Every finding on record at Riverview Health & Rehab CTR

Based on observations, record reviews, staff interviews, and review of the policy titled Falls - Clinical Protocol, the facility failed to ensure residents were free from accident hazards and falls for three of three residents (R55, R109, and R148) reviewed for fall assessments. In addition, the facility failed to ensure there were no free standing oxygen cylinder tanks in R148's room and in the facility's Medication Storage Room located near resident rooms. These practices created potential accident hazards and failed to ensure appropriate safety measures were in place for residents.1.Review of the facility's policy titled Falls-Clinical Protocol, reviewed 1/21/2026 revealed that under Assessment and Recognition .5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the event, etc. Review of the Quarterly Minimum Data Set (MDS) assessment for R109, dated 3/6/2026, revealed Section C (Cognitive Patterns) that has a Brief Interview for Mental Status (BIMS) score of 10 indication moderate cognitive impairment. Section I (Active Diagnosis) revealed diagnosis of but not all -inclusive encephalopathy, syncope, non-Alzheimer's dementia, and muscle weakness. Section N revealed resident taking antipsychotics. Review of care plan for R109 dated 03/07/2026 revealed that resident was at risk for falls related to confusion, psychotropic medication use, incontinence, hypotension, and muscle weakness with intervention for resident to evaluated and treated as ordered or as needed. Record review revealed that R109 had a fall on 02/27/2026 and was evaluated by the on-call provider on 03/01/2026 after complaining of head and shoulder pain. R109 was sent to the hospital on [DATE]. Resident return to the facility on [DATE]. Review of record revealed last fall assessment was completed on 12/19/2025. Interview on 03/15/2026 at 2:49 PM with R109 revealed that he had a fall two weeks ago and was assisted by his roommate after the fall. He reports hitting his head and shoulder. Interview on 03/17/2026 at 1:34 PM with Unit Manager (UM) Licensed Practical Nurse CC revealed fall risk assessments are to be completed upon admission and anytime a resident has a fall. She called the Director of Nursing (DON) to confirm. Interview on 03/17/2026 at 1:54 PM with Director of Nursing(DON) revealed that fall risk assessments are completed upon admission, quarterly, and after a resident has a fall. She confirmed that R109 did not have a fall assessment for the fall on 02/27/2026. 2. A policy titled Falls-Clinical Protocol last reviewed January 21, 2026, revealed under assessment and recognition, 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Review of the medical record for R55 revealed the resident was admitted to the facility on [DATE] with the following diagnosis not limited to periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, acute respiratory failure with hypoxia, unspecified dementia, moderate with other behavioral disturbance, fall on same level, unspecified subsequent encounter. Review of the Five Day Minimum Data Set (MDS) assessment for R55, dated 03/05/2026, revealed Section C (Cognitive Patterns) that has a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Record review revealed an admission fall assessment dated [DATE] with a score of 13 indicating the residents were at risk for falls. Review of R55's medical record revealed the resident had falls on 1/25/2026, 1/27/2026, 2/4/2026, 3/7/2026, and 3/15/2026. Record review revealed no fall risk assessments were completed after any of the listed falls. Interview on 03/17/2026 at 1:31 PM with Licensed Practical Nurse (LPN) DD revealed residents receive a fall risk assessment at admission, after a fall, and quarterly. Interview on 03/17/2026 at 1:34 PM with the LPN CC who is also a Unit Manager revealed fall risk assessments are to be completed upon admission and anytime a resident has a fall. LPN CC looked in the medical record and confirmed there was an admission fall risk assessment, but no fall risk assessment was completed after each of the resident's falls. Interview on 03/17/2026 at 1:55 PM with the Director of Nursing (DON) confirmed that R55 did not have a fall risk assessment completed after his falls on 01/25/2026, 01/27/2026, 02/4/2026, 3/7/2026 and 3/15/2026 and stated they should be done after each fall. 3. Record review of R148 's electronic health record revealed the following diagnoses but not limited to acute chronic respiratory failure with hypoxia. Review of R148 's admission Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview Mental Status Score (BIMS) of 15 which indicates cognitive awareness with little to no periods of confusion. Section O (Special Treatment Procedures and Program) assessed R148's for oxygen therapy use. Review of R148's physician order stated oxygen at 2L VIA NC (two liter by nasal cannula) as needed for SOB (shortness of breath), Obtain SPOC. Observation on 03/16/2026 at 1:31 PM of R148 's room revealed oxygen cylinder tank sitting on the floor not in a holder and positioned in an upright position. R148 's room door was observed wide open and allowing accessibility to the tank to other residents and the public. Observation 03/16/2026 at 1:32 PM with Licensed Practical Nurse (LPN)AA confirmed the free-standing cylinder tank in the resident room. She confirmed that the resident uses an oxygen tank. Observation on 03/16/2026 at 2:36 PM of the facility Medication Storage Room with LPN DD revealed a partially full tank was positioned upright in the medication room on the floor and not in a holder. During the interview with LPN DD revealed that oxygen tanks should be stored in a holder or a labeled closet (designated for oxygen cylinder tanks) located on another hall.

Based on observations, staff interviews, and review of the policy Storage of Medications, the facility failed to ensure two of eight medication carts were secured for medication storage. In addition, seven of 14 medication rooms and carts contained reviewed for medication storage contained expired medications. The deficient practice increased the risk of unauthorized access and administration of outdated medications.Findings Include:Review of the facility's policy titled, Storage of Medication, reviewed 01/21/2026 revealed that the Policy Heading included, The facility stores all drugs and biologicals in safe, secure, and orderly manner. The Policy Interpretation and Implementation section included, 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Observation on 3/16/2026 at 8:07 AM revealed that the wound care cart was unlocked with the keys in the lock between rooms [ROOM NUMBERS] on Evergreen Hall. There was no one near the cart. A staff member was observed walking past the cart without addressing the unlocked cart. The cart remained unlocked with the keys in it until 8:17 AM, when the Licensed Practical Nurse (LPN) Wound Care Nurse GG returned to the cart after exiting room [ROOM NUMBER].Interview on 3/17/2026 at 11:23 AM with LPN Wound Care Nurse GG confirmed that the cart was unlocked. She stated that the cart should be locked and the keys kept in her pocket before entering a resident's room.Observation of a medication pass on 3/16/2026 at 1:11 PM of Registered Nurse (RN) JJ revealed that she left the medication cart in the hallway outside room [ROOM NUMBER]. The lock was facing away from the room, and she could not view the cart from inside the room. She returned to the cart, cleaned supplies, and then pushed the cart-still unlocked-down the hall.A second observation at 1:22 PM on 3/16/2026 of RN JJ revealed that the medication cart was unlocked in front of room [ROOM NUMBER]. RN JJ's back was facing the cart, and she could not view it.Interview on 3/16/2026 at 1:25 PM with RN JJ revealed that the cart was unlocked during the medication pass. RN JJ confirmed that the cart was unlocked, unattended, and out of her direct line of sight while she was in room [ROOM NUMBER]. She also admitted that her back was to the medication cart and it was not in her direct eyesight during the medication pass in room [ROOM NUMBER].Interview on 03/16/2026 at 3:04 PM with LPN LL confirmed that the Lantus (insulin) pen without expiration date or open date and methotrexate vial were without expiration date or open date. She admits she was unsure when the vial and pen were open. She confirmed that the Arginaid (medical food) powder had expired. She states that medication carts are managed by the nurses to make sure medications are not expired.In a concurrent observation and interview on 03/17/2026 at 10:09 AM on Evergreen wing, LPN Wound care nurse GG confirmed that three tubes of hydrogel expired on 05/2025, one tube of slivasorb gel expired 04/2024, two tubes of Thera honey gel expired on 3/20/2024,one tube of Thera honey expired on 12/20/2024, two tubes of Medi honey expired on 10/1/2025, one tube of zinc oxide expired on 04/2024, one tube of mupirocin ointment two percent expired on 12/2025, and a box with packets of hydrocortisone 1% expired on 8/2024 and packets of Aquaphor (zinc oxide) expired on 7/2025. She confirmed that one tube of hydrocortisone cream 2.5 percent was prescribed for use for seven days and issued on 10/03/2024. Wound Care LPN GG admits that the hydrocortisone cream should have been removed from the cart. She admits that expired medications were supposed to remove from the cart and placed in disposable bin located on Peachtree/Jasmine medication room.In a concurrent observation and interview of [NAME] medication cart , LPN BB confirmed that sumatriptan 100mg expired 1/2026 and ondansetron 4mg expired on 01/29/2026. She states that night shifts are to manage the medication carts.In a concurrent observation and interview on 03/16/2026 at 1:45 PM in the Magnolia medication room, LPN KK confirmed that the hemorrhoidal suppositories had expired in January 2026. Two boxes of Carbamide Peroxide 6.5 percent ear drops expired in July 2024.In a concurrent observation and interview on 03/16/2026 at 1:57 PM in the [NAME] and Peachtree medication room, LPN EE confirmed that Acetaminophen 325 mg (1000 tablets) had expired in February 2026.In a concurrent observation and interview on 03/16/2026 at 2:11 PM in the Evergreen medication room, the LPN Unit Manager II confirmed that an insulin Lispro vial was open and did not have an open date or expiration date. LPN EE also confirmed that magnesium oxide 400 mg had expired in February 2026.In a concurrent observation and interview on 03/16/2026 at 2:24 PM in the Azelia and Camelia medication room, LPN DD confirmed that the nicotine patches, Step One 21 milligrams, had expired in October 2025.In a concurrent observation and interview on 03/17/2026 at 2:47 PM in the central supply room, the Central Supply staff confirmed that Dairy Aid had expired in February 2025; two Coricidin HBP products had expired in September 2025; one box of astringent solution had expired in September 2023; and three boxes of bisacodyl suppositories had expired in April 2025. She stated that she rotated stock so older items were placed in the front and newer items in the back. She explained that nurses were responsible for removing expired items from the medication rooms because she did not have access to those rooms. She admitted that the expired items were missed because they were not frequently used.Observation and interview on 03/16/2026 at 3:04 PM revealed that the [NAME] medication cart contained a Lantus (insulin) pen without an expiration date or open date, Arginaid (medical food) orange flavored powder that expired on January 21, 2026, and a methotrexate vial without an open date or expiration date. Interview with LPN LL confirmed that the Lantus insulin pen and methotrexate vial did not have expiration dates or open dates. She admitted she was unsure when the vial and pen were opened. She confirmed that the Arginaid powder was expired. She stated that medication carts were managed by the nurses to ensure medications were not expired.In a concurrent observation and interview on 03/17/2026 at 10:09 AM on the Evergreen wing, LPN Wound Care Nurse GG confirmed that three tubes of hydrogel expired in May 2025; one tube of Silvasorb gel expired in April 2024; two tubes of Thera Honey gel expired on March 20, 2024; one tube of Thera Honey expired on December 20, 2024; two tubes of MediHoney expired on October 1, 2025; one tube of zinc oxide expired in April 2024; one tube of mupirocin ointment 2% expired in December 2025; a box containing packets of hydrocortisone 1% expired in August 2024; and packets of Aquaphor (zinc oxide) expired in July 2025. She confirmed that one tube of hydrocortisone cream 2.5% was prescribed for seven days and issued on 10/03/2024. Wound Care LPN GG admitted that the hydrocortisone cream should have been removed from the cart. She admitted that expired medications were supposed to be removed from the cart and placed in the disposal bin located in the Peachtree/Jasmine medication room.In a concurrent observation and interview of the [NAME] medication cart, LPN BB confirmed that sumatriptan 100 mg expired in 10/2026 and ondansetron 4 mg expired on 01/29/2026.Interview on 03/16/2026 at 2:49 PM with Unit Manager LPN CC revealed that night shift nurses are to make sure nothing is expired. The unit supervisor is to audit cart a couple of times a week. Insulin pens and vials are to have open dates and expiration dates.Interview on 03/17/2026 at 1:00 PM with Unit Manager LPN II revealed that medications carts are to be checked by the floor nurses. Nurses are to make sure the carts are clean and does not have expired medications. Unit Managers are to make sure carts are clean and no expired medications. Medications carts are to be locked, no medications left on top of the cart, no keys left and close the computer.Interview on 03/17/2026 at 1:54 PM with DON revealed that nurses are responsible for dating and labelling medications. Nurses are to keep carts clean and no expired medications. Nurse Managers, Nurses, and Central Supply manage medication rooms to ensure there were no expired medications. She confirmed that insulin and methotrexate do not have open or expiration date. She admits that methotrexate vial, insulin vial, and insulin pen are to have open date and expiration date. Medication carts and wound care carts are locked, and keys are kept with the nurse when they walk away from cart.

