2023, 01/09/2024 and 02/04/2024. On 04/22/2024 at 3:03 p.m., a telephone interview was conducted with S5LPN. S5LPN stated she was taking care of Resident #1 when he had unwitnessed falls on 12/25/2023 and 01/09/2024. She stated she performed neuro checks following both falls and the documentation would be in the back of the narcotic book. On 04/23/2024 at 08:20 a.m., a telephone interview was conducted with S6LPN. She verified neuro checks should be done after all unwitnessed falls. After reviewing the fall which occurred on 02/04/24, she stated she more than likely completed neuro checks. She stated she would have documented the neuro checks if I didn't forget. On 04/23/2024 at 11:28 a.m., an interview was conducted with S1DON. S1DON confirmed she was unable to provide documentation of neurological assessments for the above dates. Resident #3 Review of Resident #3's clinical record revealed she was readmitted to the facility on [DATE] and had diagnoses, which included Polyosteoarthritis, Lack of Coordination, Muscle Wasting, Dementia, and Difficulty in Walking. Review of the facility's Fall Investigation Reports for Resident #3 revealed she had unwitnessed falls on 03/10/2024, 03/14/2024 at 10:15 a.m. and at 10:30 p.m., 03/20/2024 at 3:00 p.m. and 6:00 p.m. Review of Resident #1's clinical record revealed there was incomplete documentation of neurological assessments following the unwitnessed falls on 03/10/2024, 03/14/2024 at 10:15 a.m. and at 10:30 p.m., 03/20/2024 at 3:00 p.m. and 6:00 p.m On 04/23/2024 at 11:28 a.m., an interview was conducted with S1DON. She stated neuro checks are completed for all unwitnessed falls and/or if a resident hits their head. S1DON stated the neuro checks should be completed and documented every fifteen minutes for one hour, every thirty minutes for two hours, every hour for four hours, every four hours for sixteen hours, and then every shift to complete 72 hours. After reviewing Resident #3's Neurological assessment flowsheets dated 03/10/2024, 03/14/2024, and 03/20/2024, she confirmed the documentation on the flowsheets were incomplete.

Based on interviews and record reviews, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for unnecessary psychotropic medications. The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days and indicated the duration for the PRN order for Resident #3. Findings: Review of the facility's policy titled Tapering Medications and Gradual Dose Reduction, reviewed on 04/22/2024, dated 04/2007 revealed the following, in part: Policy Interpretation and Implementation: 10. Residents who use antipsychotic drugs shall receive gradual reductions. Review of Resident #3's clinical record revealed he was readmitted to the facility on [DATE] and had diagnoses, which included Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety. Review of Resident #3's active Physician Orders revealed the following: Start Date: 12/29/2023-Lorazepam 1mg by mouth every 4 hours prn for anxiety. Start Date: 12/29/2023-Temazepam 15mg one by mouth every 24 hours prn for insomnia. Further review revealed neither order had a documented end date. Review of Resident #3's Psychoactive Gradual Dose Reduction Form dated 01/16/2024 revealed the following: 1. Lorazepam 1mg q4h PRN anxiety 2. Temazepam 15mg q24h PRN insomnia 3. Psychotropic medications that are PRN are limited to 14 days and require the prescriber to evaluate the resident prior to extending the order and provide a duration for the pharmacotherapy. On 04/22/2024 at 12:00 p.m., an interview was conducted with Consultant Pharmacist. The Consultant Pharmacist confirmed orders for PRN psychotropic medications should be limited to 14 days and required the prescriber to evaluate the resident prior to extending the order and provide a duration for the pharmacotherapy. On 04/23/2024 at 11:28 a.m., an interview was conducted with S1DON. She could not answer to whether or not hospice PRN medications were limited to 14 days.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#4) of 4 (#1, #2, #3, and #4) residents reviewed for MDS. Findings: Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #4 was diagnosed with Major Depressive Disorder on 03/02/2024. Review of Resident #4's quarterly MDS with an ARD of 03/14/2024 revealed Major Depressive Disorder was not coded as an active diagnosis in Section I. An interview was conducted on 04/18/2024 at 1:11 p.m. with S2MDS. She stated she was responsible for residents' MDS assessments. She stated when the MDS assessment was performed, all diagnoses should have been coded accurately for every resident. She reviewed the quarterly MDS for Resident #4 and confirmed the MDS was not coded accurately for active diagnoses in Section I. An interview was conducted on 04/18/2024 at 1:20 p.m. with S1DON. She confirmed if a resident had an active diagnosis, the MDS should have been coded accurately with those diagnoses.

Based on record reviews and interviews, the facility failed to ensure the residents remained as free of accident hazards as possible for each resident who was transported in the facility's van via wheelchair for 1 (#2) of 8 (#1, #2, #3, #4, #5, RR#1, RR#2, RR#3) residents reviewed for transportation/accidents. The facility failed to secure Resident #2's safety (belt) during transport as recommended by manufacturer guidelines. This failed practice resulted in an actual harm for Resident #2 on 03/27/2023 when Resident #2, who was not properly restrained, slid out of her wheelchair while being transported. The resident was transferred to a local hospital on 03/27/2023 where she had a computerized tomography scan which revealed a left comminuted mildly displaced proximal tibia and fibular fracture requiring surgery. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Resident #2 Review of the clinical record for Resident #2 revealed the resident was admitted on [DATE] with the following diagnoses, in part, Fracture of Lower End of Left Tibia, Closed Facture with Routine Healing, Fracture Part of Neck of Left Femur, Closed Fracture with Routine Healing, Encounter for other Orthopedic Aftercare, Muscle Wasting and Atrophy, NEC, Multiple Sites. Other Lack of Coordination, Difficulty in Walking, Age-related Osteoporosis without Current Pathological Fracture, unspecified; Pain, unspecified; Primary Generalized Arthritis, Rheumatoid Arthritis. Review of the MDS with and ARD of 04/10/2023 revealed Resident #2 had a BIMS of 13 which indicated resident was cogitatively intact. Further review of the MDS revealed Resident #2 was coded to require extensive two person plus physical assistance with bed mobility and transfers. Resident #2 required a wheelchair for locomotion. Review of the facility's investigation revealed the following: Incident Date: 03/27/2023 Incident Occurred Time: 5:28 p.m. Incident Description: Resident was being admitted to facility from local hospital. During transportation to be admitted to the facility Resident #2 slid out of her wheelchair, landing on her knee. Resident #2 requested to go back to the hospital. Resident #2 was returned to the local hospital for evaluation and treatment. Per the diagnostic report from local hospital Resident #2 sustained a left comminuted mildly displaced proximal tibia and fibular fracture. Accused Allegation Finding: Substantiated Review of Hospital Medical Records dated 03/27/2023-04/03/2023 revealed Resident #2 was admitted to the local hospital on 03/27/2023 with diagnoses including closed fracture of left fibula and tibia with insertion of intramedullary nail to left tibia. 04/20/2023 at 11:20 a.m., an interview was conducted with Resident #2. Resident #2 stated while being transported to the facility by the facility's transport van, the van driver slammed on the brakes which caused her to fall out of her wheelchair. Resident #2 stated she was taken to the hospital where it was discovered she had a broken left leg which required surgery. On 04/21/2023 at 10:25 a.m., a telephone interview was conducted with S4CNA. S4CNA stated he had been the van driver for approximately 6 months. S4CNA stated he picked up Resident #2 at the local hospital for transport to the facility. S4CNA stated he loaded Resident #2 into the small van. S4CNA stated he was in a hurry and forgot to secure Resident #2's lap seat belt. S4CNA stated during transport he approached a red light and applied the brakes hard which brought the van to a stop. S4CNA stated he looked back and saw Resident #2 lying on the van floor. S4CNA stated Resident #2 complained of left knee pain and requested to be returned to the hospital. On 04/21/2023 at 8:54 a.m. an interview was conducted with S1ADM. S1ADM stated S4CNA reported he stopped at a stop sign and Resident #2 slid out of her wheelchair. S1ADM stated S4CNA stated he got in hurry and forgot to buckle the seatbelt. S1ADM confirmed all passengers who ride in the facility transport van are required to be restrained with a lap and shoulder belt. On 04/21/2023 at 4:20 p.m. an interview was conducted with S2DON. She stated upon S4CNA's return to the facility S4CNA stated he stopped abruptly at a stop light as he was leaving the hospital parking lot. S4CNA stated he did not restrain Resident #2 properly per the manufacturer's guidelines. S2DON stated SACNA said he was in a hurry and forgot to apply the lap seatbelt. S2DON stated she would expect all residents to be properly restrained with shoulder and lap seatbelts during transport. The facility has implemented the following actions to correct the deficient practice: QA Review revealed: On 03/28/2023 the following plan of correction was put into place to include the following: A. Initiate 30 day audit of previously transported residents to ensure no additional residents were improperly restrained during transport. Date assigned: 03/28/2023 Person Responsible: DON--resolved B. Transportation in-service and checked off on the use of safety equipment during resident transport with demonstration and return demonstrations. Date assigned: 03/28/2023 Person Responsible: Transportation Supervisor--resolved C. QAPI. Date assigned: 03/28/2023 Person Responsible: DON 1. Random audit of transported residents 2X week x 4 weeks of monitoring transportation driver compliance with using safety equipment during transportation. No negative findings 2. Random audit 2X week X 4 weeks using questionnaire regarding safety equipment use. Date assigned: 03/28/2023 Person Responsible: DON-on going 3. Discuss findings in Monday-Friday QA meetings X 4 weeks. Date assigned: 03/28/2023 Person Responsible: DON-on going 4. Discuss findings in weekly HR meetings X 4 weeks. Date assigned: 03/28/2023 Person Responsible: DON-on going The facility was found to be in compliance as of 03/28/2023. Interviews with the facility's two van drivers revealed they were able to properly secure residents for transport following the manufacture's procedures for securing residents. Observations of van drivers revealed drivers were knowledgeable and competent in use of safety equipment required in transporting residents.