Based on observations, resident and staff interviews and record review the facility failed to ensure that two of 56 sampled residents (R113 and R155) did not have unauthorized, unsecured medications at the bedside. This deficient practice had the potential to allow unauthorized access to medications by other residents and visitors in the facility.1. Review of R155's electronic health record (EHR) revealed the following diagnoses, including but not limited to acute kidney failure, hypertension, and sepsis.Review of the Physician Order Form and Medication Administration Record (MAR), both dated March 2026 for R155, revealed that the resident did not have an order in place for the prescription.Review of R155's admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. GG (Functional Abilities and Goals) assessed the resident as dependent to requiring partial or moderate assistance with ADLs and noted the resident to be non ambulatory.Review of R155's EHR revealed an omission of a completed assessment to determine whether the resident was capable of self administration of medications.Observation on 03/15/2026 at 1:00 PM and 3:03 PM, and again on 03/16/2026 at 1:26 PM, revealed nystatin cream on R155's bedside stand within public view of anyone entering the room.Interview on 03/15/2026 at 1:41 PM with R155 confirmed self administering the medication to her skin without any assistance from facility staff. R155 reported having the cream since admission.Observation and interview on 03/16/2026 at 2:00 PM with Licensed Practical Nurse (LPN) AA revealed confirmation of the unauthorized medication (nystatin cream) in R155 room. LPN AA also confirmed that R155 had not been assessed to self administer medications independently. She reported being unsure how the medication was left in the resident's possession. LPN AA then removed the medication from the room.Interview on 03/18/2026 at 1:15 PM with the Director of Nursing (DON) revealed that she was unaware of R155 having the cream in her possession. She stated that her expectation was for nurses and certified nursing assistants to monitor medications at the bedside.2. Review of R113's electronic health record (EHR) revealed the following diagnoses, including but not limited to non traumatic acute dural hemorrhage, unspecified dementia, and chronic lymphocytic leukemia of B cell type in remission.Review of the Physician Order Form and Medication Administration Record (MAR), both dated March 2026 for R113, revealed that the resident did not have an order in place for the prescription.Review of R113's Quarterly MDS assessment dated [DATE] revealed that Section C (Cognitive Patterns) documented a BIMS score of 10, which indicated moderate cognition and periods of cognitive impairment. Section GG (Functional Abilities) assessed the resident for ambulatory status.Review of R113's EHR revealed an omission of a completed assessment to determine whether the resident was capable of self administration of medications.Observation on 03/15/2026 at 1:47 PM and on 03/16/2026 at 1:59 PM revealed eye drops located on R113's bedside stand. A bottle of peroxide and wound spray were observed on a dresser drawer stand next to the resident's television. All items were in view of anyone entering the room.Interview on 03/15/2026 at 1:41 PM with R113 reported self administering eye drops without any assistance from facility staff. R113 reported having eye drops for months.Observation and interview on 03/16/2026 at 1:59 PM with Licensed Practical Nurse (LPN) AA confirmed the unauthorized medication (eye drops) in the resident's room. LPN AA also confirmed that R113 had not been assessed to self administer medications independently. She reported being unsure how the medication was left in the resident's possession.Interview on 03/16/2026 at 2:02 PM with LPN BB confirmed that R113 has periods of confusion and was not assessed to self- administer medications. She reported being unaware of medication being left in the resident room.Interview on 03/17/2026 with the DON revealed that she was unaware of R113 having eye drops in his possession. She stated that her expectation was that nursing staff monitor medications sufficiently.

Based on observation, staff interviews, record review, and review of the facility's policy titled Care Plans, Comprehensive Person-Centered, policy, the facility failed to develop or implement a comprehensive person-centered care plan for two of 32 sampled residents (R) (R56 and R6). This deficient practice had the potential to place R56 and R6 at risk of unmet needs, medical complications, and diminished quality of life.Findings Include:Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revealed that the facility's interdisciplinary team is responsible for the development of resident care plans. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.1.Review of the Quarterly Minimum Data Set (MDS) assessment for R56, dates 12/30/2025, revealed Section C (Cognitive Patterns) that has a Brief Interview for Mental Status (BIMS) score of 00 indication severe cognitive impairment. Section I (Active Diagnosis) revealed diagnosis of but not all -inclusive cerebral infarction without residual deficits, dysphagia and muscle weakness. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident.Review of care plan for R56 dated 12/25/2025 revealed oxygen therapy was not addressed.Review of the physician orders R56 revealed an order dated 8/20/2025 for continuous oxygen at 2 LPM (liters per minute) via NC (nasal cannula), every shift for comfort. Observation on 03/15/2026 at 12:36 PM revealed that R56 was receiving oxygen via NC and the concentrator flow rate was set between 3.5 and 4 LPM.Observation on 03/16 at 7:42 AM and 4:44 PM revealed that R56 was receiving oxygen via NC and the concentrator flow rate was set between 3.5 to 4 LPM.Interview and observation on 03/17/2026 at 11:23 AM with Licensed Practical Nurse (LPN) EE confirmed that R56's oxygen flow rate was set between 3.5 to 4 LPM. She confirmed that the physician order was for oxygen 2 LPM. She states that she checks the level after she has completed her medication pass.Interview on 03/17/2026 at 1:23 PM with Registered Nurse (RN)/ (Resident Assessment Instrument ) RAI Director confirmed that R56 oxygen therapy was not addressed in care plan. She also confirmed that MDS Section O for R56 reveals that he resides with oxygen therapy and the order dated 08/20/205 for 2 LPM. She also confirms that the baseline care plan does not address oxygen therapy.Interview with DON on 03/17/2026 at 1:54 PM revealed that a resident on oxygen therapy should be addressed in the care plan. She states that the oxygen order when entered in the electronic record should automatically create a generic care plan template. She states that residents are discussed in clinical meetings to capture care plans.2. Review of the Quarterly Minimum Data Set (MDS) assessment for R6, dates 01/14/2026, revealed Section C (Cognitive Patterns) that has a Brief Interview for Mental Status (BIMS) score of 12 indication moderate cognitive impairment. Section I (Active Diagnosis) revealed diagnosis of but not all -inclusive obstructive sleep apnea, cerebral infarction without residual deficits. Section O (Special Treatments, Procedures, and Programs) documented that the resident received non-invasive mechanical ventilator while a resident.Review of the physician orders for R6 revealed an order dated 09/5/2025 for Continuous Positive Airway Pressure (CPAP) removed in the morning.Observation on 03/15/2026 at 3:10 PM revealed that CPAP not bagged on top of toothpaste box in a basket of fruit.Observation on 03/16/2026 at 7:55 AM revealed that CPAP was not cleaned and laying on top of bottles of cleaning products.Observation on 03/17/2026 at 9:08 AM revealed that mask was not cleaned and was lying in a top of bottles in a basket.Interview with LPN BB on 03/17/2026 at 9:25 AM revealed that CPAP mask was not clean and laying on top of bottles in a basket. She states that mask should be bagged and night shift should have bagged and cleaned masked. She admits if not cleaned or stored correctly then day shift should be addressed.Interview on 03/17/2026 at 1:23 PM with RN/ RAI Director confirmed that care planned revealed care plan intervention was to clean mask daily.

Based on observations, staff interviews, record review, and review of the facility document titled Central Venous and Midline Catheter Flushing, the facility failed to ensure professional standards were followed for one resident (R) (R103) of five residents receiving care for a peripherally inserted central catheter (PICC.) This deficient practice had the potential to place R87 at risk of adverse clinical outcomes.Findings include:A review of the facility's policy titled Central Venous and Midline Catheter Flushing reviewed 1/26/2026, Flushing Technique section included.3. Aspirate the CVAD (central venous access device) catheter for blood return to confirm patency prior to administration of medications and solutions.Review of the physician's orders for R103 revealed an order dated 02/27/2026 for Ertapenem sodium (an antibiotic medication used to treat infections) intravenous one gram every 24hours and daptomycin (an antibiotic medication used to treat infections) intravenous solution 700 milligrams (mg) every 24 hours. Further review revealed an order dated 1/16/2026 for: Flush RUA (right upper arm) PICC line with 10 cc normal saline 0.9 precent before and after each medication administration three times a day.Observation of medication pass on 03/16/2026 at 8:57 AM revealed that Licensed Practical Nurse (LPN) EE applied gloves, cleaned the PICC line lumen (an individual access point of the PICC line), connected a ten milliliter (ml) syringe of 0.9 percent normal saline to the lumen, flushed the line with eight milliliters, and did not aspirate (draw back) to check for blood return to verify patency, disconnected the syringe, and connected the ertapenem sodium infusion.Interview on 03/16/2026 at 9:02 AM, LPN EE confirmed that she flushed the PICC line with normal saline and did not aspirate (draw back) for a blood return. She admits she should have aspirated blood (draw back) to check patency. She states that she did not flush to the end of syringe because of air in the syringe. She forgot to get the air out.Interview on 03/17/2026 at 1:54 AM with the Director of Nursing (DON) revealed that the nurse would verify the antibiotic order, prepare supplies, identify the patient, prime the antibiotic line, clean the PICC line hub, flush, and check for a blood return. Checking for blood return verifies patency of the PICC line.

Based on observations, interviews, record review, and the facility policy titled, Colostomy/Ileostomy Care, the facility failed to ensure care consistent with professional standards of practice for one of two sampled residents (R) (R78). This deficient practice placed R78 at risk for skin breakdown and discomfort.Findings Include:Review of the facility's policy titled Colostomy/Ileostomy Care, review date 01/21/2026, revealed that The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter.Review of the Quarterly Minimum Data Set (MDS) assessment for R78, dated 01/10/2026, revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Section I (Active Diagnosis) revealed diagnoses including, but not limited to, colostomy, cerebral infarction without residual deficits, and muscle weakness. Section H (Bladder and Bowel) revealed that R78 had an ostomy.Review of the care plan dated 02/05/2026 revealed that the resident was at risk for complications related to the colostomy. Interventions included performing colostomy care as ordered.Observation on 03/18/2026 at 11:25 AM of Certified Nursing Assistant (CNA) SS revealed that bed wipes were used to clean the skin area around the stoma. She used soap and water to wipe but ran out of soap. CNA SS then used bed wipes again to clean the area around the stoma, with blood observed on the wipes.Observation on 03/18/2026 at 12:15 PM of Licensed Practical Nurse (LPN) RR revealed that he used alcohol wipes to remove the wafer. He cleaned the area with soap and water. He sealed the bag to the wafer, wiped with a no sting barrier, and then applied powder to the skin. He applied the bag after removing the paper backing. He then removed gloves and washed his hands.Interview on 03/18/2026 at 1:28 PM with CNA SS revealed that she used wipes to clean the skin and observed blood on the wipes because she ran out of soap. She confirmed that she should not use wipes.Interview on 03/18/2026 at 1:18 PM with LPN RR confirmed that he used alcohol to remove the colostomy wafer. He admitted that staff should not use wipes to clean the site but should use soap and water.Interview on 03/18/2026 at 1:43 PM with LPN CC revealed that staff should not use bed wipes to clean the area but should use soap and water. She stated that staff should not use alcohol wipes to remove the wafer because the alcohol burns. Powder should be applied first, then the edges should be wiped with a skin prep wipe.Interview on 03/18/2026 at 2:14 PM with the Director of Nursing (DON) confirmed that CNAs should clean and empty the colostomy bag daily. CNAs should remove the bag and clean the area with soap and water to ensure the skin is clean.

Based on observations, staff interviews, record review, and the facility's policies titled Oxygen Administration and CPAP/BIPAP, the facility failed to ensure that one of 40 sampled residents (R) R56 received oxygen as ordered by the physician. In addition, the facility failed to ensure that one(R)(R6) had their CPAP mask properly cleaned and stored. This deficient practice had the potential to place R56 and R6 at increased risk of respiratory complications.Findings Include:Review of the facility's policy titled Oxygen Administration policy, reviewed 1/21/2026, revealed that, The purpose of this procedure is to provide guidelines for safe oxygen administration. The Steps in the Procedure section included,. 7. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.Review of the Quarterly Minimum Data Set (MDS) assessment for R56, dated 12/30/2025, revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Section I (Active Diagnoses) revealed diagnoses including, but not limited to, cerebral infarction without residual deficits, dysphagia, and muscle weakness. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident.Review of the medication administration record (MAR) dated 03/01/2026 through 03/17/2026 for R56 revealed an order dated 08/20/2025 for continuous oxygen at 2 LPM (liters per minute) via nasal cannula every shift for comfort.Observation on 03/15/2026 at 12:36 PM revealed that R56 was receiving oxygen via nasal cannula, and the concentrator flow rate was set between 3.5 and 4 LPM.Observations on 03/16/2026 at 7:42 AM and 4:44 PM revealed that R56 continued to receive oxygen via nasal cannula, and the concentrator flow rate remained set between 3.5 and 4 LPM.Interview on 03/17/2026 at 11:23 AM with Licensed Practical Nurse (LPN) EE confirmed that R56's oxygen flow rate was set between 3.5 and 4 LPM. She confirmed that the physician's order was for 2 LPM. She stated that she checked the oxygen level after completing her medication pass.Interview on 03/17/2026 at 1:07 PM with LPN II, Unit Manager (UM) for the 400, 500, and 600 halls, revealed that nurses were expected to check the oxygen flow rate upon coming on shift and ensure it was set to the ordered rate. Nurses were also expected to check the flow rate when checking on the residents.Interview on 03/17/2026 at 1:54 PM with the Director of Nursing (DON) revealed that nurses were to check the oxygen flow rate at the beginning of each shift to verify it matched the physician's order. Nurses were also expected to check the flow rate during the shift. If the flow rate did not match the order, the nurse was expected to adjust it to the correct setting.Review of the facility's policy titled CPAP/BiPAP Support, reviewed 01/21/2026, revealed that the purpose was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. Under General Guidelines for Cleaning, item 7 stated: Masks, nasal pillows, and tubing: Clean or replace daily. Allow it to air dry between uses.Review of the Quarterly MDS assessment for R6, dated 01/14/2026, revealed in Section C a BIMS score of 12, indicating moderate cognitive impairment. Section I (Active Diagnoses) revealed diagnoses including, but not limited to, obstructive sleep apnea and cerebral infarction without residual deficits. Section O documented that the resident received non invasive mechanical ventilation while a resident.Review of the MAR dated 03/01/2026 through 03/17/2026 for R6 revealed an order dated 09/05/2025 for Continuous Positive Airway Pressure (CPAP), to be removed in the morning.Review of the care plan revealed that R6 was to use a CPAP machine related to obstructive sleep apnea, with interventions directing staff to clean the mask daily.Observation on 03/15/2026 at 3:10 PM revealed that the CPAP mask was not bagged and was lying on top of a toothpaste box in a basket of fruit.Observation on 03/16/2026 at 7:55 AM revealed that the CPAP mask was not cleaned and was lying on top of bottles of cleaning products.Observation on 03/17/2026 at 9:08 AM revealed that the CPAP mask remained uncleaned and was lying on top of bottles in a basket.Interview on 03/17/2026 at 9:25 AM with LPN BB confirmed that the CPAP mask was not clean and was lying on top of bottles in a basket. She stated that the mask should have been bagged and that night shift staff should have cleaned and bagged the mask. She admitted that if the mask was not cleaned or stored correctly, day shift staff should have addressed it.Interview on 03/17/2026 at 11:23 AM with LPN II, Unit Manager, revealed that the CPAP mask should be stored in a plastic bag at the bedside and cleaned daily.Interview with the Director of Nursing (DON) on 03/17/2026 at 1:54 PM confirmed that the CPAP mask was not cleaned or stored correctly. She stated that the mask should be washed daily and left to air dry. She stated she would expect the mask to be placed on a paper towel on the nightstand to air dry.