F689 (Past non-compliance G)-Resthaven Living Center-2-22-2019 Based on observations, interviews and record reviews, the facility failed to ensure one (Resident #1) of five (Residents #1,#2, #3, #4 and #5) residents investigated for falls received adequate supervision and assistance to prevent accidents. This deficient practice resulted in an actual harm for Resident #1 on 02/07/2019 at 2:35 p.m. when the resident, who had not been secured with a shoulder/lap belt, fell out of her wheelchair onto the facility transportation van's floor when the van driver abruptly applied the brakes. Resident #1 was assisted back into the wheelchair and brought back to the facility where she was assessed by the Director of Nursing then transported to the local hospital for an evaluation. The resident was diagnosed with [REDACTED]. The facility implemented corrective actions, which were completed prior to the State Agency's investigation; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the clinical record revealed Resident #1 was a sixty eight year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS with an Assessment Reference Date of 12/31/2018, revealed a BIMS score of 15, which indicated she was cognitively intact. The MDS also indicated resident used a wheelchair for mobility with total dependence for bed mobility and transfers. Review of Resident #1's Care Plan revealed the following: I am at risk for injuries from repeated falls. Fall on 9/12/17 with injury-return from hospital with a posterior cervical fusion secondary to odontoid fracture. Recent fall in van on 2/07/19 resulting in fractures to Left Distal Tibia and Fibula Review of the Hospital Summary, dated 02/07/2019, included the following: Resident #1 was seen in the local emergency roiagnom on [DATE]. Her chief complaint was: Fall, Head pain, Foot pain, and Arm injury. Patient told emergency room nurse she was in an accident while riding on the facility van. Patient stated she was not secured properly in the wheelchair and when the driver slammed on the brakes she fell forward out of her wheelchair and hit her head on an old milk crate. Skin tears to right arm and leg. Bottom of toes on right foot with active bleeding. Pain 10 out of 10. Pre-existing Stage Four pressure ulcer to sacrum. Two wounds to left leg and necrotic tissue to left heel. Hospital course: Proximal tibial and fibular fractures. Patient was admitted to the hospital for evaluation. Discharge [DIAGNOSES REDACTED]. An interview was conducted with S1ADM on 02/21/2019 at 9:10 a.m. He stated he got a call from S8Driver telling him she had an incident on the van and could he meet her outside the facility in about 10 minutes. S1ADM stated he met the driver and brought S4DON with him. He stated S8Driver first explained she put seatbelts on Resident's #1 and #2 before leaving from the doctor's office, she unexpectedly had to slam on the van brakes and Resident #1 fell forward out of her wheelchair and hit her head. He stated S8Driver then reported she pulled the van over to the side of the road, assessed both residents, and then put Resident #1 back in her wheelchair. She secured both residents shoulder/lap belt, called the administrator, then returned to the facility. He reported the van was 10 minutes away from the facility when the incident occurred. He told S8Driver that was impossible because if the safety belt was secured, the resident would not have fallen out of her wheelchair. S1ADM stated S8Driver then admitted she had not secured the safety belts on Residents #1 or #2 after she secured both wheelchairs with four point restraints to the van floor. S1ADM verified the transportation driver was responsible for securing both residents wheelchairs with four point restraints at the base of the wheelchair and securing the shoulder/lap seatbelt/harness prior to departure. S1ADM stated he interviewed Resident #2 and the resident verified the driver did not secure the shoulder/lap seatbelt for her or Resident #1 prior to leaving the doctor's office. He stated S8Driver was immediately terminated and remaining drivers received training after the incident. An interview was conducted on 02/22/2019 at 9:30 a.m. with S3Maint. She explained that S8Driver only drove the facility van when the regular full time drivers were absent. She verified S8Driver was responsible for securing the seatbelt and the wheelchair properly prior to departure in the transportation van. S3Maint verified that all the transportation drivers had received trainings and in-services a month before the incident regarding van safety and security as well as other annual trainings. An interview was conducted on 02/22/2019 at 12:43 p.m. with Resident #2 who had a BIMS score of 8. She reported that she did remember the accident on 02/07/2019. She verified that she nor Resident #1 had their seatbelts put on by the driver prior to leaving the doctor's office to return to the facility. Throughout the survey of dates 02/20/2019 - 02/22/2019, three full time and one fill in transportation staff were observed and interviewed on how to safely secure a resident in the van. Direct visual observations were made of each staff taking a resident in a wheelchair, using the van lift, then securing the wheelchair with four point restraints and shoulder/lap safety belt. These staff members were knowledgeable of the facility's transportation policy, how to use the van safety equipment and their roles and responsibilities during transport of residents in wheelchairs. Throughout the survey of dates 02/20/19 - 02/22/19, ten cognitive facility residents who used the van and were documented on the facility transportation logs for the past 3 months were interviewed. All ten residents verified transportation drivers had secured their wheelchairs using the four point restraint system as well as securing the shoulder/lap safety belt before leaving or returning to the facility. The facility implemented the following actions to correct the deficient practice on 2/07/19: 1. An in-service was conducted with remaining transportation staff on 2/8/19. The training topics covered were: use of the van safety belts, pre-trip logs, and properly fastening seatbelts. Hands on training was utilized. Three transportation staff signatures were noted on the sign-in sheet. 2. Maintenance Director maintains monitoring by documenting each transport on Company Owned Vehicle Driver In-service Checklist. Documentation include signing off on the vehicle controls, signing off on driving the vehicle, and signing off on patient/passenger safety and special equipment. All three transportation drivers as well as S1ADM and S3Maint signed this in-service on 02/12/19. 3. QAPI was implemented beginning 02/07/19. A Root Cause Analysis was conducted and a plan of correction implemented. The Plan of Correction included: establishing daily, weekly and random spot checks for driver compliance; transportation drivers randomly spot checked every week; which includes S1ADM and S3Maint observing the driver loading a resident onto the van and applying the safety devices correctly. The plan also included the driver, S1ADM, and S3Maint sign off on a monthly calendar, maintenance safety checks of each van every Friday by S3Maint, and all drivers will attend monthly trainings on how to secure a resident in a wheelchair, van safety, and fall precautions. Annual transportation driver trainings were changed to quarterly trainings with annual competency evaluations on hire anniversary.

Based on observation, interviews and record reviews, the facility failed to ensure a resident's right to be free from sexual abuse for 1 (Resident #6) of 7 (Residents #1, #2, #3, #4, #5, #6 and #7) sampled residents. This was evidenced by the facility's failure to: 1. Ensure the staff recognized what constituted abuse and the appropriate actions/interventions to take, 2. Protect a resident who was incapable of making a decision for herself (Resident #6) from a resident who was able to make decisions for himself (Resident #7) and 3. Report the incident to the facility's administration when it occurred. The failed practice resulted in an Immediate Jeopardy situation which began on 06/28/18 at 9:30 p.m. when Resident #6, who was not capable of making decisions for herself, and Resident #7 were observed sitting in the hallway near the front of Station 1 nursing station. As several staff members ambulated back and forth in front of the residents, Resident #7 kissed and touched Resident #6's breast without any staff intervention. Resident #7 continued to engage Resident #6 in a sexual manner from approximately 9:30 p.m. to approximately 1:30 a.m. at which time Resident #6 was returned to her room. The immediate jeopardy ended for Resident #6 when Resident #7 was placed on one to one supervision on 06/29/2018 at 6:00 a.m. The Administrator, S1Admin, was notified of the Immediate Jeopardy on 7/19/2018 at 5:45 p.m. The Immediate Jeopardy was removed on 7/20/2018 at 2:00 p.m. when the facility submitted an Immediate Jeopardy Plan of Removal which included: 1. On 7/19/2018 through 7/21/2018, the facility conducted in-services with staff to educate them on abuse and abuse reporting per the facility's policies and procedures; 2. The Administrator and DON/Designee will initiate weekly interviews with cognitive residents 3 times a week for 3 months to ensure there are no further sexual inappropriate allegations that have not been reported; 3. The Administrator, DON, ADON, Charge Nurse and Weekend RN will provide daily direct observations for those residents cognitively impaired to ensure there are no sexual inappropriate behaviors 3 times a week for 3 months; 4. The Administrator, DON, ADON, Charge Nurse or the Weekly RN will hold weekly mandatory in-services regarding abuse and abuse reporting 3 times a week for 3 months; 5. The facility staff will be able to verbalize the facility's policy regarding abuse and will be able to give an example indicating their understanding on weekly interviews 3 times a week for 3 months and 6. The facility staff will be able to verbalize proper chain of command for reporting abuse. The staff will continue with the chain of command until the Administrator is notified. An example: nurse, charge nurse ADON, DON, and leading to the Administrator. The deficient practice continued at a potential for more than minimal harm for the other 52 residents incapable of making decisions. Findings: Review of the facility's policy entitled Abuse/Neglect Reporting revealed the following excerpt: (3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, an occurrence will be reported to the Administrator of the facility, who will notify the Chief Operating Officer and the Chief Nursing Officer. The appropriate state officials per state guidelines must be notified within 2 hours of occurrence or discovery of such an alleged incident involving abuse or results in serious bodily injury 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. 5. During and after an investigation, the residents will be protected from harm through supervision by staff. In the case of resident-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed.) Review of the facility's Client Incident Report (OTIS) Incident ID: 7 revealed Discovered 6/28/18 09:30 p.m. Entered 6/29/18 12:16 p.m. Accused/Allegation Finding - Resident #7, Abuse: Sexual, Substantiated Victims - Resident #6 Resident #6 Review of the clinical record for Resident #6 revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 07/04/18 revealed in part the resident was unable to complete a BIMS assessment. Further review of this MDS revealed her cognitive skills for daily decision making were moderately impaired-decisions poor; cues/supervision required; acute onset mental status changes and inattention was coded as behavior continuously present. Review of Resident #6's Social History completed by S4SW revealed the following: Emotional mental status: forgetful, confused, alert, friendly Problems/Needs: Potential for behaviors due to dementia, will maintain appropriate behaviors. Potential for alteration in moods and altered coping due to new admit all related to [DIAGNOSES REDACTED]. Review of the admission care plan dated 06/06/18 revealed the following: 2. Cognitive Loss: Goal: Resident will be as alert and orient as possible (BLANK) 9. Behavioral Symptoms: Goal: Resident will have few episodes (BLANK) Further review of the care plan revealed the following: Problem Onset: 06/07/18 Problem/Need: Moderately impaired decision making ability manifested by decline in intellectual functioning Goal: Will preserve dignity Further review of care plan with a problem on set date of 06/07/18 revealed the following: Problem/Need: Moderately impaired decision making ability manifested by decline in intellectual functioning dx Alzheimer's Goal/Target Date: Will preserve dignity 09/05/18 Approaches, in part: Pleasant interaction which reassures resident when confused; Verbal reminders which reassure resident in orientation. On 07/18/18 at 11:45 a.m., Resident #6, a frail elderly lady, was observed sitting in a wheelchair with a lap tray. She was observed to be alert and awake with little facial expression. When spoken to, she mumbled and was not able to answer screening questions or carry on a meaningful conversation. She was able to follow simple instruction from the nurse during medication administration. Resident #7 Review of the medical record for Resident #7 revealed he was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. His [DIAGNOSES REDACTED]. Review of his current MDS with an ARD of 06/29/18 revealed Resident #7 had a BIMS summary score of 11 indicating he had moderate cognitive impairment. His functional status was assessed to require supervision/cueing with bed mobility and transfers and his locomotion on the unit required supervision and oversight. He had no impairment of upper or lower extremities and used a wheelchair for a mobility device. Review of Resident #7's Social History completed by S4SW on admission revealed he was admitted for therapy and planned to return home when completed. Her notes indicated no behaviors, speech was clear, understood by others and comprehension of most conversation. Review of the Social Progress Notes for Resident #7 dated 06/29/18 revealed in part the following: Staff reports that resident was inappropriately touching on another resident's breast. When I spoke with resident he said he may have touched his girlfriend's breast. But he wasn't able to recall her name. Resident appears anxious and sadness. Expressed he didn't mean to cause harm to the lady. But also expresses he wants a girlfriend. He remains in the office with me. He is able to recall the year, date and month. States no delusions, no harm to self. He admitted to touching another resident's breast without her consent. He said he can't help himself if he likes someone. States he didn't like any other lady. Review of his care plan revealed: Problem Onset 02/14/18: Modified independence with decision-making Goal: Will assist resident in making important daily decisions 9/2018 Problem Onset 06/29/18: Sexually inappropriate behavior exhibited towards another female resident Goal & Target Date: Episodes of inappropriate sexual behavior will be eliminated 9/01/18 Approaches included: 6/29/18 Admit to Geri psych. On 07/18/18 at 12:52 p.m., an interview was conducted with S6RN. He stated he had worked at the facility for one month and was working on the night shift on (MONTH) 28 and was assigned Resident #7. He stated at about 4:00 a.m., S7LPN, who was working on another unit, reported to him that Resident #7 had touched Resident #6's breast. He stated at that time when he looked at them, Resident #7 was about 12-15 feet from Resident #6. He stated when he asked Resident #7 if he was touching Resident #6, he said he was getting something off of her blouse. He stated he told Resident #7 not to put his hands on her anymore and he told him that if there was something on her blouse, to report it to staff for them to take care of it. He was asked if he was sure about the time when S7LPN reported this to him and he said yes he was sure because it was about time for Resident #7 to go to bed anyway and he was doing med pass. He stated he took Resident #7 to his room and he got in the bed. He stated he had no proof of Resident #7 touching Resident #6 because he did not witness anything himself for him to report. He stated he reported this in the morning report and they must have reported it to administration because he was called in that same day to write a statement. He stated he did not recall any training on the policy/procedure for Abuse/Neglect or training following the incident. On 07/18/18 at 3:45 p.m., an interview was conducted with S10LW. She stated on 06/28/18 at around 9:30 p.m., she was bringing laundry out for delivery. She stated Resident #7 and Resident #6 were sitting in wheelchairs at Station 1, Resident #7 was rubbing her side. She stated when she turned and looked back, Resident #7 had his hand on top of her shirt. She stated, I went and reported this to the night shift nurse on Station 1. S10LW stated the nurse showed no concern so she continued with her linen delivery and reported the information to S11CNA. S10LW stated when she passed the residents to clock out at 10:00 p.m., both residents were still in the same location sitting next to each other. On 07/18/18 at 4:40 p.m., an interview was conducted with S11CNA. She stated she witnessed Resident #7 touching and rubbing Resident #6 at about 10:00 p.m. on 6/28/18. She stated she told Resident #7 to move over and not to touch Resident #6. She stated she reported this to S13CNA, who was assigned to care for Resident #7. S11CNA stated at about 10:00 p.m., she and S13CNA reported this to S8LPN. On 07/19/18 at 9:36 a.m., an interview was conducted with S5Maint. She stated she was responsible for maintaining the camera system. She stated on (MONTH) 29, in the morning meeting around 8:30 a.m., S2DON asked her to review and record the camera from the Station 1 area for an incident involving two residents touching inappropriately. She stated she viewed the recording, saved it on her phone and took it to S2DON for her to review. She described what took place beginning around 9:30 p.m. on 6/28/2018 when Resident #7 approached Resident #6 until around 1:30 a.m. according to the time on the video. She stated she witnessed Resident #7 inappropriately touching Resident #6 inside of her shirt on her breast, kissing her and his attempted removal of her lap tray. She stated several staff were seen throughout the video passing in the line of visible sight of the residents but she did not see any staff actions taken to intervene or remove the residents. She further stated she observed S12CNA on the video pass in the hall twice while Resident #6 was touched and kissed by Resident #7. She stated Resident #6 remained in the same location until about 1:30 a.m. when a CNA came and got her and rolled her away. On 07/19/18 at 12:15 p.m., an interview was conducted with S8LPN. She stated on 06/28/19 she was aware of Resident #7 and Resident #6 holding hands and then at about 10:10 p.m. S11CNA reported Resident #7 and Resident #6 were getting friendly. She stated she overheard one CNA say to another CNA that they had been smooching so she went and told Resident #7 to keep it PG (parental guidance) and that they could just hold hands. She stated they both just sat there holding hands. She stated Resident #6 was smiling and so she thought she was okay with this. She stated she went back to her med pass but she did peek down the hall and they were just holding hands. She stated that because S6RN was aware of what the CNAs had said, she trusted he would tell her if there was something that she needed to do. She stated she had received a packet on Abuse and Neglect when she was hired about 3 months ago but she did not remember receiving training since the incident occurred. Review of the facility's documents entitled In-service/Meeting Record revealed the following; Name: When and What to Call Administration For (Abuse, Neglect, Resident on Resident Contact, Falls with Major Injury, Elopements, Meds (Medication) Not Available, Fire Alarms, Staffing, Environmental Issues, Resident Rights and Dignity (see attached) - No documents were attached to the record, only the signatures of staff members followed. Date: 06/29/18 Time: 1:30 p.m. Instructors: S2DON and S3ADON Further review of the documents revealed S6RN and S8LPN's names/signatures were not on the sheets to indicate their participation. On 07/19/18 at 12:35 p.m., an interview was conducted S2DON. She stated on 06/29/18, a little after 8:00 a.m., she overheard two CNAs taking in the hallway near Station 1. She stated one of the CNAs stated to the other, Did you hear about what happened last night between (Resident #7 and Resident #6)? S2DON confirmed that no one actually reported this to her, she just overheard about the incident in a conversation. She stated after viewing the recording from the cameras with S5Maint, she saw Resident #7's hand in Resident #6's blouse. She stated she saw staff walking pass the residents within visual sight but she did not see any staff response. She confirmed staff intervention should have been immediate and she expected to be notified when it happened. On 07/19/18 at 1:12 p.m., an interview was conducted with S1Admin. He stated he reviewed the video from a recording and he could see Resident #6 and Resident #7 leaning and kissing and he could see Resident #7 put his hand down her shirt on her breast. He stated he did not have any concerns for Resident #6 once Resident #7 was sent out of the building because S4SW had reported Resident #7 was looking for a girlfriend. He stated he interviewed one or two staff members and he reviewed the statements, which S2DON had obtained, for his investigation. When asked when he expected staff to report abuse, he stated he had told staff anything that happened in this house, he wanted to know about it. When asked if any other measures were put in place to identify and monitor other residents who were not capable of making decisions for themselves, he stated he had instructed S2DON to provide staff training but other measures or monitors were done. On 07/19/18 4:10 p.m., an interview was conducted with S12CNA. She stated she worked the night shift on (MONTH) 28 and was sitting in the doorway outside of another resident's room next to Resident #7's room and she witnessed Resident #7's hand down inside of her blouse with his hand on her breast. She stated she reported this to S6RN and he told Resident #7 to stop and then she told S8LPN who was Resident #6's nurse but she did not try to stop him. She stated she was called to come in on (MONTH) 29 and write a statement about what she witnessed but it was her day off so she didn't come in and no one asked her for her written statement again.