Based on observations, staff interviews, record reviews, and review of the facility policies titled Enhanced Barrier Precautions and Hand Washing/Hand Hygiene, the facility failed to ensure proper hand hygiene during wound care and colostomy care for two of thirty two sampled residents (R) (R78 and R97). In addition, the facility failed to ensure the correct use of required personal protective equipment during care provided to three residents (R103, R78, and R97) receiving intravenous therapy, wound care, and colostomy care under enhanced barrier precautions. These deficient practices had the potential to place residents at increased risk for infection.Findings include: 1.Review of the facility's policy titled, Enhanced Barrier Precautions, review date 01/21/2026, revealed that the Policy Interpretation and Implementation,. Enhanced barrier precatuions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. 3. Example of high contact resident care activities requiring the sue of gown and gloves for EBPs include: .b. bathing/showering.g.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). Review of the facility's policy titled, Handwashing/Hand Hygiene, review date 01/21/2026, revealed that Indications for Hand Hygiene . 1. Hand Hygiene is indicated: a immediately before touching a resident,. b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);. c. after contact with blood, body fluids, or contaminated surfaces;. d. after touching a resident; . e. after touching the resident's environment;. f. before moving from work on a soiled body site to a clean body site on the same resident,; and. g. immediately after glove removal. Observation on 03/16/2026 at 9:02 AM of Licensed Practical Nurse (LPN) EE revealed she prepared supplies for intravenous (IV) therapy for Resident R103. LPN EE entered the room without wearing a gown. She washed her hands, applied gloves, and completed the IV connection. Interview on 03/16/2026 at 9:02 AM with LPN EE confirmed she was not wearing a gown. She stated she should have worn a gown because R103 has a peripherally inserted central catheter (PICC). She acknowledged that enhanced barrier precautions (EBP) are identified in the electronic medical record next to the resident's name and that signage is posted on the resident's door. Observation on 03/17/2026 at 9:32 AM revealed Wound Care LPN GG prepared a tray with supplies while wearing gloves. She removed gauze, ABD pads, and a super absorbent dressing from their packaging with ungloved hands. She entered the resident's room wearing a gown and gloves. After packing the wounds, she did not change her gloves or wash her hands before applying the gauze, ABD pad, and super absorbent dressing. Interview on 03/17/2026 at 10:09 AM with LPN GG confirmed she did not wear gloves while preparing supplies. She also confirmed she did not wash her hands or change gloves after packing the wound. Interview on 03/17/2026 at 1:07 PM with Unit Manager LPN II revealed that residents with PICC lines, wounds, feeding tubes, and catheters require staff to wear gowns and gloves during wound care, activities of daily living, transferring, and IV antibiotic administration. She stated there is a box outside the resident's room containing gowns and gloves. Interview on 03/17/2026 at 1:54 PM with the Director of Nursing (DON) revealed staff are required to wear gowns and gloves when caring for residents with open wounds, IV access, and dialysis. The DON stated residents on enhanced barrier precautions are identified in the electronic medical record and by signage on the door. She reported that carts in the hallway contain gowns, gloves, and masks. The DON stated the wound care nurse should use gloves when removing items from packaging and should change gloves and sanitize hands after packing the wound and before applying the outer dressings. Staff are required to wash hands and don new gloves when transitioning from dirty to clean tasks. 3.Review of the facility's policy titled, Handwashing/Hand Hygiene, review date 1/21/2026, revealed that Indications for Hand Hygiene . 1. Hand Hygiene is indicated: a immediately before touching a resident,. b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);. c. after contact with blood, body fluids, or contaminated surfaces;. d. after touching a resident; . e. after touching the resident's environment;. f. before moving from work on a soiled body site to a clean body site on the same resident,; and. g. immediately after glove removal. Interview on 03/18/2026 at 1:19 PM with Licensed Practical Nurse (LPN) RR confirmed he did not wear a gown while providing care to Resident R78. LPN RR stated he was aware the resident was under enhanced barrier precautions and acknowledged he should have worn a gown, mask, and gloves. He further admitted he did not change his gloves or wash his hands after cleaning the colostomy site with soap and water and stated he should have changed gloves and washed his hands before cutting out the colostomy bag. Interview on 03/18/2026 at 1:25 PM with Certified Nurse Assistant (CNA) SS confirmed she was not wearing a gown while providing care. CNA SS stated she could not recall what precautions the resident was under but acknowledged she should have worn a gown and gloves. She confirmed she used wipes to clean the skin and wafer after removing the bag, reported she ran out of soap, and admitted she should not have used wipes to clean the area. Interview on 03/18/2026 at 1:41 PM with LPN CC revealed that residents with colostomies are under enhanced barrier precautions. LPN CC stated staff should wear gowns and gloves. She explained that nurses manage the colostomy, while CNAs empty and burp the colostomy bag. Staff are required to clean the area with soap and water and should not use bed wipes. LPN CC stated nurses should wash their hands and change gloves after cleaning the colostomy area, and staff should wash hands when moving from dirty to clean tasks. She further stated staff should not use alcohol wipes to remove the wafer because they can cause burning, and that powder should be applied first, followed by wiping the edges with skin prep. Interview on 03/18/2026 at 2:14 PM with the Director of Nursing (DON) revealed that residents with colostomies are under enhanced barrier precautions and staff should wear gowns, gloves, and goggles. The DON stated CNAs clean and empty the colostomy bag daily. She reported CNAs remove the bag and wash the area with soap and water to ensure it is clean. Staff should wash their hands and apply new gloves after cleaning the ostomy area, and again before cutting out the colostomy wafer. Staff are required to wash hands and don new gloves when transitioning from dirty to clean tasks.

Based on observations, interviews, and the facility policy titled Call System, Resident, the facility failed to ensure the call light was within reach for one of 32 sampled residents (R ) (R121). This deficient practice had the potential to place R121 at risk of not having their needs met when required.Findings Include:Review of the facility's policy titled Call System, Resident with a review date of 01/21/2026 revealed that Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.Review of the Quarterly Minimum Data Set (MDS) assessment for R121, dated 03/03/2026, revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section I (Active Diagnosis) revealed diagnoses including, but not limited to, vascular dementia, traumatic brain injury, repeated falls, and normal pressure hydrocephalus. Section GG (Functional Abilities) revealed that R121 was dependent for activities of daily living.Observation and interview with the resident on 03/15/2026 at 2:37 PM revealed that R121 was in bed on her right side. The call light was located in the overhead light. The resident stated that she did not have a call light, but her roommate had one. She stated she did not call for help.Observation on 03/16/2026 at 8:03 AM revealed R121 in bed lying on her right side, with the call light observed in the overhead light.Observation and interview on 03/16/2026 at 3:36 PM revealed that R121 was in bed on her right side. The call light remained in the overhead light. R121 stated that she did not have a call light and that she did not call for help.Interview on 03/17/2026 at 1:07 PM with Unit Manager, LPN II revealed that residents should have access to a call light. The call light should be clipped to the bedside within reach. Residents who could not push the button had access to a push pad.Interview on 03/17/2026 at 1:54 PM with the Director of Nursing (DON) revealed that all residents should have a call light near them. If they were unable to press the call light, then the resident would use a touch button.