Based on interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to prevent sexual abuse of 1 (Resident #6) of 7 (Residents #1, # 2, #3, #4, #5, #6 and #7) sampled residents as evidenced by failure to: 1. Protect a resident (Resident #6), who was not capable of making decisions for herself, from sexual abuse; 2. Ensure staff were trained to recognize and report abuse; 3. Complete a thorough and complete investigation of sexual abuse. The failed practice resulted in an Immediate Jeopardy situation which began on 06/28/18 at 9:30 p.m. when Resident #6, who was not capable of making decisions for herself, and Resident #7 were observed sitting in the hallway in front of Station 1 nursing station. As several staff members ambulated back and forth in front of the residents, Resident #7 kissed and touched Resident #6's breast without any staff intervention. Resident #7 continued to engage resident #6 in a sexual manner from approximately 9:30 p.m. to approximately 1:30 a.m. at which time Resident #6 was returned to her room. The immediate jeopardy ended for Resident #6 when Resident #7 was placed on one to one supervision on 06/29/2018 at 6:00 a.m. The Administrator, S1Admin, was notified of the Immediate Jeopardy on 7/19/2018 at 5:45 p.m. The Immediate Jeopardy was removed on 7/20/2018 at 2:00 p.m. when the facility submitted an Immediate Jeopardy Plan of Removal which included: 1. On 7/19/2018 through 7/21/2018, the facility conducted in-services with staff to educate them on abuse and abuse reporting per the facility's policies and procedures; 2. The Administrator and DON/Designee will initiate weekly interviews with cognitive residents 3 times a week for 3 months to ensure there are no further sexual inappropriate allegations that have not been reported; 3. The Administrator, DON, ADON, Charge Nurse and Weekend RN will provide daily direct observations for those residents cognitively impaired to ensure there are no sexual inappropriate behaviors 3 times a week for 3 months; 4. The Administrator, DON, ADON, Charge Nurse or the Weekly RN will hold weekly mandatory in-services regarding abuse and abuse reporting 3 times a week for 3 months; 5. The facility staff will be able to verbalize the facility's policy regarding abuse and will be able to give an example indicating their understanding on weekly interviews 3 times a week for 3 months and 6. The facility staff will be able to verbalize proper chain of command for reporting abuse. The staff will continue with the chain of command until the Administrator is notified. An example: nurse, charge nurse ADON, DON, and leading to the Administrator 3 times a week for 3 months. The deficient practice continued at a potential for more than minimal harm for the other 52 residents incapable of making decisions. Findings: Cross refer to F600 Cross refer to F943 Review of the facility's policy entitled Abuse/Neglect Reporting revealed the following excerpt: (3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, an occurrence will be reported to the Administrator of the facility, who will notify the Chief Operating Officer and the Chief Nursing Officer. The appropriate state officials per state guidelines must be notified within 2 hours of occurrence or discovery of such an alleged incident involving abuse or results in serious bodily injury. 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. 5. During and after an investigation, the residents will be protected from harm through supervision by staff. In the case of resident-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed.) On 07/19/18 at 12:35 p.m., an interview was conducted S2DON. She stated on 06/29/18, a little after 8:00 a.m., she overheard two CNAs taking in the hallway near Station 1. She stated one of the CNAs stated to the other, Did you hear about what happened last night between Resident #7 and Resident #6? S2DON confirmed that no one actually reported this to her, she just overheard about the incident in a conversation. She stated after viewing the recording from the cameras with S5Maint, she saw Resident #7's hand in Resident #6's blouse. She stated she saw staff walking pass the residents within visual sight but she did not see any staff response. She confirmed staff intervention should have been immediate and she expected to be notified when it happened. As the interview with S2DON continued on 07/19/18 at 12:35 p.m., she stated that she did not interview the night shift staff, she had them write statements. She stated she started staff training on 6/29/18 and she was not sure how many employees were trained. She stated she did not check to see who did not complete the training. She stated Resident #7 was transferred to another facility and staff training on reporting abuse was started but there was no monitoring put in place following the training. On 07/19/18 at 12:50 p.m., an interview was conducted with S3ADON. He verified S12CNA had worked that night and there was not a statement from her when he transcribed the information into the OTIS report. On 07/19/18 at 1:12 p.m., an interview was conducted with S1Admin. He stated he reviewed the video from a recording and he could see Resident #6 and Resident #7 leaning and kissing and he could see Resident #7 put his hand down her shirt on her breast. He stated he did not have any concerns for Resident #6 once Resident #7 was sent out of the building because S4SW had reported Resident #7 was looking for a girlfriend. He stated he interviewed one or two staff members and he reviewed the statements, which S2DON had obtained, for his investigation. When asked when he expected staff to report abuse, he stated he had told staff anything that happened in this house, he wanted to know about it. When asked if any other measures were put in place to identify and monitor other residents who were not capable of making decisions for themselves, he stated he had instructed S2DON to provide staff training but other measures or monitors were done. On 07/19/18 at 5:45 p.m., an interview was conducted with S1Admin. He stated he was not aware that all of the staff had not completed the training for reporting abuse which was started on (MONTH) 29 or that statements were not obtained from all staff who witnessed the sexual abuse of Resident #6. He confirmed S3ADON transcribed the information into the OTIS report. He stated other than the discharge of Resident #7 and the training, there were no other measures implemented following this incident.

Based on interviews and record reviews, the facility failed to provide training that at a minimum educated all staff on activities that constituted abuse, procedures for reporting incidents of abuse and resident abuse prevention. The failed practice resulted in an Immediate Jeopardy situation which began on 06/28/18 at 9:30 p.m. when Resident #6, who was not capable of making decisions for herself, and Resident #7 were observed sitting in the hallway near the front of Station 1 nursing station. As several staff members ambulated back and forth in front of the residents, Resident #7 kissed and touched Resident #6's breast without any staff intervention. Resident #7 continued to engage resident #6 in a sexual manner from approximately 9:30 p.m. to approximately 1:30 a.m. at which time Resident #6 was returned to her room. The immediate jeopardy ended for Resident #6 when Resident #7 was placed on one to one supervision on 06/29/2018 at 6:00 a.m. The Administrator, S1Admin, was notified of the Immediate Jeopardy on 7/19/2018 at 5:45 p.m. The Immediate Jeopardy was removed on 7/20/2018 at 2:00 p.m. when the facility submitted an Immediate Jeopardy Plan of Removal which included: 1. On 7/19/2018 through 7/21/2018, the facility conducted in-services with staff to educate them on abuse and abuse reporting per the facility's policies and procedures; 2. The Administrator and DON/Designee will initiate weekly interviews with cognitive residents 3 times a week for 3 months to ensure there are no further sexual inappropriate allegations that have not been reported; 3. The Administrator, DON, ADON, Charge Nurse and Weekend RN will provide daily direct observations for those residents cognitively impaired to ensure there are no sexual inappropriate behaviors 3 times a week for 3 months; 4. The Administrator, DON, ADON, Charge Nurse or the Weekly RN will hold weekly mandatory in-services regarding abuse and abuse reporting 3 times a week for 3 months; 5. The facility staff will be able to verbalize the facility's policy regarding abuse and will be able to give an example indicating their understanding on weekly interviews 3 times a week for 3 months and 6. The facility staff will be able to verbalize proper chain of command for reporting abuse. The staff will continue with the chain of command until the Administrator is notified. An example: nurse, charge nurse ADON, DON, and leading to the Administrator 3 times a week for 3 months. The deficient practice continued at a potential for more than minimal harm for the other 52 residents incapable of making decisions. Findings: Review of the facility's policy entitled Abuse/Neglect Reporting revealed the following excerpt: (3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, an occurrence will be reported to the Administrator of the facility, who will notify the Chief Operating Officer and the Chief Nursing Officer. The appropriate state officials per state guidelines must be notified within 2 hours of occurrence or discovery of such an alleged incident involving abuse or results in serious bodily injury. 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. 5. During and after an investigation, the residents will be protected from harm through supervision by staff. In the case of resident-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed.) Review of the facility's Client Incident Report (OTIS) Incident ID: 7 revealed Discovered 6/28/18 09:30 p.m. Entered 6/29/18 12:16 p.m. Accused/Allegation Finding - Resident #7, Abuse: Sexual, Substantiated Victims - Resident #6 Documented statements were attached to the report from S6RN, S7LPN, S8LPN, S10LW, S11CNA and S13CNA. Review of the facility's documents entitled In-service/Meeting Record revealed the following; Name: When and What to Call Administration For (Abuse, Neglect, Resident on Resident Contact, Falls with Major Injury, Elopements, Meds (Medication) Not Available, Fire Alarms, Staffing, Environmental Issues, Resident Rights and Dignity) Date: 06/29/18 Time: 1:30 p.m. Instructors: S2DON and S3ADON Review of the facility's employee list compared to the training sign-in sheets dated 06/29/18 at 1:30 p.m. revealed there were 66 employees who had not completed the training entitled When and What to Call Administration For. Signatures for S6RN, S8LPN and S13CNA, staff who wrote statements attached to the substantiated OTIS report above, were not observed on the training sign-in sheets. On 07/18/18 at 12:52 p.m. in an interview with S6RN, he stated he did not notify administration because he did not witness the inappropriate sexual behavior, it was just reported to him. He stated he reported it to the next shift in report. He stated he did not recall training specific to the policy/procedure for abuse or neglect reporting. He stated he did not recall any training on the policy/procedure for Abuse/Neglect training after the incident but sometimes the trainings are just papers that you sign. On 07/19/18 at 12:15 p.m., an interview was conducted S8LPN. She stated she thought Resident #7 holding Resident #6's hand was cute. She was not able to verbalize what constituted sexual abuse. She stated she had training on abuse and neglect when she was hired 3 months ago and she received a packet but she could not remember receiving training since that time. On 07/19/18 at 4:25 p.m., S3ADON stated he and S2DON had tried to reach as many staff members as they could. He stated he thought the staff knew what abuse was but did not think they knew to notify administration immediately. He reviewed the comparison of the employee list provided by the facility with the names on the In-service/Meeting Attendance Records dated 6/29/18. He verified that according to the comparison of the sign-in sheets and the list of employees, 66 staff employees had not been trained following the sexual abuse incident. He stated it was mandatory for all staff. He also verified that S6RN, S8LPN and S13CNA who submitted statements that were attached to the OTIS report did not participate in the staff training. On 07/19/18 at 12:35 p.m., an interview was conducted with S2DON. She stated she started staff training on 6/29/18 and she was not sure how many employees were trained because S3ADON had also provided some of training. She stated she did not check to see who or how many staff members did not complete the training. She stated the staff received in-person training but there was no monitoring put in place following the training. On 07/19/18 at 5:45 p.m., during an interview with S1Admin, when asked if all of the facility staff had training on abuse, he stated he thought staff had been trained in a meeting and then again following the incident of sexual abuse. He stated he was not aware that all of the staff did not complete the training. He stated he was not aware of monitoring to determine if the staff training was effective.

Based on observation, interview, record review, and review of the American Nurses Association for Gerontological nursing scope and standards of practice the facility failed to provide professional standards of quality for 1 (#4) of 5 (#1, #2, #3, #4, #5) residents investigated for falls. The facility failed to ensure that nursing staff and CNA's (Certified Nursing Assistant) did not leave a resident unsupervised while seated in a wheelchair without the alarm on. This failed practice resulted in a fall with an acute [MEDICAL CONDITION] to Resident #4 when she unbuckled her seatbelt and fell . The resident's chair alarm was off and she was unsupervised when she fell on [DATE]. The facility failed to: 1. Identify that staff did not turn on the physician ordered wheelchair alarm while the resident was unsupervised in the wheelchair. This resulted in an acute [MEDICAL CONDITION] for Resident #4. 2. Ensure that a resident was not left alone without nursing staff or CNA's when the physician ordered wheelchair alarm was not on. Resident #4 had a history of [REDACTED]. The resident was care planned for fall risk due to her recent fall and traumatic left [MEDICAL CONDITION]. She was care planned on 02/20/13 to have an alarming self-releasing seat belt prior to her fall on 04/07/13. Resident #4 was placed at the harm level when she was left unattended by the nursing staff in the facility's dining room with the alarm turned off. Resident #4 unbuckled her seat belt, stood up and fell . This fall resulted in an acute [MEDICAL CONDITION]. Findings: American Nurses Association. Gerontological nursing: scope and standards of practice. Silver Springs, Maryland: Nursebooks.org, October, 2010. "Standards of Practice" "Standard 1. Assessment The gerontological nurse collects comprehensive data pertinent to the older adult's physical and mental health or situation. Standard 2. Diagnosis The gerontological nurse analyzes the assessment date to determine the [DIAGNOSES REDACTED]. Standard 3. Outcome Identification The gerontological nurse identifies expected outcomes for a plan individualized to the older adult or situation. Standard 4. Planning The gerontological nurse develops a plan to attain expected outcomes. The gerontological nurse: - Provides for continuity within the plan - Uses the plan to provide direction and guidance to formal and informal caregivers and other members of the healthcare team Standard 5. Implementation The gerontological nurse implements the identified plan The gerontological nurse: - Implements the plan of care in a safe and timely manner Standard 5A. Coordination of Care The gerontological nurse coordinates care delivery. The gerontological registered nurse: - Coordinates implementation of the plan Standard 6. Evaluation The gerontological registered nurse evaluates progress toward attainment of outcomes." On 04/18/13 a review of the clinical record was conducted. The clinical record revealed Resident #4 was an [AGE] year old female whom was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admitting MDS (Minimum Data Sets) with ARD (Assessment Reference Date) of 03/08/13 revealed a BIMS (Brief Interview for Mental Status) score of 9. This score indicates the resident's cognitive status was moderately impaired. A review of the April 2013 Physicians Orders revealed the following: Alarming Bed Alarm while in bed Alarming Seat Belt while in wheelchair (w/c) A review of the Care Plan revealed the following: Problem onset: 02/20/13 At risk for injuries from falls as resident has recent hx of falls with fx to L Hip Goal & Target Date: Will minimize or decrease risk for falls by providing safe environment - 05/01/13 Approaches: Assist with turning and repositioning q (every) 2 hrs (hours) Assist appropriately with all transfers Fall Prevention Program Full S/R (siderails) (padded) up x 2 in bed Self-releasing alarming seat belt Alarming bed mat; answer promptly A review of the Fall Risk Evaluation form revealed the following: 02/07/13 (date of admit) - 15 02/27/13 (date of 1st fall) - 18 04/08/13 (date after 2nd fall) - 18 A score of 10 or greater indicates the resident was at high risk for falls. A review of the Incident and Accident report revealed the following: 04/07/13 - fell out of w/c in dining room, 2 lacerations to left eyebrow, transferred to hospital per EMS (Emergency Medical Service). Alarm box off on w/c, alarming seat belt unbuckled. A review of the facility's Fall Quality Indicator form dated 04/07/13, completed the day of the fall, revealed the safety measure in place at the time of the fall was an alarming seat belt. The device was not on at the time of the fall; the box was off and did not sound when resident removed seatbelt. A review of the radiology report dated 04/07/13 from the hospital Resident #2 was transferred to reveal the following: Comminuted distal radial fracture. Ulnar styloid process fracture (A distal radius fracture almost always occurs about 1 inch from the end of the bone. ... Comminuted fracture - when a bone is broken into more than two pieces; Ulnar styloid fracture is an injury commonly seen in association with fractures of the wrist) A review of the CT (Computerized Tomography) report dated 04/07/13 from the hospital Resident #2 was transferred to reveal the following: Acute [MEDICAL CONDITION] (An [MEDICAL CONDITION] is bleeding in the brain). On 04/18/13 at 9:25 a.m. during the general tour of the facility an observation was performed of Resident #R1being transferred from bed to w/c by S3RN and S4CNA. When they stood the resident up, the alarm did not sound indicating the resident was out of bed. The alarm box switch was observed in the "on" position. S3RN stated the batteries must be dead. After the batteries were replaced, S3RN and S4CNA stood Resident #R1 up and the alarm did not sound. S3RN confirmed the alarm did not sound after the batteries were replaced. S3RN was asked who she reports to when alarms are found to be malfunctioning. She stated, "Maintenance is notified." A review of the yellow "Repair Requisition" forms revealed no documentation of maintenance being notified of Resident #R1's bed alarm malfunctioning. On 04/18/13 at 2:39 an interview was conducted with S6Maint. He was asked how often safety equipment was checked. He stated, "Once a week and whenever the staff notifies me of a problem". S6Maint was asked if he had been notified of resident #R1's bed alarm malfunctioning this morning. He stated, "No". He stated he does a weekly safety check from the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. The week of 04/03/13 - Resident #4's physician's orders [REDACTED]. The week of 03/27/13 - Resident #4's physician's orders [REDACTED]. The week of 03/21/13 - Resident #4's physician's orders [REDACTED]. The week of 03/14/13 - Resident #4's physician's orders [REDACTED]. S6Maint was asked to review the physician's orders [REDACTED]. He stated Resident #4 ' s safety equipment was not included and there was no documentation of him checking her safety equipment. A review of the facility's policy and procedure entitled "Work Orders, Maintenance" revealed the following: Policy Interpretation and Implementation "In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director" . Further review revealed "Maintenance will perform weekly safety checks on all resident safety devices including alarms and rails". On 04/18/13 at 3:23 p.m. an interview was conducted with S5CNASup. She was asked who the CNA's notify when they find an alarm is not functioning correctly. She stated, "They are taught to notify the nurse assigned to the resident, the charge nurse and to fill out a yellow slip for the maintenance department. They are also taught to stay with the resident until the alarm is fixed." S5CNASup was asked how she ensured the CNA's were checking the alarms to ensure they were on when a resident was in a w/c and were functioning properly. She stated she made rounds daily and checks them every shift. S5CNASup was asked if she documented her daily rounds and checks. She stated, "No". The facility was unable to provide any documented evidence that the CNA staff were checking to ensure the resident's alarms were working properly. A review of the In-Service/Meeting Attendance Record dated 04/08/13 revealed an inservice was held the day after Resident #4 fell in the dining room. The inservice did not contain information regarding checking to ensure wheelchair alarms were functioning properly. The inservice sign in sheet revealed the inservice was attended by 52 employees out of 148 employed by the facility. 96 employees were not inserviced on ensuring that the residents' w/c alarms were functioning properly. On 04/18/13 at 3:39 p.m. an interview was conducted with S2DON. He was asked to review the inservice sign in sheet dated 04/08/13. After reviewing the sign in sheet, S2DON was asked if the inservice was attended by everyone that comes in contact with the resident. He stated, "No, it wasn't." S2DON was asked how he was going to ensure that all staff was inserviced. He stated, "I will have to hold inservices around the clock until all of the employees are inserviced." S2DON was asked who was responsible for ensuring residents alarms were working. He stated, "Everyone that comes in contact with the resident. The alarms are managed many times throughout the day." S2DON was also asked to review the fall Incident & Accident report dated 04/07/13 for Resident #4. S2DON was asked to verify the information documented on the report form, he confirmed the alarm box was not on. S2DON was asked how do you ensure that the staff was implementing the care plan. He stated, "I walk around and check to see if the staff is doing what they are suppose to." S2DON was asked where it was document. He stated, "I don't write it down" . The facility was unable to provide any documented evidence that safety checks were performed to ensure properly working equipment. Resident #2: A review of the clinical record revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. On 01/06/13- wheelchair alarm On 01/09/13- floor mat alarm A review of the Care Plan revealed the following: Problem onset 01/18/2013- At risk for injuries from falls as resident has history of falls Approaches: Fall prevention Program W/C (wheelchair) and floor mat alarm; answer promptly Provide safe and secure environment; encourage safety precautions with repeated reminders New approaches following fall on 01/31/13 included CNA in-serviced to ensure alarms on and functional; alarm checked and on and fully functioning Fall Risk assessments were documented by facility as follows (score of 10 or above represents High Risk): 01/14/13- score of 10 01/31/13- score of 12 04/01/13- score of 12 A review of the MDS (Minimum Data Set) with ARD (Assessment Reference Date) 01/17/13 revealed the following: Section C (Cognitive Patterns) - score was 11 (score of 8-12 indicates moderate impairment) Section G (Functional Status) - required limited assistance with transfers and toilet use; resident not steady, only able to stabilize with staff assistance with moving form seated to standing position and surface-to-surface transfer. A review of the Investigations completed by the facility following Resident #2's falls on 01/31/13 and 04/12/13 revealed the following: 1/31/13 at 1:00 p.m. - fall in bathroom by dining room while resident was trying to go to bathroom by himself. The resident's wheelchair alarm did not alarm, it was unplugged. The resident had a scrape to his left upper back that was treated by the treatment nurse. Staff was in-serviced on checking to make sure alarms were on and plugged in with increased supervision. 