Based on record review, staff and resident interviews, and review of the facility policy titled Abuse Policy, the facility failed to protect residents from verbal, sexual and physical abuse. Specifically, the facility failed to protect three residents (R) (R30, R60, and R125) of four sampled residents safe from sexual abuse from R64. In addition, the facility to protect R30 from physical and verbal abuse from Certified Nursing Assistant (CNA) AA. The failure of the facility to keep residents safe had the potential to diminish their quality of life and likelihood of resident abuse to continue. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: A review of the facility policy titled Abuse Policy dated December 2023 documented the policy of [name of facility] that each resident will be free from Abuse. Abuse can include all types of abuse, neglect, exploitation or residents, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms and not imposed for purposes of discipline or convenience. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm or any type will be tolerated, and residents and staff will be monitored for protection. The facility will have systems in place to educate employees, residents, resident representatives, contractors, agents, volunteers and other applicable individuals in techniques to protect all parties. Procedure: Letter F. Protection: Immediately upon receiving a report of alleged abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, the Administrator, and or designee will immediately protect the resident, and coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individuals are of utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. Staff witnessing abuse or when reported will immediately intervene to stop the abuse and protect the resident. ii. The alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion be immediately removed from the facility and will remain removed pending the results of a thorough investigation. iv. If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instruction from administration, if possible. If the situation is an emergent danger to the other residents or staff, dial 911 for immediate assistance. vii. If the resident could be at risk in the same environment, evaluate the situation and consider options including a room change or roommate change. x. The facility staff will protect the resident from retaliation. 1. Review of the electronic medical record (EMR) revealed R30 was readmitted to the facility on [DATE] with diagnoses including cerebral palsy, epilepsy, anxiety, depression (Other Than Bipolar), muscle spasm, and pain. Review if the Quarterly Minimum Data Set (MDS) assessment dated [DATE] Section C documented a Brief Interview for Mental Status (BIMS) score of 99 indicating the assessment was incomplete. Review of an undated statement written by CNA DD documented I didn't observe R64 around R30. I heard about the situation. I have never to attempt {sic} to touch R30 or any other residents. I overheard R64 saying he can't {sic} kissing who can't say yes or no. Interview on 2/2/2025 at 4:27 pm, Licensed Practical Nurse (LPN) CC stated that on 12/25/2024, R64 put his tongue down R30's throat. She stated that the incident was reported to the DON and LPN Unit Manager (UM) EE. During further interview, LPN CC revealed that R64 self-reported to her that the administration staff coached him what to say if anyone asked him about the incident of him putting his tongue down R30's throat, to say that he was giving her a holiday kiss. She stated that LPN BB, who witnessed the incident was an agency nurse, and her contract was cancelled, and the notes she documented were deleted from the EMR. Phone interview on 2/4/2025 at 10:39 am, agency nurse LPN BB stated that on 12/25/2024 she saw R64 kissing R30 deeply in the mouth. She stated staff had reported R64 several times when observed in R30's room doing other sexual acts. During further interview, LPN BB revealed that LPN UM EE stated that the DON was reviewing the video footage. She stated that LPN UM EE informed her that the DON knows about it and she will handle it. She stated that staff members informed her of other incidents involving R64 abusing other residents. Interview on 2/4/2025 at 12:00 pm, LPN UM EE stated she received a phone call on Christmas day that LPN BB saw R64 and R30 in the Evergreen common area, engaged in what looked like a kiss. During further interview, she stated that she reported the incident to the DON via text message, inquiring whether the incident was a state reportable. She stated the DON revealed she would look into it. Furthermore, LPN UM EE stated she never heard back from the DON regarding the incident between R64 and R30. 2. Review of the EMR revealed R60 was admitted to the facility on [DATE] with diagnoses including traumatic brain dysfunction, dementia, anxiety disorder and depression. Review of the Quarterly MDS assessment dated [DATE] revealed Section C documented a BIMS score of 99, indicating the assessment as unable to recall. Review of a handwritten statement written by LPN BB, documented, On 10/28/2024, I was performing patient care with CNA AA on R60's roommate, while R60 was moaning and yelling in her bed. CNA AA said, I'm sick of you and threw the __ lift pad at R60's face. I said, CNA AA! She stated, LPN BB, you didn't see that, I'm sorry. She asked me, are you going to tell on me? I said no. We continued care on R60's roommate, and R60 continued yelling. I notified unit manager upon leaving the room. The statement was signed by LPN BB. Review of the statement written by CNA AA dated 10/28/2024, documented, I put the __ pad on the side of R60 because she was reaching for it I never made the statemat {sic} that I was tired of hearing her moth {sic}. I placed it on the side of her. She always reaches for mechanical lift pad. Interview on 2/4/2025 at 11:40 am, with CNA AA stated that she typically works by herself, unless other staff need her assistance. She stated that she had not witnessed any type of physical abuse nor had she been a part of any type of physical abuse investigations. During further interview, CNA AA stated she had not verbally or physically abused any residents, and stated that she did not drop a mechanical lift pad on a resident. CNA AA confirmed that she had not received any recent Abuse training from the facility staff. Phone interview on 2/5/2025 at 8:54 am, LPN BB stated that on 10/28/2024 she was assisting CNA AA with resident care for R60's roommate in B bed. She stated that CNA AA was standing between A bed and B bed, while she was near the window. R60 was in her bed, with the curtain open and was heard moaning aloud. She stated there was a mechanical lift pad in the B bed's bedside chair. While completing resident care for the resident in B bed, CNA AA turned around to R60 stating, I'm sick of you and grabbed the mechanical lift pad from the chair and threw it aggressively at R60. The pad landed on R60, hitting her upper body and face. LPN BB reported that R60 appeared shocked for a brief moment then continued making noises. During further interview, LPN BB stated she called out CNA AA's name in which CNA AA responded saying, Im sorry, you didn't see that, are you going to tell on me? LPN BB replied, No. LPN BB stated she reported the incident to LPN UM EE and the DON. She stated that the DON told her to write up a statement on what happened. LPN BB stated the DON did not ask her any other questions regarding that incident. She stated LPN UM EE told her that was not CNA AA's first, second, or even fifth time having something like that happen. Interview on 2/5/2025 at 12:00 pm, LPN UM EE stated that LPN BB reported abuse by CNA AA when CNA AA took a mechanical lift pad and threw it on R60. She stated the DON immediately suspended CNA AA following the incident, but stated there were no in-services completed related to Abuse. During further interview, LPN UM EE stated that CNA AA had returned to work, and working on that hall since the incident. 3. Review of the EMR revealed R64 was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia affecting left side. Review of the annual MDS assessment dated [DATE] revealed Section C documented a BIMS score of 15, indicating no cognitive impairment. Section E documented no history of exhibiting physical, verbal, or other behaviors towards others. Interview on 2/3/2025 at 5:30 pm, R64 stated he remembered the incident on Christmas day with R30. He stated that he was in R30's room and he gave her a quick kiss on the lips. He stated he does not have a relationship with R30 and has not had any interactions with any other residents in the facility. R64 stated that the only person that has talked with him about the incident was the DON. He revealed that the DON told him that he could not kiss residents who could not give consent, or only kiss them on the hand. Interview on 2/4/2025 at 1:00 pm, LPN GG stated there had not been any type of in-service or training since the 12/25/2024 incident between R64 and R30. She also stated that she heard of an incident involving R64 and R125, where he went in her room, kissed her and touched her breast. She stated R125 was unable to consent to the actions of R64. During further interview, she revealed there had not been any in-services or follow up from leadership related to abuse. Interview on 2/4/2025 at 2:51 pm, the DON verified that LPN UM EE reported to her that LPN BB witnessed R64 kissing R30 on 12/25/2024. She stated that she reported the incident, but was uncertain if she reported it to the appropriate reporting entity, as she did not get a confirmation about submitting the 5-day follow up report. When questioned why she did not follow up to confirm the reported incident, she stated that she got busy and never could figure out how to do the 5-day follow up. She confirmed that R64 reported to her he did kiss R30. During further interview, she stated there was a very limited investigation into the incident because R64 admitted that he did it. Interview on 2/4/2025 at 3:45 pm, the Administrator stated that he was aware of the incident on 12/25/2024 when it was reported to the DON. He stated that law enforcement was not contacted regarding the incident. Interview on 2/5/2025 at 4:11 pm, the SSD stated she was informed about R64 going into other resident's room uninvited, and instructed him that he could not do that. She stated the DON is aware of the many situations with R64, dating back to 2023. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to maintain an environment free from abuse by R64 affecting R60, R125, and R30 and one physical abuse incident affecting R30. 2. Resident #64 is currently residing at the facility. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psych services requesting an onsite evaluation, however services have been refused by residents. On 2/5/2025 Social Services reviewed status with IDT for appropriate placement. On 2/5/2025 LTC Ombudsman has been notified. On 2/5/2025 law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30. As of 2/9/2025 resident R64 has discharged from facility. On 2/5/2025 law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30. 3. Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and reporting to staff. On 2/6/2025 resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 a psych follow- up visit was provided. On 2/5/2025 law enforcement was notified of the reported abuse incident. 4. Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents. On 2/5/2025 the facility has referred R60 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 5. Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents. On 2/5/2025 the facility has referred R30 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 6. As of 2/6/2025 the facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 8. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 9. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 10. On 2/5/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 11. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 12. As of 2/8/2025, 132 of 150 (88% (percent)) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 13. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 15. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. 16. On 2/7/2025 The facility administration reviewed all audits related to residents vulnerable for potential abuse for identification of safety concerns. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Observation and interviews on 2/11/2025-2/12/2025 revealed the facility environment to free from abuse. 2. R64 is no longer a current resident at the facility; he was discharged [DATE] to a personal care home. A review of the records revealed the facility started paper charting 1:1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1:1 monitoring with staff.), 2/6/2025 at 7:00 am- 7:00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7:20 pm, 2/7/2025 at 7:25 pm - 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3:00 pm, 2/8/2025 at 3:15 pm- 2/9/2025 at 7:00 am - 3:00 pm. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64: CBC, CMP, UA with C&S, PSA, TSH, RPR, and HIV viral load. Record review on 2/11/2025 revealed that the care plan for R64 has been updated Record reviews on 2/11/2025 revealed the Social Worker offered mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that 2/7/2025 R64 was verbally notified of a bed offer at another skilled nursing facility. Residents agreed to transfer on Monday, 2/10/25. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Record review revealed that R64 had been discharged to a personal care home on 2/9/2025. 3. Interview on 2/11/2025 with R125 revealed she was safe and with no concerns. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based on the incidents identified by 2/6/2025. Record reviews on 2/11/2025 revealed that the care plan for R125 has been updated. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. A progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidence also revealed that law enforcement was notified on 2/5/2025 of the abuse in the facility. 4. Observation on 2/11/2025 at 2:00 pm revealed R60 making moaning sounds to alert staff for assistance. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note Documenting Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Record reviews on 2/11/2025 revealed that the care plan for R60 has been updated. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and the Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note documenting R60 reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs and symptoms (s/s) of pain or distress, no facial grimacing or nonverbal moaning at this time. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Record review on 2/11/2025 revealed a police report was completed on 2/5/2025 with the following reference number CC250205029. 5. Interview on 02/12/2025 at 4:07 pm with the SSD revealed they communicate with the resident by doing observations. She mentioned that sometimes she makes sounds. She mentioned that most of the staff have been with her for a while and know her mannerisms. Confirmed care plan revisions were made on 2/6/2025, Evidenced by a progress note dated 2/5/2025, which revealed the R30's family was contacted by Social Services: The resident's family was contacted about an investigation of the alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Confirmed care plan revisions have been made for R30 on 2/6/2025. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. Review of the progress note dated 2/6/2025 revealed that R30 was reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs and symptoms (s/s) of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. A progress note dated 2/5/2025 revealed that R30's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidenced by police report case number CC250205029 on 2/5/2025. 6. Record review on 2/11/2025 at 12:45 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R125's roommate R252. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R252 received a skin assessment due to her low BIMS score of 99. Record review on 2/11/2025 at 12:56 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R60's roommate R36. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R36 received a skin assessment due to her low BIMS score of 3. Record review on 2/11/2025 at 1:04 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R30's roommate R19. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R19 received a skin assessment due to her low BIMS score of 2. 7. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMS greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMS less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. An interview with R14 at 12:09 pm in her room revealed that she feels safe in the facility. R14 has a BIMS of 14. An interview with R17 at 12:12 pm in her room revealed that she feels safe in the facility. R17 has a BIMS of 13. 8. An interview with the Administrator and DON on 2/11/2025 at 1:34 pm revealed that CNA AA has been suspended and potentially terminated pending investigation. Record review on 2/11/2025 revealed a time clock in the report, which revealed CNA AA was clocked out on 2/5/2025 with a start time of 7:06 am and work ending at 7:18 pm. 9. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. 10. During an interview on 2/11/2025 at 2:50 pm with the Administrator, revealed that the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was updated on 2/6/2025. 11. Evidence shows the Administrator Spoke with a representative from an external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with Admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection

Based on record review, staff interviews, review of the Administrator and Director of Nursing job descriptions, and review of the policy titled Abuse Policy, the facility administration failed to provide protective oversight to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident physical and verbal abuse for resident (R) R60; and failed to protect R30, R60, and R125 from sexual abuse from R64. The failures of the Administration to take appropriate action has the likelihood to lead to future allegations of abuse, that are not identified, reported, or investigated. The facility census was 161. Specifically: 1. Facility Administrator and Director of Nursing (DON) failed to perform duties of their job descriptions that facilitated providing a safe environment to the residents of the facility. 2. Administration failed to adhere to the facility policies, including the prevention, reporting, and investigating of allegations of abuse. Cross Refer F600, F609, F610 3. Administration failed to provide ongoing abuse and behavioral training to staff related to care for residents with repeated acts of abuse and hypersexual behaviors. Cross Refer F740 On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: Review of the blank document titled, Job Title: Administrator revealed the job description is to direct the day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients. Essential Regulatory Functions: Number 7. Operates the Nursing Center in accordance with the established guidelines of the Organization and in compliance with federal state and local regulations. Number 8. Enforce the Nursing Center guidelines. Number 9. Maintains a working knowledge of current licensure standards and survey process.Number 13. Acts as a liaison between the Nursing Center and regulatory agencies, patient advocacy groups and fiscal intermediaries. Number 15. Assists department heads in the planning, conducting, and scheduling in-service training classes and orientation programs. Number 19. Assumes responsibility for procedural guidelines relative to the prevention and reporting of patient abuse. Essential Associate Relations Functions: Number 42. Supervises all department supervisors and administrative staff. Meets with department heads at regular intervals. Review of the blank document titled, Job Title: Nursing Services Director of Nursing Services revealed the job description is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director, to provide appropriate care. Essential Skill/Knowledge Function: Number 38. Maintain effective lines of communication with attending physicians. Number 40. Maintain knowledge of documentation procedures including appropriate use of forms, timelines, and Medicare documentation. Number 41. Maintains a working knowledge of current licensure standards and survey process. Essential Clinical Services Functions: Number 42. Direct, evaluate and supervise patient care and initiates corrective action as necessary. Number 49. Report problems of the Administrator, conducts daily patient rounds, and initiates corrective actions as necessary. Number 69. Assume responsibility for procedural guidelines relative to the prevention and reporting of patient abuse. Number 79. Maintain appropriate personnel file documentation including reference checks, screenings, corrective actions, evaluations, skills verification, and others as necessary. Review of the facility policy titled, Abuse Policy dated December 2023 documented B. Training Components: Abuse Policy Requirements: It is the policy of this facility that all new and existing employees receive training on all forms of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown origin, and involuntary seclusion, including freedom from physical or chemical restraints. Training is to include prohibiting and prevention and identification, recognition, reporting and understanding behavioral symptoms that may increase risk of abuse and neglect. C. Prevention: The facility is to prevent abuse by establishing a safe environment, identifying, correcting and intervening in situations in which abuse is more likely to occur ensure the health and safety of all residents in regard to visitors and provide residents information on how and to whom to report concerns or grievances without fear of reprisal. D. Identification: All staff to monitor residents and trained on how to identify potential signs and symptoms if abuse, neglect, exploitation of residents, misappropriation of resident property Occurrences, patterns and trends that constitute abuse will be investigated. E. Investigation: Reports of abuse, neglect, exploitation of residents, misappropriation of resident property . are promptly and thoroughly investigated. F. Protection. The resident(s) will be protected from the alleged offender(s). G. Reporting and Response: Allegations of abuse, neglect, exploitation of residents, misappropriation of resident property are reported per federal and state law. The facility failed to ensure that R30 and R125 were free from sexual abuse by R64. Specifically, Administration failed to investigate and report allegations from Licensed Practical Nurse (LPN) CC of witnessed sexual abuse acts which R64 was seen fondling R30's breast with her adult brief undone. Furthermore, the Administration failed to investigate and report allegations from LPN BB who witness R64 tongue kissing R30 in the tv common area without consent. The facility failed to ensure R60 was free from verbal and physical abuse by Certified Nursing Assistant (CNA) AA. Administration failed to thoroughly investigate and report a witnessed and handwritten account of physical abuse by CNA AA towards R60 when CNA AA threw a mechanical lift pad at R60, landing on her face. The facility was not able to provide any documentation to show a thorough investigation, including follow-up interviews with staff, additional resident interviews related to experiences, observations related to potential sexual abuse was conducted, or reporting the incidents to family or local authorities. Interview on 2/4/2025 at 2:51 pm, the DON confirmed that she is the Abuse Coordinator. She stated that all staff are aware to report any allegations of abuse to her. She revealed that she was aware of the incident R64 and R30 that occurred on 12/25/2024. She revealed she did not do a thorough investigation for the incident since R64 admitted that he did it. There was no follow-up interviews with residents or staff done because she had a written statement and R64 admitted to it. Furthermore, the DON stated she did not do any other follow up because she assumed that the girl who reported it would call the family and the police to report the incident on 12/25/2024. When asked about the physical abuse incident 10/28/2024, the DON stated CNA AA was immediately put on suspension following the allegation. Interview on 2/12/2025 at 1:21 pm, the Administrator stated that he was aware of both 10/28/2024 and 12/25/2024 incidents which was reported by the DON. The 10/28/2024 incident he thought it was reported by the DON, the team discussed it and the ball got dropped because the follow up was not done for either incident. He stated his expectations are for staff to know how to do their jobs, since they have the tools to do their job. During further interview, he stated that if his expectations are not carried out, he revealed the negative effect if any staff is not able to perform their job duties then harm to others can happen. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to provide oversight and supervision to ensure residents R30, R60, and R125 were protected from abuse by R64 and abuse by CNA AA to R30. 2. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 3. On 2/5/2025 resident R64 placed on 1:1 supervision upon report from State surveyor of other alleged incidents. 4. As of 2/9/2025 resident R64 has discharged from facility. 5. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 6. As of 2/7/2025 the facility had completed meeting/assessing with all residents who were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. On 2/7/2025 The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified. 8. On 2/5/2025 the facility administration contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 9. On 2/7/2025 education was provided to Administration from external consultant on job description. 10. On 2/5/2025 the facility administration notified President of Governing Board of Directors. 11. On 2/5/2025 the facility administration reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. As of 2/8/2025, 132 of 150 of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities (88%) staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, been educated on 3 abuse social prevention, workers, 5 unit abuse reporting helpers/clerks, and 1 DON comprehensive and 1 LNHA) have assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 prevention, EVS staff, abuse and 1 reporting unit and helper/clerk) comprehensive team assessments members will their be next educated scheduled on abuse workday. 13. As of 2/8/2025, 5 of 5 (100% (percent)) agency staff (4 LPN and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments of their next scheduled workday. 15. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. 16. On 2/5/2025 a Performance Improvement Plan (PIP) was initiated related to abuse prevention and abuse reporting. ADHOC meeting held on 2/5/2025. All corrective actions were completed by 2/9/2025. All immediacy of the U was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Observation on 2/11/2025 revealed R64 was discharged , R25, R30, RG0, and R125 were noted to safe with no concerns. 2. Interview on 2/11/2025 revealed DON suspend CNA AA via phone pending investigation. 3. R64 is no longer a current resident at the facility, he was discharged on [DATE]. A review of the records revealed the facility started paper charting 1: 1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am, (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1 :1 monitoring with staff.) 2/6/2025 at 7:00 am- 7: 00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7: 20 pm, 2/7/2025 at 7:25 pm 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3: 00 pm, 2/8/2025 at 3: 15 pm, 2/9/2025 at 7: 00 am - 3:00 pm. 4. Record review revealed R64 was discharged on [DATE] to a personal care home. 5. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. On 2/5/2025 the facility referred to R30 for psych services for assessment and support. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs of pain or distress, no facial grimacing or nonverbal moaning currently. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. Evidenced by: Confirmed care plan revisions have been made on 2/6/2025. Evidenced by: Progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. 6. By evidence of record review, it was confirmed that the facility had completed a meeting assessing with all residents who were deemed vulnerable for potential abuse. 7. Interview with Administrator on 2/7/2025 at 1:30pm revealed steps were made for improvement, weekly audits, review of reportable, education, and discussing change in clinicals meetings. 8. An interview with the Administrator on 2/11/2025 at 1:30 pm revealed contact was made with external consultants and the board to assist with policy review, education development and leadership training on abuse prevention and reporting. 9. By evidence of interview on 2/14/2025 at 12:49 pm with the Administrator and Record review revealed education was provided to Administration from an external consultant on job description. 10. By interview on 2/11/2025 at 1:30pm with Administrator revealed the President of Governing Board of Directors with notified about the abuse allegations. 11. By interview on 2/11/2025 Record review revealed administration reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with Admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 13. Review of facility in-service record dated 2/8/2025, five of five (100%) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 14. Review of facility in-service record dated 2/8/2025, five of five (100%) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 15. By evidence of record review revealed 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements 16. By evidence of an interview with the Administrator on 2/11/2025 at 1:30 pm confirmed on 2/5/2025 a Performance Improvement Plan (PIP) was initiated related to abuse prevention and abuse reporting. ADHOC meeting held on 2/5/2025. Record review confirmed ADHOC meeting held on 2/5/2025. All corrective actions were completed by 2/9/2025. All immediacy of the U was removed on 2/10/2025. 48338