4/12/13 at 2:30 p.m. - fall while staff in resident's room. There was no injury. The resident slipped on his floor mat. The care plan was updated and Velcro was placed under alarming floor mat. On 04/18/13 at 11:44 a.m. an interview was conducted with Resident #2's son in resident's room. His son was asked if he had ever observed his father ' s wheelchair alarm off while he was in the wheelchair. Resident #2's son stated that he had visited on multiple occasions when the chair alarm was off. He stated he noticed it off several times following therapy and many occasions in the dining room when he came before and after lunch. On 04/18/13 at 3:23 p.m. an interview was conducted with S5CNASup. She was asked who the CNA's notify when they find an alarm is not functioning correctly. She stated, "They are taught to notify the nurse assigned to the resident, the charge nurse and to fill out a yellow slip for the maintenance department. They are also taught to stay with the resident until the alarm is fixed. " S5CNASup was asked how she ensured the CNA's were checking the alarms to ensure they were on when a resident was in a w/c and were functioning properly. She stated she made rounds daily and checks them every shift. S5CNASup was asked if she documented her daily rounds and checks. She stated, "No". The facility was unable to provide any documented evidence that the CNA staff were checking to ensure the resident's alarms were working properly. On 04/18/13 at 3:39 p.m. an interview was conducted with S2DON. He was asked to review the inservice sign in sheet dated 04/08/13. After reviewing the sign in sheet, S2DON was asked if the inservice was attended by everyone that comes in contact with the resident. He stated, "No, it wasn't". S2DON was asked how he was going to ensure that all staff was inserviced. He stated, "I will have to hold inservices around the clock until all of the employees are inserviced." S2DON was asked who was responsible for ensuring residents alarms were working. He stated, "Everyone that comes in contact with the resident. The alarms are managed many times throughout the day." S2DON was also asked to review the fall Incident & Accident report dated 04/07/13 for Resident #4. S2DON was asked to verify the information documented on the report form, he confirmed the alarm box was not on. S2DON was asked how do you ensure that the staff was implementing the care plan. He stated, "I walk around and check to see if the staff is doing what they are suppose to." S2DON was asked where it was document. He stated, "I don't write it down". The facility was unable to provide any documented evidence that safety checks were performed to ensure properly working equipment.

Based on observations, interviews and record reviews the facility failed to ensure residents' environment remained as free of accident hazards as possible. The facility failed to ensure residents who required safety equipment alarms received adequate supervision to prevent avoidable accidents for 2 (#4, #2) of 5 (#1, #2, #3, #4, #5) residents investigated for falls and 1 (#R1) of 1 random resident. This failed practice resulted in harm to Resident #4 when she sustained a fall with an acute intracranial hemorrhage and fractured her wrist following her fall on 04/07/13. The facility failed to: 1. Ensure the safety of unsupervised residents' with physician ordered wheelchair and bed alarms. 2. Ensure weekly safety checks were performed as per policy and procedure. 3. In-service all nursing staff and CNA's (Certified Nursing Assistant) on proper use and safety hazard requirements of wheelchair alarms. 4. Supervise and monitor staff practices to ensure the residents' wheelchair alarm was functioning. Findings: Resident #4 On 04/18/13 a review of the clinical record was conducted. The clinical record revealed Resident #4 was an [AGE] year old female whom was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admitting MDS (Minimum Data Sets) with ARD (Assessment Reference Date) of 03/08/13 revealed a BIMS (Brief Interview for Mental Status) score of 9. This score indicates the resident's cognitive status was moderately impaired. A review of the April 2013 Physicians Orders revealed the following: Alarming Bed Alarm while in bed Alarming Seat Belt while in wheelchair (w/c) A review of the Care Plan revealed the following: Problem onset: 02/20/13 At risk for injuries from falls as resident has recent hx of falls with fx to L Hip Goal & Target Date: Will minimize or decrease risk for falls by providing safe environment - 05/01/13 Approaches: Assist with turning and repositioning q (every) 2 hrs (hours) Assist appropriately with all transfers Fall Prevention Program Full S/R (siderails) (padded) up x 2 in bed Self-releasing alarming seat belt Alarming bed mat; answer promptly A review of the Fall Risk Evaluation form revealed the following: 02/07/13 (date of admit) - 15 02/27/13 (date of 1st fall) - 18 04/08/13 (date after 2nd fall) - 18 A score of 10 or greater indicates the resident was at high risk for falls. A review of the Incident and Accident report revealed the following: 04/07/13 - fell out of w/c in dinning room, 2 lacerations to left eyebrow, transferred to hospital per EMS (Emergency Medical Service). Alarm box off on w/c, alarming seat belt unbuckled. A review of the facility's Fall Quality Indicator form dated 04/07/13, completed the day of the fall, revealed the safety measure in place at the time of the fall was an alarming seat belt. The device was not on at the time of the fall; the box was off and did not sound when resident removed seatbelt. A review of the radiology report dated 04/07/13 from the hospital Resident #2 was transferred to revealed the following: Comminuted distal radial fracture. Ulnar styloid process fracture (A distal radius fracture almost always occurs about 1 inch from the end of the bone. ... Comminuted fracture - when a bone is broken into more than two pieces; Ulnar styloid fracture is an injury commonly seen in association with fractures of the wrist) A review of the CT (Computerized Tomography) report dated 04/07/13 from the hospital Resident #2 was transferred to revealed the following: Acute intracranial hemorrhage... (An intracranial hemorrhage is bleeding in the brain). On 04/18/13 at 9:25 a.m. during the general tour of the facility an observation was performed of Resident #R1being transferred from bed to w/c by S3RN and S4CNA. When they stood the resident up, the alarm did not sound indicating the resident was out of bed. The alarm box switch was observed in the "on" position. S3RN stated the batteries must be dead. After the batteries were replaced, S3RN and S4CNA stood Resident #R1 up and the alarm did not sound. S3RN confirmed the alarm did not sound after the batteries were replaced. S3RN was asked who she reports to when alarms are found to be malfunctioning. She stated, "Maintenance is notified." A review of the yellow "Repair Requisition" forms revealed no documentation of maintenance being notified of Resident #R1's bed alarm malfunctioning. On 04/18/13 at 2:39 an interview was conducted with S6Maint. He was asked how often safety equipment was checked. He stated, "Once a week and whenever the staff notifies me of a problem". S6Maint was asked if he had been notified of resident #R1's bed alarm malfunctioning this morning. He stated, "No". He stated he does a weekly safety check from the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. The week of 04/03/13 - Resident #4's physician's orders [REDACTED]. The week of 03/27/13 - Resident #4's physician's orders [REDACTED]. The week of 03/21/13 - Resident #4's physician's orders [REDACTED]. The week of 03/14/13 - Resident #4's physician's orders [REDACTED]. S6Maint was asked to review the physician's orders [REDACTED]. He stated Resident #4's safety equipment was not included and there was no documentation of him checking her safety equipment. A review of the facility's policy and procedure entitled "Work Orders, Maintenance" revealed the following: Policy Interpretation and Implementation "In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director". Further review revealed "Maintenance will perform weekly safety checks on all resident safety devices including alarms and rails". On 04/18/13 at 3:23 p.m. an interview was conducted with S5CNASup. She was asked who the CNA's notify when they find an alarm is not functioning correctly. She stated, "They are taught to notify the nurse assigned to the resident, the charge nurse and to fill out a yellow slip for the maintenance department. They are also taught to stay with the resident until the alarm is fixed." S5CNASup was asked how she ensured the CNA's were checking the alarms to ensure they were on when a resident was in a w/c and were functioning properly. She stated she made rounds daily and checks them every shift. S5CNASup was asked if she documented her daily rounds and checks. She stated, "No". The facility was unable to provide any documented evidence that the CNA staff were checking to ensure the resident's alarms were working properly. A review of the In-Service/Meeting Attendance Record dated 04/08/13 revealed an inservice was held the day after Resident #4 fell in the dining room. The inservice did not contain information regarding checking to ensure wheelchair alarms were functioning properly. The inservice sign in sheet revealed the inservice was attended by 52 employees out of 148 employed by the facility. 96 employees were not inserviced on ensuring that the residents' w/c alarms were functioning properly. On 04/18/13 at 3:39 p.m. an interview was conducted with S2DON. He was asked to review the inservice sign in sheet dated 04/08/13. After reviewing the sign in sheet, S2DON was asked if the inservice was attended by everyone that comes in contact with the resident. He stated, "No, it wasn't" S2DON was asked how he was going to ensure that all staff was inserviced. He stated, "I will have to hold inservices around the clock until all of the employees are inserviced." S2DON was asked who was responsible for ensuring residents alarms were working. He stated, "Everyone that comes in contact with the resident. The alarms are managed many times throughout the day." S2DON was also asked to review the fall Incident & Accident report dated 04/07/13 for Resident #4. S2DON was asked to verify the information documented on the report form, he confirmed the alarm box was not on. S2DON was asked how do you ensure that the staff was implementing the care plan. He stated, "I walk around and check to see if the staff is doing what they are suppose to." S2DON was asked where it was document. He stated, "I don't write it down". The facility was unable to provide any documented evidence that safety checks were performed to ensure properly working equipment. Resident #2: A review of the clinical record revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. On 01/06/13- wheelchair alarm On 01/09/13- floor mat alarm A review of the Care Plan revealed the following: Problem onset 01/18/2013- At risk for injuries from falls as resident has history of falls Approaches: Fall prevention Program W/C (wheelchair) and floor mat alarm; answer promptly Provide safe and secure environment; encourage safety precautions with repeated reminders New approaches following fall on 01/31/13 included CNA in-serviced to ensure alarms on and functional; alarm checked and on and fully functioning Fall Risk assessments were documented by facility as follows (score of 10 or above represents High Risk): 01/14/13- score of 10 01/31/13- score of 12 04/01/13- score of 12 A review of the MDS (Minimum Data Set) with ARD (Assessment Reference Date) 01/17/13 revealed the following: Section C (Cognitive Patterns) - score was 11 (score of 8-12 indicates moderate impairment) Section G (Functional Status) - required limited assistance with transfers and toilet use; resident not steady, only able to stabilize with staff assistance with moving form seated to standing position and surface-to-surface transfer. A review of the Investigations completed by the facility following Resident #2's falls on 01/31/13 and 04/12/13 revealed the following: 1/31/13 at 1:00 p.m. - fall in bathroom by dining room while resident was trying to go to bathroom by himself. The resident's wheelchair alarm did not alarm, it was unplugged. The resident had a scrape to his left upper back that was treated by the treatment nurse. Staff was in-serviced on checking to make sure alarms were on and plugged in with increased supervision. 