Based on record review, staff and family interviews, and review of the policy titled Abuse Policy, the facility failed to ensure that allegations of verbal, sexual, and physical abuse were reported to the State Survey Agency (SSA). Specifically, residents (R) R30 and R125 were sexually abused by R64; and R60 was verbally and physically abused by Certified Nursing Assistant (CNA AA). The sample size was 57 residents. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: Review of the facility policy titled Abuse Policy dated December 2023 documented B. Training Components: Abuse Policy Requirements: It is the policy of this facility that all new and existing employees receive training on all forms of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown origin, and involuntary seclusion, including freedom from physical or chemical restraints. Training is to include prohibiting and prevention and identification, recognition, reporting and understanding behavioral symptoms that may increase risk of abuse and neglect. G. Reporting and Response: Allegations of abuse, neglect, exploitation of residents, misappropriation of resident property are reported per federal and state law. The facility will ensure that: b. All alleged violations involving abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, corporal punishment and involuntary seclusion are reported immediately to the administrator. c. All alleged violations involving abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, corporal punishment and involuntary seclusion must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. a. Immediately, but no later than two hours if the alleged violation involves abuse or results in serious bodily injury. b. No later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury c. Results of all investigations of alleged violations must be reported within five working days of the incident. Review of the employee personnel file for CNA AA revealed a handwritten note written by Licensed Practical Nurse (LPN) CC stating that she had witnessed CNA AA verbally and physically abuse R60 by yelling at her I'm sick of you and then threw a mechanical lift pad at R60, hitting her in the face. Further review of the employee personnel file contained a handwritten statement by CNA AA stating that she did not throw the mechanical lift pad at R60, but instead placed it near her because she always reaches for the mechanical lift pad. Further review of the employee file did not reveal any evidence of reporting of these allegations to the SSA or to law enforcement. The facility staff was asked to provide a copy of the facility reported incident, but none was provided. Interview on 2/4/2025 at 2:51 pm, the DON confirmed that she is the facility's Abuse Coordinator. She revealed the kissing incident between R64 and R30 was reported to her on 12/25/2024 by LPN UM EE. She stated that she reported the incident, but was uncertain if she reported it to the appropriate reporting entity, as she did not get a confirmation about submitting the 5-day follow up report. When asked why she did she not follow up for a confirmation, she revealed she got busy and did not get back around to do the 5-day follow up. During further interview, she stated she could not figure out how to do the 5-day follow up. The DON stated when allegations of abuse are received, it is to be reported within two hours if there is physical harm, and within 24 hours for all other incidents. She stated she asks the resident and/or family if they would like to file a police report. The DON revealed she called the family to inform of the 12/25/2024 incident, but stated the family did not want a police report completed. She was unable to provide the documentation of contacting the families. Furthermore, she revealed she did not follow up with staff regarding a direct order of documenting the occurrence or any other issues. In looking over the behavior notes for R64, the DON stated it is her responsibility to review all of the notes that are put in the system and discuss during the clinical and interdisciplinary team meetings. She revealed that she had not reviewed these notes and they were not discussed with the team. Interview on 2/4/2025 at 3:45 pm with the Administrator revealed he was aware of the incident on 12/25/2024 when it was reported to the DON however, law enforcement was not contacted. There was no evidence that the staff to resident abuse by CNA AA to R60 was reported to the SSA and there was no evidence that the sexual abuse perpetrated by R64 towards R125 was reported to the local law enforcement. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to notify family and resident representatives of R30, R125, and R60 of alleged incidents of abuse. The facility failed to report incidents of abuse to law enforcement. The facility failed to report the results of the investigations for R30, R60 and R125 to the Administrator and State Survey agency of alleged incidents of abuse. 2. Resident #64 is currently residing at Riverview Health and Rehabilitation Center. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psychiatric services requesting an onsite evaluation, however services have been refused by resident. On 2/5/2025 Social Services reviewed current status with IDT for appropriate placement. On 2/5/2025 LTC Ombudsman has been notified. On 2/5/2025 law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30. 3. Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and report to staff. On 2/6/2025 resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 a psych follow up visit was provided. On 2/5/2025 law enforcement was notified of the reported abuse incident. 4. Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents On 2/5/2025 the facility has referred R60 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 5. Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents On 2/5/2025 the facility has referred R30 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 6. As of 2/6/2025 the facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns identified. 8. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 9. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 10. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 11. On 2/5/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 12. As of 2/8/2025, 132 of 150 (88% (percent)) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 13. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 15. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Observation, interviews and record reviews on 2/l l/2025-2/12/2025 revealed the facility environment to free from abuse. 2. R64 is no longer a current resident at the facility; he was discharged [DATE] to a personal care home. A review of the records revealed the facility started paper charting 1:1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1:1 monitoring with staff.), 2/6/2025 at 7:00 am- 7:00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7:20 pm, 2/7/2025 at 7:25 pm - 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3:00 pm, 2/8/2025 at 3:15 pm- 2/9/2025 at 7:00 am - 3:00 pm. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64: CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load. Record review on 2/11/2025 revealed that the care plan for R64 has been updated. Record reviews on 2/11/2025 revealed the Social Worker offered mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that 2/7/2025 R64 was verbally notified of a bed offer at another skilled nursing facility. Residents agreed to transfer on Monday, 2/10/2025. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Record review revealed that R64 had been discharged to a personal care home from the facility. 3. Interview on 2/11/2025 with R125 revealed she was safe and with no concerns. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based on the incidents identified by 2/6/2025. Record reviews on 2/11/2025 revealed that the care plan for R125 has been updated. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made for R125 on 2/6/2025. A progress note dated 2/5/2025 revealed R125's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidence also revealed that law enforcement was notified on 2/5/2025 of the abuse in the facility. 4.Observation on 2/11/2025 at 2:00 pm revealed R60 making moaning sounds to alert staff for assistance. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note Documenting Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Record reviews on 2/11/2025 revealed that the care plan for R60 has been updated. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and the Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents. Record review on 2/11/2025 revealed a progress note in the system for R60 dated 2/6/2025 as a Health Status Note documenting R60 reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning at this time. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Record review on 2/11/2025 revealed a police report was completed on 2/5/2025 with the following reference number CC250205029. 5.Interview on 02/12/2025 at 4:07 pm with the SSD revealed they communicate with the resident by doing observations. She mentioned that sometimes she makes sounds. She mentioned that most of the staff have been with her for a while and know her mannerisms. Confirmed care plan revisions were made on 2/6/2025, Evidenced by a progress note dated 2/5/2025, which revealed the R30's family was contacted by Social Services: The resident's family was contacted about an investigation of the alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Confirmed care plan revisions have been made for R30 on 2/6/2025. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. Review of the progress note dated 2/6/2025 revealed that R30 was reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. The bed is at the safest level, with a floor mat at the bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. A progress note dated 2/5/2025 revealed that R30's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Evidenced by police report case number CC250205029 on 2/5/2025. 6. Record review on 2/11/2025 at 12:45 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R125's roommate R252. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R252 received a skin assessment due to her low BIMs score of 99. Record review on 2/11/2025 at 12:56 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R60's roommate R36. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R36 received a skin assessment due to her low BIMS score of 03. Record review on 2/11/2025 at 1:04 pm of a document titled Assessment of Vulnerable Population revealed the facility met with and assessed R30's roommate R19. All residents with low BIMs scores received a skin assessment, and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R19 received a skin assessment due to her low BIMS score of 2. 7. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMS greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMS less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. An interview with R14 at 12:09 pm in her room revealed that she feels safe in the facility. R14 has a BIMS of 14. An interview with R17 at 12:12 pm in her room revealed that she feels safe in the facility. R17 has a BIMS of 13. 8. An interview with the Administrator and DON on 2/11/2025 at 1:34 pm revealed that CNA AA has been suspended and potentially terminated pending investigation. Record review on 2/11/2025 revealed a time clock in the report, which revealed CNA AA was clocked out on 2/5/2025 with a start time of 7:06 am and work ending at 7:18 pm. 9. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and has participated in clinical meetings daily in the mornings with the facility's clinical team. 10. During an interview on 2/11/2025 at 2:50 pm with the Administrator, revealed that the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was updated on 02/06/2025. 11. Evidence shows the Administrator Spoke with a representative from an external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with Admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 13. Review of facility in-service record dated 2/8/2025, five of five (100%) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 14. By evidence of interview and record review, staff is currently receiving training. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 15.Record review of facility documents titled Associate Orientation Checklist and Facility Name Orientation revealed reviews and revisions to the documents made on 2/7/2025, including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency and facility staff. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. 48338 49673

Based on record review, staff interview, and review of the facility policy titled, Abuse Policy, the facility failed to ensure allegations of abuse were thoroughly investigated for two of four residents (R) R30 and R60 reviewed for abuse. Specifically, the facility failed to investigate allegations of resident-to-resident sexual abuse for R30 perpetrated by R64 and an allegation of employee to resident abuse for R60, perpetrated by Certified Nursing Assistant (CNA)AA. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: Review of the facility policy titled Abuse Policy dated December 2023 documented E. Investigation. Abuse Policy Requirements: It is the policy of this facility that reports of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. During the investigation, caution will be exercised when handling evidence that could potentially be used in a criminal investigation. The investigation will include statements from all individuals involved to include: i. Statement from individual reporting alleged abuse ii. Resident's statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. iii. Resident's roommate statements (if applicable) iv. Visitor statements for anyone who may have witnessed the alleged abuse (if applicable) v. All involved staff who have or may have witnessed the abuse vi. Any non-staff witness statements of events vii. A description of the resident's behavior and environment at the time of the incident viii. An full assessment of the resident to identify any Injuries present ix. Observation of resident and staff behaviors during the investigation x. Environmental considerations *All staff must cooperate during the investigation to assure the resident is fully protected. Additional Investigation Protocols. The results of the investigation will be documented and attached to the report. Review of the facility state reportable incidents failed to document a complete investigation of the incident between R64 and R30 on 12/25/2024. Further review of the documents showed there was only a copied and pasted email statement, an un-dated written statement from the unit manager, two un-dated written statement from a staff who did not witness the incident, and a hand written note regarding the reporting and follow up date, written by the Director of Nursing. There were no resident statements, no evidence the incidents were reported to law enforcement, and no evidence the residents were assessed for physical and/or psychological harm. Review of the employee personnel file for CNA AA revealed a handwritten note written by Licensed Practical Nurse (LPN) CC stating that she had witnessed CNA AA verbally and physically abuse R60 by yelling at her I'm sick of you and then threw a mechanical lift pad at R60, hitting her in the face. Further review of the employee personnel file contained a handwritten statement by CNA AA stating that she did not throw the mechanical lift pad at R60, but instead placed it near her because she always reaches for the mechanical lift pad. Further review of the employee file did not reveal any evidence of reporting of these allegations to the SSA or to law enforcement. The facility staff was asked to provide a copy of the facility reported incident, but none was provided. Interview on 2/4/2025 at 2:51 pm, the DON confirmed that she is the Abuse Coordinator. When questioned why did she not follow up on the confirmation of the reportable, she revealed she got busy and did not get back to complete the 5-day follow up and could not figure out how to do the 5-day follow up but she tried. Interview on 2/12/2025 at 1:21 pm, the Administrator stated that he was aware of both 10/28/2024 and 12/25/2024 incidents which was reported by the DON. The 10/28/2024 incident he thought it was reported by the DON, the team discussed it and the ball got dropped because the follow up was not done for either incident. He stated his expectations are for staff to know how to do their jobs, since they have the tools to do their job. During further interview, he stated that if his expectations are not carried out, he revealed the negative effect if any staff is not able to perform their job duties then harm to others can happen. The facility implemented the following actions to remove the IJ: 1. On 2/5/2025, the facility failed to thoroughly investigate incidents of abuse. 2. Resident #64 is currently residing at the facility. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and __ viral load have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psych services requesting an onsite evaluation, however services have been refused by resident. On 2/5/2025 Social Services reviewed current status with IDT for appropriate placement. On 2/5/2025 LTC Ombudsman has been notified. On 2/5/2025 law enforcement was notified of the reported abuse incident to R30, R60, and R125. As of 2/9/2025 resident R64 has discharged from facility. 3. Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and report to staff. On 2/6/2025 resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 a psych follow up visit was provided. On 2/5/2025 law enforcement was notified of the reported abuse incident. 4. Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents On 2/5/2025 the facility has referred R60 for psych services for assessment and support. On 2/5/2025 law enforcement was notified of the reported abuse incident. 5. Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. On 2/6/2025 resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. On 2/6/2025 the care plan has been reviewed and updated. On 2/5/2025 the resident's representative and primary care physician were notified by facility of the reported incidents. On 2/5/2025 the facility has referred R30 for psych services for assessment and support. 6. As of 2/7/2025 the facility has met and assessed with R60, R125 and R30's roommates as well as residents who are deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 7. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 8. On 2/5/2025 upon the report from the State surveyor, CNA AA has been suspended pending further investigation. 9. On 2/5/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 10. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 11. On 2/5/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting. 12. As of 2/8/2025, 132 of 150 (88% (percent)) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 13. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 14. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 15.On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Interview on 2/11/2025 at 1:10 pm with DON revealed all reported investigation are pending an investigation. 2. R64 is no longer a current resident at the facility, he was discharged on [DATE]. A review of the records revealed the facility started paper charting 1: 1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am, (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1 :1 monitoring with staff.) 2/6/2025 at 7:00 am- 7: 00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7: 20 pm, 2/7/2025 at 7:25 pm 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3: 00 pm, 2/8/2025 at 3: 15 pm, 2/9/2025 at 7: 00 am - 3:00 pm. By evidence of an interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R 125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64. By evidence of a phone Interview on 2/11/2025 at 2:30 pm with the physician of R30, R60, R64, and R125 and Medical Director of the facility revealed she was notified and contacted of the incidents with the Record review on 2/11/2025 revealed the care plan for R64 has been updated. Record reviews on 2/11/2025 revealed the Social Worker offered an external contracted mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that on 2/7/2025 R64 was verbally notified of bed offer at another skilled nursing facility. Residents agreed to transfer on Monday 2/10/2025. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Interview ombudsman on 2/10/2025 at 3:00pm confirm she was notified about abuse in the facility. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Record review revealed R64 has been discharged from the facility on 2/9/2025 to a personal care home. 3. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified by 2/6/2025. Record review R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified by 2/6/2025. Record reviews on 2/11/2025 revealed the care plan for R125, R60, R30 and R64 has been updated. Evidenced by Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. Progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. By evidence of record review, it was confirmed that R125 has been reassessed for safety and potential physical/psychosocial harm, care plan has been reviewed and updated, and a psychiatric follow up visit was provided. Evidence also revealed law enforcement was notified of the abuse in the facility. 4.Observation on 2/11/2025 at 2:00 pm revealed R60 making moaning sounds alert staff for assistance. Resident's BIMs is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises. Record review on 2/11/2025 revealed a progress note in the system for R60 dated for 2/6/2025 as a Health Status Note documenting Resident reassessed for safety and potential. physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No signs and symptoms (s/s) of pain or distress, no facial grimacing or nonverbal moaning at this time. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. By evidence of Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. On 2/5/2025 the facility referred to R30 for psychiatric services for assessment and support. Progress Note dated 2/6/2025: Resident reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified. Vital signs at baseline. No s/s of pain or distress, no facial grimacing or nonverbal moaning currently. Bed at safest level with floor mat at bedside. Assessment outcomes were reviewed with the primary care physician. Confirmed care plan revisions have been made on 2/6/2025. Progress note dated 2/5/2025 revealed resident's family was contacted by Social Services: The resident's family was contacted about an investigation of alleged abuse. Confirmed mental health services were offered, and the resident's family gave verbal consent for the mental health services. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. 6. Record review on 2/11/2025 at 12:45 pm of document titled Assessment of Vulnerable Population revealed the facility met with and assessed R125's roommate R252. All residents with low BIMs scores received a skin assessment; and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R252 received a skin assessment due to her low BIMS score of 99. Record review on 2/11/2025 at 12:56 pm of document titled Assessment of Vulnerable Population revealed the facility met with and assessed R60's roommate R36. All residents with low BIMs scores received a skin assessment; and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R36 received a skin assessment due to her low BIMS score of 03. Record review on 2/11/2025 at 1:04 pm of document titled Assessment of Vulnerable Population revealed the facility met with and assessed R30's roommate R19. All residents with low BIMs scores received a skin assessment; and residents with high BIMs scores received a written/verbal assessment. It was revealed that the roommate of R19 received a skin assessment due to her low BIMs score of 02. 7. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMs greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMs less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. An interview with R14 at 12:09 pm in her room revealed that she feels safe in the facility. R14 has a BIMs of 14. An interview with R17 at 12:12 pm in her room revealed that she feels safe in the facility. R17 has a BIMs of 13. 8. An interview with the Administrator and DON on 2/11/2025 at 1:34 pm revealed CNAAA has been suspended and potentially terminated pending investigation. Record review on 2/11/2025 revealed a time clock in report which revealed CNA AA was clocked out on 2/5/2025 start time 7:06 am and work end at 7: 18 pm. 9. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. 10. During an interview on 2/11/2025 at 2:50 pm with Administrator revealed the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, was updated on 2/06/2025. Evidence shows the Administrator Spoke with a representative from external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 11. Evidence revealed the Administrator collaborated with a representative from external consultant. She began her assistance with the NHA as well as the DON on 2/5/2025 and is currently making revisions and recommendations. 12. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with Admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 13. Review of facility in-service record dated 2/8/2025, five of five (100% (percent)) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 14. By evidence of interviewed and record review staff is currently receiving training. An interview with the Administrator on 2/11/2025at 1:05 pm revealed 91% of staff have been educated on abuse. 15. Evidenced by: Record review of facility documents titled, Associate Orientation Checklist and The facility Orientation revealed reviews and revisions to the documents made on 2/7/2025 including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency staff and facility staff. All corrective actions were completed by 2/9/2025. All immediacy of the l was removed on 2/10/2025. 48338 49673