4/12/13 at 2:30 p.m. - fall while staff in resident's room. There was no injury. The resident slipped on his floor mat. The care plan was updated and Velcro was placed under alarming floor mat. On 04/18/13 at 11:44 a.m. an interview was conducted with Resident #2's son in resident's room. His son was asked if he had ever observed his father's wheelchair alarm off while he was in the wheelchair. Resident #2's son stated that he had visited on multiple occasions when the chair alarm was off. He stated he noticed it off several times following therapy and many occasions in the dining room when he came before and after lunch. On 04/18/13 at 3:23 p.m. an interview was conducted with S5CNASup. She was asked who the CNA's notify when they find an alarm is not functioning correctly. She stated, "They are taught to notify the nurse assigned to the resident, the charge nurse and to fill out a yellow slip for the maintenance department. They are also taught to stay with the resident until the alarm is fixed." S5CNASup was asked how she ensured the CNA's were checking the alarms to ensure they were on when a resident was in a w/c and were functioning properly. She stated she made rounds daily and checks them every shift. S5CNASup was asked if she documented her daily rounds and checks. She stated, "No". The facility was unable to provide any documented evidence that the CNA staff were checking to ensure the resident's alarms were working properly. On 04/18/13 at 3:39 p.m. an interview was conducted with S2DON. He was asked to review the inservice sign in sheet dated 04/08/13. After reviewing the sign in sheet, S2DON was asked if the inservice was attended by everyone that comes in contact with the resident. He stated, "No, it wasn't." S2DON was asked how he was going to ensure that all staff was inserviced. He stated, "I will have to hold inservices around the clock until all of the employees are inserviced." S2DON was asked who was responsible for ensuring residents alarms were working. He stated, "Everyone that comes in contact with the resident. The alarms are managed many times throughout the day." S2DON was also asked to review the fall Incident & Accident report dated 04/07/13 for Resident #4. S2DON was asked to verify the information documented on the report form, he confirmed the alarm box was not on. S2DON was asked how do you ensure that the staff was implementing the care plan. He stated, "I walk around and check to see if the staff is doing what they are suppose to." S2DON was asked where it was document. He stated, "I don't write it down". The facility was unable to provide any documented evidence that safety checks were performed to ensure properly working equipment.

Based on interviews and record reviews the facility failed to ensure residents were free from abuse and prevent resident #5 from abusing other residents by failing to: 1) increase supervision of resident #5 following an incident of inappropriate sexual behavior on [DATE]; 2) assess resident #5's behavior and implement a behavioral management plan in a timely manner including increasing supervision of resident #5 according to the facility's policy and procedure for abuse involving behavior problems. The facility failed to monitor resident #5, a cognitively intact resident who uses an electric wheelchair for mobility with locomotion throughout the facility and has a known history of inappropriate sexual behavior and prevent resident #3 from experiencing actual harm on [DATE] when resident #5 touched her breast. This resulted in Immediate Jeopardy which began on [DATE] when resident #5 allegedly touched resident #3's breast and the facility failed to monitor resident #5 on 1:1 supervision to protect resident #3 and other female residents from possible sexual abuse. The Immediate Jeopardy ended when resident #5 was transferred out of the facility on [DATE]. The deficient practice continues for resident #3 at actual harm and for other female residents at a lower scope and severity level. Findings: Review of the facility's policy and procedure entitled, "Abuse Investigation" revealed in part the following:"1. When an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source it shall be reported, the Administrator and/or Director of Nursing." Review of the facility's policy and procedure entitled, "Abuse/Neglect Prevention Program revealed in part the following:POLICYAll occurrences of abuse, neglect, and mistreatment, injuries of unknown origin and theft or misappropriation of resident property will be investigated immediately. Review of the facility's policy and procedure entitled, "Behavior Management Policy, Revised [DATE], revealed in part the following:POLICY It is the policy of this facility to have a behavioral management program. Residents will have an individualized behavior plan upon admission, quarterly, with significant change, and as needed otherwise. OBJECTIVE 2. To provide consistent care for optimal functioning of each resident. 4. To provide a means of determining the cause of behaviors and finding interventions to manage them to lessen distress to the resident and others. PROCEDURE 2. The Social Services Representative will investigate and assess each problem behavior noted... When completed, the plan will be incorporated into the overall care plan and any teaching will be done by the Social Service Representative. 3. The Social Service Representative will be responsible for tracking the effectiveness of the interventions being utilized. If the interventions are found to be effective, the plan will be continued. However, if the interventions prove ineffective, the plan will be subject to review by the care plan committee and revised accordingly.... The Social Service Representative will council with the resident regarding their individual treatment plan. On [DATE] a record review was conducted for resident #5. Review of the Quarterly MDS (Minimum Data Set) ARD (Assessment Reference Date) [DATE] revealed a BIMS (Brief Interview for Mental Status) was conducted and assessed at this time. The MDS utilizes a BIMS as a screener to help detect cognitive impairment and the total score is highly correlated with Mini-Mental State Exam scores. Review of the total score for resident #5 was 15 indicating he was cognitively intact. Further review of the MDS revealed resident #5 required limited assistance with transfers, was independent (no help or staff oversight at any time) with locomotion both on and off the unit, and used a wheelchair for mobility. Review of the OTIS System revealed the facility submitted an OTIS Report dated [DATE] involving inappropriate sexual behavior by resident #5 towards resident #3. On [DATE] at 9:45 a.m. during the Entrance Conference with S1Adm, she was asked for the facility's OTIS (Online Incident Tracking System) Reports. Review of the OTIS Reports given to the surveyor revealed no [DATE] report. At 11:20 a.m. S1Adm was asked if she had anymore OTIS Reports. She stated she did. She stated S1DON had one but he was out of the facility right now. She stated the police were called regarding this incident and they will be sending out an investigator. She stated this incident involved resident #5. She stated he had "acting out behaviors towards females". On [DATE] at 12:25 p.m. S1Adm provided a statement signed by her and stated, "This is all I have regarding the OTIS incident dated [DATE]". She was asked if an investigation was conducted. S1Adm stated, "I don't know". She stated S2DON told her the Social Worker and Nurses documented this in the resident's record. The surveyor further requested a summary of the OTIS Report and any investigation conducted thus far. Review of the statement provided by S1Adm revealed the following: "On Tuesday, [DATE] at approximately 4:45 p.m. (S3SW) (Social Worker) reported to me that resident (#3) reported to her that resident (#5) had touched her breast. (S3SW) and I went into the room of (resident #3) and she was crying. I asked (resident #3) what was wrong and she told us (resident #5) had touched her breast. I asked if this had ever happened before. (Resident #3) said no. I repeated the question and added this is the only time this has ever happened. She again said yes. We reassured her that this would never happen again and that she would be given increased supervision. We also asked if she would be willing to tell the police what happened and she said yes. I spoke with (Name of another resident) who said he had witnessed this and asked him if he could tell me exactly where the incident happened and approximately what time it happened. The police came and spoke with (resident #3). The officer stated that he would take this report back and an investigator would be assigned and come back to the facility for further investigation. At this time camera footage was reviewed where the incident was reported to have occurred. We were unable to see the incident". Review of the Social Progress Notes for resident #3 who accused resident #5 of touching her breast revealed one entry dated [DATE] documenting the following: "Visit with resident and reassure her safety. She stated she felt safe here". On [DATE] at 12:55 p.m. an interview was conducted with S3SW in the presence of S2DON. She was asked to describe the incident that occurred on [DATE] involving resident #5 and resident #3. She stated there was an incident of inappropriate sexual behavior involving resident #5 and resident #3. She stated she spoke with resident #3 about the inappropriate sexual behavior and he denied the accusation. She stated she asked him to go on a behavioral management plan and he refused. When asked what a behavioral management plan was she stated she visit the resident daily and staff would monitor him. She stated resident #5 was allowed to stay in the building following the incident of [DATE] and informed the staff to provide increased supervision with resident #3. S2DON stated the police were called and the resident (#5) went to the hospital. He was asked for documentation of informing the staff to provide increased supervision and his investigation of this incident. S2DON stated, "You have what I have. When I get the police report it will be completed Tuesday". Review of the Social Progress Notes for resident #5 dated [DATE] revealed the following: "MD (physician) here to visit. MD and SSD (Social Service Director) spoke with resident he has agreed to go to (Name of Behavioral Hospital)... SSD called and made referral to (Name of Behavioral Hospital) they would be able to send anyone out until [DATE]. Staff notified to monitor closer". Resident #5 was not discharged from the facility until [DATE]. On [DATE] at 1:15 p.m. an interview and record review was conducted with S1Adm. She was asked to review the Social Progress Notes dated [DATE] for resident #R1. She reviewed the notes and confirmed the incident documented was in regards to a male resident approaching another resident and asking her out for sex. She was asked if she knew about this incident. S1Adm verified she not aware this incident occurred between resident #5 and resident #R1. On [DATE] at 3:30 p.m. an interview and record review was conducted with S3SW. She was asked to provide the Behavior Management Plans for resident #5. She presented two plans. One of the behavior management plans was dated [DATE] when resident #5 was accused of asking a male roommate for oral sex. The other behavior management plan was dated [DATE] when resident #5 was accused of asking a staff member for sex and grabbing the staff member's breast. S3SW was asked if there were any other Behavioral Management Plans for resident #5. She verified she only had two documented plans. Review of the facility's policy and procedure entitled, "Behavior Management Policy" revealed in part the following: "... Residents will be assessed for the need of a behavioral plan upon admission, quarterly, with significant change, and as needed otherwise". S3SW was asked to review her Social Progress Notes for resident #5 at this time to identify a timeline of the behavioral incidents that occurred beginning with the incident occurring on [DATE]. She reviewed her notes and stated resident #5 was having inappropriate behavior with a visitor. She stated resident #5 was sent to (Name of Hospital with Psychiatric Unit) and returned on [DATE]. She verified resident #5 was seen by (name of Psychiatrist) on [DATE] and stated, "He is on the follow up list to see him again". S3SW was asked if the Psychiatrist was notified since [DATE]. She verified he was not. S3SW continued to review her Social Service Progress Notes. S3SW stated, "There was no further inappropriate sexual behavior until [DATE]. S3SW was asked to review her documentation dated [DATE]. S3SW stated there was a female resident (#R1). She stated this resident was not at the facility any longer. She stated this resident expired. When asked what happened between resident #5 and R1 she stated resident #5 asked this resident if she had a boyfriend. S3SW stated she did not remember anything else. S3SW was requested to obtain the resident R1's closed record for the surveyor to review. Review of the closed record for R1 revealed the following: "[DATE] Spoke with resident today. She stated a male resident asked her out for sex. And she informed him that she weren't looking for a relationship. Informed her I would speak with resident". Review of the Social Service Progress Notes for resident #5 dated [DATE], three days after the incident occurred on [DATE], revealed the following documentation: " Had 1:1 counsel with resident today about inappropriate behavior (eg. sexual) towards female resident " .... [DATE] " No behaviors present " . [DATE] " No present behavior observed or reported today " . There was no further daily monitoring documented by S3SW. There was no documented evidence in the Nurses Notes this incident occurred. Further review of the Social Progress Notes revealed resident #5 was not assessed until [DATE] and later refused to attend outside services for behavioral management on [DATE]. Resident #5 attended staffing on [DATE] The Social Progress Notes revealed he was informed at this time, "Not to visit with resident who he has been receiving complaints from". Resident #5 was not placed on a behavioral management plan until the second documented plan dated [DATE] when the next inappropriate sexual incident occurred involving resident #5 accused of grabbing a staff member's breast. Review of the Social Service Progress Notes dated [DATE] revealed resident #5 "refused to go to a psych apt (appointment) today.... Had 1:1 with him about appropriate behavior". Further review of the Social Progress Notes revealed resident #5 was informed on [DATE] the Behavior Management Plan would be ending on [DATE]. Further interview with S3SW and review of the timeline of behavioral incidents that occurred involving resident #5 continued. S3SW stated another incident occurred on [DATE]. She was asked to review her notes and tell the surveyor what happened. She stated, "He (resident #5) had sexually inappropriate behavior with a housekeeper". On [DATE] at 9:45 a.m. an interview was conducted with S4Maint. She verified she was responsible for the Laundry and Housekeeping Department. She was asked if she was familiar with resident #5. She stated yes. She was asked if there were any incidences of inappropriate sexual behavior exhibited by him. She stated yes. She stated she had a housekeeper who experienced two incidents with him where he tried to touch her breast and also made inappropriate comments. She was asked what happened after that. She stated she told the employee to report it and that she could notify the police. Asked her what do you do now when you have to provide housekeeping services to him. She stated, "We will have two housekeepers or I will go in his room with the housekeeper, or we wait until he is out of his room". Review of the care plans for resident #5 revealed in part the following evidence of documentation: "[DATE] Problem: Behavior Problem Resident has been accused of sexually inappropriate behavior. Short Term Goal: Resident will have decreased episodes of inappropriate behavior ,[DATE] Xs (times) per week. Resident will understand behavior is not acceptable. Interventions: Redirect / deescalate to positive behaviors send to (Name of hospital) for more intense therapy. Staff Responsible: SSD (Social Service Director) Date Est (Established): [DATE] Target Date: BLANK Review Status: [DATE]" "[DATE] Problem: Inappropriate sexual behaviors. Goal: Behavior will be decreased. Interventions: Encourage app (appropriate) behavior and discourage inappropriate behaviors allow his discuss concerns or techinic Have 1:1 with him about offensive behavior Educate staff to monitor inform nurse & SSD of any new behaviors. [DATE]- No present behaviors." "[DATE] No present behaviors spoke with resident about him receiving new roommate". "[DATE] Problem: Inappropriate sexual behavior Short Term Goal: Inappropriate behavior will be decreased ,[DATE]. Interventions:1) Encourage appropriate behavior; Staff responsible: All 2) Psych consult as per order. Staff responsible: All 3) Discussion with resident regarding behavior; allow him to discuss his feelings. Staff responsible: All 4) observe resident's interaction with other residents to prevent offensive behavior. Staff responsible: All 5) Education of staff involved in resident's care. Staff responsible: Nsg (Nursing)" "[DATE]Psychiatric evaluation as per order. Staff responsible: Nsg.". [DATE] Sent to psych for evaluation". Review of the Social Progress Notes dated [DATE] revealed the following documentation: "Spoke with resident today. About him asking a co-worker to play with her breast... Had 1:1 with him about sexual harassment. and informed him he could go to jail...". The next Social Progress Note dated [DATE] revealed the following: ... "No behaviors present or reported". On [DATE] at 3:30 p.m. S3SW was asked why resident #5 was not put on a behavioral management plan at the time of this incident. S3SW stated, "I don't know". She stated he had no further inappropriate behavior reported following the incident with the housekeeper. She was asked if the resident was offered a behavioral treatment plan or treatment following the incident with the housekeeper. S3SW verified resident #5 was not offered anything at this time. S3SW stated, "The housekeeper was reassigned to another area". Review of the Nurses Notes documentation following the incident of [DATE] revealed resident #5 was only monitored on [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the the next inappropriate sexual incident occurred on [DATE] as documented in the Louisiana DHH Client Incident Report OTIS Incident ID: Accused / Allegation (Resident #5) Victim: (Resident #3) Abuse: Sexual Review of the Case Notes Description revealed the following evidence of documentation: "Resident (#3), was observed to be upset and crying. Staff went into the room and resident, (#3) stated that another resident, (#5) touched her breast without permission". On [DATE] at 2:45 p.m. an interview and record review of the OTIS Report involving resident #5, dated [DATE], was conducted with S1Adm and S2DON. Review of this report revealed resident #5 was accused of abuse: sexual with resident #4. S1Adm stated resident #5 was moved to another unit and room following this incident. S2DON was asked if resident #5 was assessed at this time according to the facility policy for a behavioral plan. S2DON verified resident #5 was not assessed at this time. During the interview with S2DON he stated resident #5 saw a psychiatrist following this incident. S1ADM stated the psychiatrist comes once a month. Review of the Social Progress Notes documented resident #5 was not seen by a psychiatrist until [DATE]. S2DON verified resident #5 was not seen until [DATE]. On [DATE] at 3:17 p.m. the following interviews were randomly conducted throughout the facility: S6CNA was asked if he was familiar with resident #5. He stated yes. He was asked if he was aware of any inappropriate behaviors from this resident. S6CNA stated, "I heard what he had done". He was asked if there was anything he needed to do for this resident regarding his behaviors. S6CNA stated, "What do you mean?" He was asked if resident #5 had to be monitored. S6CNA stated, "Yes but he is all over the building in an electric wheelchair and it is hard to keep an eye on him all the time". S7CNA was asked if she was familiar with resident #5. She stated yes. She stated she heard what happened recently with resident #3. She was asked if the facility has instructed staff to monitor him and his behavior. S7CNA stated, "No, I didn't think I was supposed to". S8MDS was asked if she was familiar with the facility's Behavioral Management Plan. She stated, "Yes. S3SW is responsible for this". S9RN was asked if she was familiar with resident #5. She stated yes. She was asked what does she do when an incident of inappropriate sexual behavior has been reported. She stated when staff report to her then S3SW is notified and after that S2DON and S1Adm get notified and they decide what to do with him. S9RN stated she does make rounds inside and outside the building but it was difficult to monitor him all the time since he is all over the building. On [DATE] at 5:00 p.m. during the Exit Conference S2DON was asked if resident #5 was supervised following the sexual abuse incident on [DATE] until he was discharged on [DATE]. He stated yes. S2DON was asked to show evidence of this. He stated this was discussed verbally in report. He was asked if he had any additional information or documentation to provide regarding this complaint investigation. S2DON stated, "No".