Based on record review, resident and staff interviews, and review of the facility policy titled Specialized Services the facility failed to ensure one resident (R) R64 received necessary behavioral health services to address repeated verbal abuse and hypersexuality behaviors towards other residents in the facility. The sample size was 57. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 2/10/2025. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC).This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings Include: Review of the facility policy titled Specialized Services revised December 2021, documented routine and emergency specialized services are available to meet the resident's health services (dental, vision, podiatry, psychological, etc.) in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: Number 2. Selected specialists must be available to provide follow-up care. Failure of a specialist to provide follow-up services will result in the facility's right to use its consultant specialist to provide the residents specialized needs. Number 4. Social Services representatives will assist residents with appointments, transportation arrangements, and reimbursement of specialized services under the state plan, if eligible. Review of the EMR revealed R64 was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia affecting left side. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section E documented no history of exhibiting physical, verbal, or other behaviors towards others. Review of the Behavior Progress Notes for R64 revealed on 3/16/2023, R64 was yelling and berating two female residents. The DON was notified; 3/16/2023, R64 was noted to be in room [ROOM NUMBER], yelling and cursing at the resident in bed A. He was noted in room [ROOM NUMBER] and grabbed residents arm while she was sleeping; 4/12/2023 the Social Services Director (SSD) documented worker spoke to resident about his going into female rooms uninvited and those who are unable to speak for themselves. Resident stated that he was trying to be helpful, or they have invited him in. Worker informs him that going into these ladies' rooms are against their rights. Interview on 2/3/2025 at 5:30 pm, R64 stated he remembered the incident on Christmas day with R30. He stated that he was in R30's room and he gave her a quick kiss on the lips. He stated he does not have a relationship with R30 and has not had any interactions with any other residents in the facility. R64 stated that the only person that has talked with him about the incident was the DON. He revealed that the DON told him that he could not kiss residents who could not give consent, or only kiss them on the hand. Interview on 2/11/2025 at 1:05 pm with the Administrator and the DON revealed they dropped the ball. They further revealed an attempt to send R64 out for psychiatric services and R64 refused. There was no evidence that Psychiatric Services were sought out by the facility for R64 until after the survey had began. The facility implemented the following actions to remove the IJ: 1. On 2/7/2025, the facility failed to complete a comprehensive assessment in order to provide the necessary behavioral health care and services to R64 based upon incidents identified. 2. Resident #64 is currently residing at Riverview Health and Rehabilitation Center. On 2/5/2025 resident placed on 1:1 supervision on upon report from State surveyor of other alleged incidents. On 2/5/2025 the resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents. On 2/5/2025 the facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, ___ viral load, and head CT without contrast have been ordered. On 2/5/2025 the resident's care plan has been reviewed and revised. On 2/5/2025 the facility contacted psych services requesting an onsite evaluation, however services have been refused by resident. On 2/5/2025 the facility administration and social services have reviewed the need for potential alternative placement for R64. This has been reviewed with R64 and the Ombudsman. The facility will continue to seek out options for R64 placement. As of 2/7/2025 Resident R64 has been accepted and agreed to go to another SNF. discharge date pending per other SNF. On 2/5/2025 L TC Ombudsman has been notified. On 2/7/2025 LTC Ombudsman updated. On 2/5/2025 law enforcement was notified of R64's reported abuse incidents and behaviors. As of 2/9/2025 resident R64 has discharged from facility. 3. As of 2/7/2025 the facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified. 4. On 2/7/2025 the facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy. 5. On 2/7/2025 the administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on comprehensive assessment related to behavioral health care and services to attain or maintain the highest practical well-being for residents. 6. On 2/5/2025 the facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting and comprehensive assessment related to behavioral health care and services policies and procedures on 2/7/2025. 7. As of 2/8/2025, 132 of 150 (88%) of facility team members (36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, 3 activities staff, 13 dietary staff, 19 EVS staff, 4 maintenance staff, 3 social workers, 5 unit helpers/clerks, 1 DON and 1 LNHA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 18 (5 CNAs, 1 LPN, 2 PRN RNs, 6 dietary staff, 3 EVS staff, and 1 unit helper/clerk) team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 8. As of 2/8/2025, 5 of 5 (100%) agency staff (4 LPNs and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. 9. As of 2/8/2025, 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday. 10. On 2/6/2025 a review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements. 11. On 2/7/2025 a review and update of the facility orientation program and agency orientation program for licensed nursing and therapy staff has been completed with respect to comprehensive assessment processes related to residents behaviors and corresponding interventions for behavioral health care and services requirements. 12. On 2/7/2025 The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified. 13. As of 2/8/2025, the facility has reviewed records of residents who display behaviors and corresponding documentation and assessment completion per policy. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1.Evidence of observations. interviews, and record reviews the facility completed a comprehensive assessment on R64 to address his behavioral health. 2. R64 is no longer a current resident at the facility, he was discharged on [DATE]. A review of the records revealed the facility started paper charting 1: 1 hourly monitoring for R64 for the following: 2/5/2025 at 7:05 pm - 5:32 am, (Interview with Administrator on 2/11/2025 at 3:00 pm revealed the video recording of where R64 was on 1 :1 monitoring with staff.) 2/6/2025 at 7:00 am- 7: 00 pm, 2/6/2025 at 7:00 pm- 2/7/2025 at 7:00 am, 2/7/2025 at 7:00 am- 7: 20 pm, 2/7/2025 at 7:25 pm 2/8/2025 at 7:00 am, 2/8/2025 at 7:00 am- 3: 00 pm, 2/8/2025 at 3: 15 pm, 2/9/2025 at 7: 00 am - 3:00 pm. Phone Interview on 2/11/2025 at 2:30 pm with the physician of R30. R60. R64, and Rl25 and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and ordered the following labs for R64. Record review revealed an email was sent on 2/5/2025 to R64's primary care physician to order lab and CT without contrast was ordered and completed on 2/6/2025. Record review on 2/11/2025 revealed the care plan for R64 has been updated. Record review on 2/11/2025 revealed the Social Worker offered mental health services, and he declined the services. Record review on 2/11/2025 revealed documentation that on 2/7/2025 R64 was verbally notified of bed offer at another skilled nursing facility. Resident agreed to transfer on Monday 2/10/25. As of 2/9/2025 resident R64 has discharged from facility to a Personal care home. Interview on 2/11/2025 with the Administrator and the DON revealed they were able to contact the Ombudsman. Record review on 2/11/2025 revealed there is a police report with the following reference number CC250205029. R64 has been discharged from the facility. 3. Record review of assessments conducted by the facility. The vulnerable population is defined by the facility as all women in the facility. Female residents with BIMS greater than or equal to 13 had a written/verbal assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by social services. Female residents with BIMS less than 13 had a skin assessment conducted on 2/5/2025 through 2/7/2025 and signed and dated by nursing staff. Reviewed all assessments with no safety concerns. 4. Phone Interview on 2/11/2025 at 2:30 pm with the physician and Medical Director of the facility revealed she was notified and contacted of the incidents with the above residents and have participated in clinical meetings daily in the mornings with the clinical team of the facility. 5. Evidence revealed the Administrator collaborated with a representative from external consultant. She began her assistance with the NHA as well as the DON on 02/05/2025 and is currently making revisions and recommendations. 6. During an interview on 2/11/2025 at 2:50 pm with Administrator revealed the policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, was updated on 2/6/2025. Evidence show the Administrator Spoke with a representative from external consultant. She stated she discussed the immediate actions needed to remove the IJ citations and began the initial review and revision of the abuse prevention policy and procedures with NHA and DON. Recommendations were also provided. 7. A review of facility in-service record dated 2/8/2025 revealed 36 CNAs, 25 LPNs, 7 RNs, 15 administrative staff, three activities staff, 13 dietary staff, 19 EVS staff, four maintenance staff, three social workers, five-unit helpers/clerks, one DON and one LNHA have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interview on 2/11/2025 at 6:15 am with Certified Nursing Assistant (CNA) XX, 2/11/2025 at 6:17 am with Licensed Practical Nurse (LPN) JJ, 2/11/2025 at 6:21 am with LPN YY, 2/11/2025 at 6:26 am with CNA ZZ, 2/11/2025 at 6:31 am with CNA NN, 2/11/2025 at 6:36 am with CNA AAA, 2/11/2025 at 6:46 am with LPN GG, 2/11/2025 at 6:48 am with LPN BBB, 2 /11/2025 at 6:51 am with CNA CCC, 2/11/2025 at 6:54 am with CNA DDD, 2/11/2025 at 7:58 am with Maintenance Director, 2/11/2025 at 8:30 am with Maintenance Assistant, 2/11/2025 at 8:15 am with Housekeeping GGG, 2/11/2025 at 8:46 am with Environmental Services Manager, 2/11/2025 at 8:23 am with Social Services Director, 2/11/2025 at 9:16 am with Social Worker HHH, 2/11/2025 at 8:50 am with Activities Assistant III, 2/11/2025 at 8:35 am with Admission Coordinator JJJ, 2/11/2025 at 8:48 am with Medical Records KKK, 2/11/2025 at 10:30 am with Director of Business Development, 2/11/2025 at 6:01 am with CNA MMM, 2/11/2025 at 6:20 am with CNA NNN, 2/11/2025 at 6:31 am with RN Supervisor OOO, 2/11/2025 at 6:31 am with LPN PPP, 2/11/2025 at 6:46 am with Unit Manager (UM) EE, 2/11/2025 at 7:40 am with Assistant Food Service Manager, 2/11/2025 at 7:45 am with Dietary Manager, 2/11/2025 at 8:00 am with Occupational Therapist (OT) WWW, 2/11/2025 at 8:08 am OT XXX, 2/11/2025 at 8:00 am Physical Therapist Assistant (PTA), 2/11/2025 at 6:18 am with Unit Secretary (US) ZZZ, 2/11/2025 at 6:23 am with Staffing Coordinator MM, 2/11/2025 at 6:28 am with LPN AAAA, 2/11/2025 at 6:32 am with LPN QQ, 2/11/2025 at 6:42 am with Floor Tech (FT) BBBB, 2/11/2025 at 6:42 am with CNA CCCC, 2/11/2025 at 6:47 am with CNA CCC, 2/11/2025 at 6:50 am with Housekeeping DDDD, 2/11/2025 at 6:56 am with FT EEEE, 2/11/2025 at 7:52 am with DA FFFF, 2/11/2025 at 8:07 am with Receptionist GGGG, 2/11/2025 at 8:21 am with Admissions Coordinator HHHH, 2/11/2025 at 8:17 am with Housekeeping IIII, 2/11/2025 at 8:20 am with Financial Assistant JJJJ, 2/11/2025 at 8:28 am with Activities Director, 2/11/2025 at 12:53 pm with UM SS, 2/11/2025 at 12:56 pm with Director of Finances, 2/11/2025 at 12:57 pm with US KKKK, 2/11/2025 at 1:07 pm with CNA NNNN, 2/11/2025 at 1:09 pm with Wound Care CNA OOOO, 2/11/2025 at 1:12 pm with CNA PPPP, 2/11/2025 at 1:15 pm with US QQQQ, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 1:20 pm with LPN LL, 2/11/2025 at 1:22 pm with Director of Rehabilitation, 2/11/2025 at 1:32 pm with OT RRRR, 2/11/2025 at 1:35 pm with PT SSSS, 2/11/2025 at 1:37 pm with PTA TTTT, 2/11/2025 at 1:40 pm with Speech Therapist (ST) UUUU, 2/11/2025 at with 1:46 pm with Rehab Technician VVVV, 2/11/2025 at 1:56 pm with LPTA WWWW, 2/11/2025 at 1:59 pm with Laundry XXXX, 2/11/2025 at 2:09 pm with ST YYYY, 2/11/2025 at 2:49 pm with EVS Assistant Supervisor, 2/11/2025 at 2:56 pm with CNA DD, 2/11/2025 at 3:00 pm with Housekeeper DDDDD, 2/11/2025 at 3:02 pm with CNA EEEEE, 2/11/2025 at 3:04 pm with Central Supply Clerk FFFFF, 2/11/2025 at 3:07 pm with Registered Dietician, 2/11/2025 at 3:28 pm with LPN TT, 2/11/2025 at 3:30 pm with CNA GGGGG, 2/11/2025 at 3:32 pm with CNA HHHHH, 2/11/2025 at 3:34 pm with DA IIIII, 2/11/2025 at 3:36 pm with [NAME] JJJJJ, 2/11/2025 at 3:43 pm with CNA VV, 2/11/2025 at 3:45 pm with LPN KK, 2/11/2025 at 3:50 pm with DA KKKKK, 2/11/2025 at 3:51 pm with MDS Coordinator LLLLL, 2/11/2025 at 4:02 pm with MDS Coordinator MMMMM, 2/11/2025 at 4:05 pm with DA NNNNN, 2/11/2025 at 4:06 pm with Financial Coordinator OOOOO, 2/11/2025 at 4:08 pm with Payroll Clerk PPPPP, 2/11/2025 at 4:10 pm with Human Resources Director, 2/11/2025 at 4:12 pm with [NAME] RRRRR, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 5:41 pm with Infection Preventionist, 2/11/2025 at 5:46 pm with Receptionist YYYYY, 2/11/2025 at 5:58 pm with LPN QQQQQ, 2/11/2025 at 5:59 pm with DA A1, 2/11/2025 at 6:11 pm with LPN D1, 2/11/2025 at 6:19 pm with CNA E1, 2/12/2025 at 12:03 pm with Nurse Educator, 2/12/2025 at 12:19 pm with DON, 2/12/2025 at 12:49 pm with Administrator. A review of the facility in-service record dated 2/9/2025 revealed 18 (five CNAs, one LPN, two PRN RNs, six dietary staff, three EVS staff, and one unit helper/clerk) team members were educated on abuse prevention, abuse reporting, and comprehensive assessments. Also verified the above education by the following staff interviews 2/11/2025 at 2:44 pm with Housekeeper ZZZZ, 2/11/2025 at 2:46 pm with Housekeeper AAAAA,2/11/2025 at 2:52 pm with Housekeeper BBBBB, 2/11/2025 at 7:10 with am Dietary Aide (DA) QQQ, 2/11/2025 at 7:15 am with [NAME] RRR, 2/11/2025 at 7:20 am with DA SSS, 2/11/2025 at 7:25 am with DA TTT, 2/11/2025 at 7:30 am with DA UUU, 2/11/2025 at 7:35 am with DA VVV, 2/11/2025 at 6:54 pm with LPN TTTTT, 2/11/2025 at 7:05 pm with RN UUUUU, 2/11/2025 at 7:11 pm with CNA VVVVV, 2/11/2025 at 7:20 pm with CNA WWWWW, 2/11/2025 at 5:37 pm with CNA XXXXX, 2/11/2025, 2/11/2025 at 6:03 pm with CNA B1, 2/11/2025 at 6:08 pm with CNA C, 2/11/2025 at 1:18 pm with Activities Assistant FF, 2/11/2025 at 6:02 am with Wound Care Registered Nurse (RN) LLL. An interview with the Administrator on 2/11/2025 at 1:05 pm revealed that 91% of staff have been educated on abuse. 8. Review of facility in-service record dated 2/8/2025, five of five (100% (Percent)) agency staff (four LPNs and one CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments. Also verified the above education by the following staff interviews on 2/11/2025 at 1:01 pm with LPN LLLL, 2/11/2025 at 1:04 pm with LPN MMMM, 2/11/2025 at 5:58 pm with LPN RR, 2/11/2025 at 6:57 pm with LPN SSSSS, 2/11/2025 at 6:42 am with CNA CCCC. 9. By evidence of interviewed and record review staff is currently receiving training. An interview with the Administrator on 2/1 I /2025 at 1 :05 pm revealed 91 % of staff have been educated on abuse. 10. Record review of facility documents titled, Associate Orientation Checklist and Riverview Health and Rehabilitation Orientation revealed reviews and revisions to the documents made on 2/7/2025 including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency staff and facility staff. 11. Record review of facility documents titled. Associate Orientation Checklist and Riverview Health and Rehabilitation Orientation revealed reviews and revisions to the documents made on 2/7/2025 including the addition of comprehensive assessments and abuse reporting. The Administrator confirmed on 2/11/2025 at 1:59 pm that the orientation checklist and agenda are the same for both agency staff and facility staff. 12. An interview with the Administrator on 2/11/2025 at 2:01 pm revealed that these audits include a review of the 24-hour reports. behavioral reports, and the skin and verbal/written assessments for the defined vulnerable population. Review of these records revealed that it has been signed and dated by the Administrator on 2/7/2025. 13. An interview with the Administrator on 2/11/2025 at 2:01 pm revealed that these audits include a review of the 24-hour reports. behavioral reports, and the skin and verbal/written assessments for the defined vulnerable population. Review of these records revealed that it has been signed and dated by the Administrator on 2/7/2025. All corrective actions were completed by 2/9/2025. All immediacy of the IJ was removed on 2/10/2025. 48338

Based on staff interviews, record review, and a review of the facility policy titled Staffing, Sufficient and Competent Nursing and [NAME] Payroll-Based Journal (PBJ) dated July 1, 2024, through September 30, 2024, the facility failed to ensure the required Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days per week. This had the potential to affect all residents residing in the facility. The facility census was 161 residents. Findings include: A review of the policy titled Staffing, Sufficient and Competent Nursing, revised September 2022, revealed the facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. Review of the [NAME] Payroll-Based Journal (PBJ) dated July 1, 2024, through September 30, 2024, revealed that during the fourth quarter reporting, the facility was identified as not having a Registered Nurse (RN) working on the dates of 7/20/2024, 7/28/2024, 8/4/2024, 8/18/2024, 9/1/2024, 9/15/2024 and 9/22/2024, for 8 eight consecutive hours each day. After reviewing Review of the RN clock hour report that was provided by the Administrator he titled 3Q PBJ submission Report dated 7/1/2024 thru 9/30/2024, it was verified that there were seven days that there was no RN coverage for the entire facility (7/20/2024, 7/28/2024, 8/4/2024, 8/18/2024, 9/1/2024, 9/15/2024 and 9/22/2024). Interview on 2/5/2025 at 11:38 AM with Administrator revealed that he understands what the PBJ shows regarding the no RN hours for seven days during the fourth quarter. The Administrator stated that the expectation was to have RN coverage. He could not provide any explanation to why there was no RN staff at the facility on those nine days. He stated that he knows what the printout shows and pointed to the 0s in the columns indicating 0 hours. He went on to say, I didn't want to give you that, but it is what it is. He did confirm that there is an RN currently in the facility providing patient care.

Based on observations, staff interviews, and review of the facility's policy titled, Infection Prevention and Control Manual Dietary Department, the facility failed to ensure food stored in the main kitchen was labeled and dated, and failed to ensure staff wore proper hair restraints while in the food prep area. The deficient practice had the potential to affect 52 of 61 residents receiving an oral diet. Findings include: Review of the undated facility policy titled, Infection Prevention and Control Manual Dietary Department, under Section C Dietary Staff number 5. Practice proper food handling procedures, including but not limited to hand washing, wearing hairnets or caps, beard nets, and clean uniforms, no bare hand contact with food, wearing disposable gloves to perform certain food handling tasks, and discarding gloves on completion of the task. Continued review revealed under Section D All Food 1E. Food is labeled, dated, and monitored in order for it to be used by the use-by date or discarded. Observation on 2/2/2025 at 12:32 pm with [NAME] RRR tour of kitchen revealed dietary aide KKKKK without hair net and dietary aide QQQ without beard guard. Observation on 2/2/2025 at 12:45 pm of the walk in cooler revealed metal containers with puree eggs, ground pork sausage, puree corn beef, chopped turkey sausage and chopped ham that were not dated with an expiration date. Interview on 2/2/2025 at 2:02 pm with Dietary Manager revealed that sometimes missed labeling is a human error. DM confirmed the food items were not dated with an expiration date and that staff were not wearing hair restraints and beard guards in the food prep area. DM stated that everyone is to wear a hairnet, and the two male dietary staff members were asked to wear masks until the beard guards arrive.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Self -Administration of Medication, the facility failed to ensure two of 57 sampled residents (R) (R303) and (R136) did not have unauthorized and unsecured medicated treatment products at the bedside. This deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors. Findings include: Review of the policy titled Self -Administration of Medication It is the policy that if resident requests to self-administer medication (s) that the interdisciplinary team will determine if the practice is clinically appropriate to honor the residents' choice to keep resident at their highest practicable level of functioning. The resident has the right to defer the responsibility to the facility. A resident may only self-administer medications after the IDT has determined which medications may be safely self-administered. Procedure: 1. A periodic assessment of the residents' ability to self-administer medication will be performed by the IDT, based on changes in the residents' medical and decision-making status. 2. A physician's order will be obtained and recorded in the charts. The order will also include which specific medications can be kept at the bedside. 3. Transcribe physician's order on Medication Administration Record. 4. Provide equipment to facilitate self-administration, demonstrate use and implement return demonstration. 5. Nurse to check with resident each shift for appropriate medication administration. 1. Review of the electronic medical record (EMR) for R303 revealed diagnoses included, but were not limited to sepsis, unspecified organism, calculus in urethra, acute kidney failure, type 2 diabetes mellitus with diabetic polyneuropathy and need for assistance with personal care. Review of R303 quarterly change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 8, indicating moderate cognitive impairment. Review of the physician orders for R303 revealed there was no physician's order for self- administer medication. Review of R303's EMR revealed a Self-Administration Assessment Form had not been completed to determine the resident's capability with medication self-administration. Observation on 2/2/2025 at 3:51 pm with R303 revealed nystatin hydrocortisone topical with an expiration date of 1/20/2025 on his bedside table. Interview on 2/3/2025 at 10:41 am Certified Nursing Assistant (CNA) UU confirmed nystatin hydrocortisone topical on R303's bedside table. CNA UU revealed it should not be at his bedside table without having order for self-administration of medication. Interview on 2/7/2025 at 10:38 am with licensed Practical Nurse (LPN) EE confirmed that R303 should not have medication at his bedside without physician orders to self-administrator. Interview on 2/10/2025 at 2:26 pm with Director of Nursing (DON) and Administrator confirmed residents should not have any medication at bedside without having an order for self-administration of medication. 2. Review of the EMR for R136 revealed diagnoses included but were not limited Methicillin-Susceptible Staphylococcus Aureus (MSSA) Bacteremia. Review of R136 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS of 14, indicating little to no cognitive Impairment. Review of the physician orders for R136 revealed there was no physician's order for self- administer medication. Review of R303's EMR revealed a Self-Administration Assessment Form had not been completed to determine the resident's capability with medication self-administration. Observation and interview on 2/2/2025 at 4:15 pm with R136 revealed he had Benadryl and Desitin cream at bedside on his bedside table. Observation on 2/3/2025 at 9:40am revealed Benadryl and Desitin cream on his bedside table. Interview on 2/3/2025 at 10:41 am CNA UU confirmed Benadryl and Desitin cream should not be at his bedside table without having order for self-administration of medication. Interview on 2/7/2025 at 10:38 am with LPN EE confirmed that R136 should not have medication at his bedside without physician orders to self-administrator. Interview on 2/10/2025 at 2:26 pm with Director of Nursing (DON) and Administrator confirmed residents should not have any medication at bedside without having an order for self-administration of medication.

Based on interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADL) Supporting, the facility failed to provide a shower and/or bed bath for one of seven residents (R) R357. Findings include: Review of the facility policy titled, Activities of Daily Living, revised dated January 2022, revealed under Policy Interpretation and Implementation Number 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). Record review for R357 revealed resident was admitted to the facility on [DATE] with diagnoses included but not limited to Cellulitis of Buttocks. Review of the Shower List revealed R357 was not scheduled for shower preferences upon admission. During an interview on 2/2/2025 at 4:37 pm with R357 revealed that he was not offered a shower nor bed bath since last Tuesday, when he was admitted . Interview on 2/5/2025 at 1:00 pm with Licensed Practical Nurse (LPN) WW revealed the shower sheets for R357 in January and February 2025 could not be located, and R357 was not on the shower log. LPN WW emphasized it is the charge nurse responsibility to ask residents about preferences so Certified Nurse Assistant (CNA) can provide care. Interview on 2/5/2025 at 5:28 pm, with Director of Nursing (DON) revealed when a resident completes admission a shower should be offered, and the next day inquiry about preference based on the resident. DON emphasized that the unit manager is responsible for ensuring the first shower or bed bath and documenting preferences. Interview on 2/12/2025 at 2:22 pm with CNA PPPP revealed she does not know why R357 was not provided a bed bath on admission. The only reason residents would not get a shower is because it was not offered or the resident refused.

Based on observations, staff interviews, and review of the policy titled, Food Safety Requirements Policy, the facility failed to ensure that food items were discarded after expiration date from the walk-in cooler in the main kitchen. The facility also failed to ensure that food stored in the residents' pantry on two of four pantries reviewed had resident food items that were dated and labeled properly, and expired foods were removed from refrigerator. The deficient practice had the potential to affect 160 of 166 residents receiving an oral diet. Findings include: Review of facility policy dated ,d+[DATE] titled Food Safety Requirements Policy revealed C. Food and Beverage Brought in For Residents: d. Foods requiring refrigeration will be received by the facility designee (activity department, food and nutrition department, charge nurse, etc.) for proper and immediate storage including labeling and dating. Review of an undated document titled Condiments/Sauces revealed that all sauces if unopened are good for three months and only one month after the sauce had been opened. Once opened it is good for one month. Observation on [DATE] at 9:19 a.m. of main kitchen walk-in cooler located in the dish room of the facility revealed the following food items were noted to be expired or not utilized by use by date. 1.There was a one-gallon Chilly Sweet sauce container that was not labeled or dated. 2. There was one container of Rosarita enchilada Sauce opened with a received by date of [DATE] but there was no use by date indicated. 3. There was a container of Teriyaki Sauce with a received date of [DATE] but no use by date was indicated. Interview on [DATE] at 9:26 a.m. with the Dietary Manager, who verified, that items observed in cooler should have been removed and not in use. Further interview also revealed that all food items should be labeled and dated when placed in the cooler and discarded after expiration date. Observation on [DATE] at 9:48 a.m. of resident food pantry on Evergreen Hall revealed there were three bags of food stored in the refrigerator that were not labeled or dated with various food items in the bag. Observation and confirmation with the Dietary Manager on [DATE] at 9:50 a.m. of the food pantry on Magnolia Hall revealed the following: 1. There was a storage container (not labeled or dated) with red, yellow and green peppers that had gray furry substance on the surface of each pepper. 2. There was one clear storage container that was unlabeled and dated that contained mac and cheese that had a white substance on top of the food item. 3. A storage container with unidentifiable food item in container that was not dated or labeled. 4. There was one gallon of prune juice unlabeled and not dated. 5. There were four bags of various food items not labeled or dated, 6.There was one box of Eggo Pancakes with an expiration date of [DATE]. 7.There was half a gallon of vanilla ice cream not dated or labeled with an expiration date of [DATE]. During an interview with the Administrator on [DATE] at 2:38 p.m. it was revealed that only staff are permitted in the pantry. Administrator further explained that the residents are permitted to have their food in the refrigerators, but the food should be dated, labeled, and after three days it is to be discarded. The dietary staff are responsible for ensuring that all food is labeled and dated in the pantry on each unit.

Based on observation, record review, staff interviews and review of the facility policy titled Catheter Care, Urinary, the facility failed to secure the catheter tubing to prevent tension on the urethra for four residents ((R) R#20, R#42, R# 55, and R#127,); failed to have an appropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] # 127 and R# 128), and failed to provide a urinary privacy bag for one resident (R# 128) . This deficient practice impacted five of 13 residents observed with indwelling urinary catheters. Findings include: Review of facility's undated policy titled Catheter Care, Urinary under Infection Control #2, b. Be sure the catheter tubing and drainage bag are kept off the floor; Changing catheters #2 - Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Steps in Procedure - #18. Secure catheter utilizing a leg band. #20. Place catheter in a privacy bag. 1. Review of R# 20's clinical record revealed resident has an indwelling catheter due to Stage 3 sacral pressure ulcer. 2. Review of R#42's clinical record revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of record revealed resident does not have a documented supporting diagnosis/justification for use of indwelling catheter. 3. Review of R#55's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 (a BIMS score of 12 indicates mild cognitive impairment), and an indwelling catheter. Further review of the R#55's clinical record revealed resident did not have order for the indwelling catheter or a supporting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation and resident interview on 9/6/22 at 9:52 a.m. revealed R#55 lying in bed. R#55 is observed to have a catheter. R#55 reported that she had the catheter because she has a bed sore on her butt. A CNA in giving care to resident, when linen removed surveyor observed resident without a catheter strap to secure the catheter. Observation of R# 55 on 9/7/22 at 9:17 a.m. lying in bed and was receiving Activities of Daily Living (ADL)care. Resident was observed not to have a catheter securing device in place. 4. Review of R #127's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 (a BIMS score of 10 indicates moderate cognitive impairment), and an indwelling catheter. Observation on 9/6/22 at 10:50 a.m. revealed R#127's catheter drainage bag and privacy bag lying on the floor along the left side of the bed. The resident pulled back covers to show surveyor his catheter tubing. The catheter tubing was not secured to his leg. Observation on 9/7/22 at 9:36 a.m. revealed R# 127 lying in bed, the catheter's drainage bag and privacy bag was lying on the floor. Observation on 9/7/22 at 1:17 p.m. revealed R# 127 lying in bed with both legs exposed. The resident did not have a catheter strap in place. The catheter's drainage and privacy bag were still lying on the floor. On 9/8/22 at 8:46 a.m., during walking rounds with Licensed Practical Nurse (LPN) Unit Manager (UM) GG, the following observations were observed and verified; R#127 lying in bed indwelling catheters drainage bag and privacy bag was lying on the floor beside of bed. R#127 also observed to not have a catheter securing device. R# 55 was confirmed to not have a catheter securing device. R#42 was confirmed to not have a catheter securing device. R#20 was confirmed to not have a catheter securing device and the catheter's drainage bag was not attached to a stable surface. LPN UM GG stated all residents with catheters should have a securing device. She further stated that these residents did not have the securing device because the nurses who insert the catheters are not in the habit of placing a securing device. LPN UM GG further stated that the nursing assistants should also be checking and ensuring the catheters are secure, the drainage bag should be in the privacy bags and secured to the bed frame and never on the floor. LPN UM GG verified that R# 42 does not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/8/22 at 11:01 a.m. with LPN DD, she stated that she checked the catheters on her shift to ensure that the urine is draining properly. LPN DD further stated that she has not checked or assessed the catheters today, but she does not usually check for securing devices. During an interview with Director of Nursing (DON) on 9/8/22 at 1:26 p.m. R# 55's current orders were reviewed, and DON verified R# 55 did not have current orders for the use of the catheter. DON further stated that it is very odd that R#55 does not have orders or justification for the foley. DON stated that R# 55 should have orders to change the catheter every 30 days. DON expressed that every resident with a catheter should have a foley strap to properly secure the catheter. DON further stated that there is not a reason for the residents to not have them, because we have tons of foley straps here at the facility. During an interview on 9/8/22 at 2:53 p.m. Certified Nursing Assistant (CNA) II, she stated that she does foley care and checks for the catheter straps during care. CNA II furthered stated that she is aware that some of the residents do not have catheter straps and she has informed the nurse. 5. Observation on 9/7/22 at 12:51 p.m. of Resident # 128 sitting up in Geri chair at bedside being assisted with the lunch meal. Amber urine noted in the tubing and in the drainage bag, bag hanging from bed frame, not covered, and not in dignity bag. Observation on 9/8/22 at 1:15 p.m. revealed R# 128's tubing with amber urine draining into a drainage bag hung from the bed rail, not covered, not in a dignity bag, and tubing on floor. Record Review (RR) of the medical record revealed R#128 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#128 had a Brief Interview of Mental Status (BIMS) score of 01 which indicated severely impaired cognition. Section H - Bladder and Bowel documented, has indwelling catheter (including suprapubic) and ostomy (including [CONDITION(S)]). Section I -Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of current physician orders revealed no order for suprapubic catheter, and/or [MEDICATION(S)]. Observation on 9/8/22 at 1:50 p.m. with the Administrator, confirmed that R#128 had a Suprapubic catheter, and the drainage bag was not in a dignity bag, and not covered by other means. The Administrator was not sure about a policy related to covering a drainage bag, but her expectation was that all catheter drainage bags should be covered, tubing should not be on the floor, there should be a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator reported that not having a dignity bag should have been identified and addressed. -End-