Every finding on record at Shearer-Richardson Memorial Nursing Home

Based on staff interview, record review and facility policy review, the facility failed to ensure laboratory tests were obtained as ordered by the physician for (1) one of five (5) resident laboratory reviews conducted. (Resident # 14).Findings include: Review of the facility policy titled, Diagnostic Testing Services, last reviewed 7/22/25, revealed: Policy: This facility will provide the appropriate diagnostic services (laboratory/radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines . Record review of Order Details revealed a physician's order dated 6/7/24 to obtain a HGBA1C (Glycated Hemoglobin) every 3 months (July, Oct, Jan, April). Record review of Resident #14's HGBA1C results revealed there were no results for January 2025 or July of 2025. An interview with the Director of Nursing (DON) on 10/7/25 at 1:49 PM, confirmed that Resident #14 did not have a HGBA1C obtained for January 2025 or July of 2025. She revealed that the physician's order for the HGBA1C was not correctly entered into the electronic medical record, and the lab was not scheduled. The DON stated that failure to obtain the lab as ordered could result in missed elevated levels and adversely affect the resident's diabetic management. Record review of the admission Record revealed the facility admitted Resident #14 on 5/16/25 with diagnoses that included of Type 2 Diabetes Mellitus.

Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident had a functioning call light system in the bathroom for one (1) of 67 residents' rooms observed. Resident #55Findings include: Review of the facility's policy titled, . Call Lights: Accessibility and Timely Response dated [DATE], revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 7. The call system must be accessible to the residents at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . During an observation and interview on [DATE] at 10:44 AM, Resident #55 revealed that when she pulls the cord on the call light in her bathroom, it does not activate the call light system. She stated that she took her phone into the bathroom with her, so that she had a way to call for assistance if needed. An observation of the bathroom call light system confirmed that the cord was not able to be pulled to activate the call system. On [DATE] at 2:45 PM, during an observation and interview, the Director of Nursing (DON) confirmed that the call light system in Resident #55's bathroom could not be activated with the pull cord. Resident #55 informed the DON that she took her phone in the bathroom with her in case assistance was needed. The DON confirmed that each call light in resident's room and bathroom was required to function properly to alert the staff if needed. She confirmed the facility failed to ensure a call light in a resident's bathroom was functioning properly. During an interview on [DATE] at 2:50 PM, the Administrator revealed it was her expectation that each resident's room and bathroom have a call light system to alert staff of the need for assistance. She confirmed the facility failed to provide a functioning call light in Resident #55's bathroom. Record review of the admission Record for Resident #55 revealed the facility admitted the resident on [DATE] with diagnoses that included Hypertensive Chronic Kidney Disease and weakness. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated a moderate cognitive impairment.

Based on staff interview, record review, and facility policy review the facility failed to ensure that all nursing staff had valid and current certification to provide care to residents. This deficient practice resulted in a Certified Nursing Assistant (CNA) working 15 shifts while her certification was expired, which placed residents at risk of receiving care from an unqualified individual for one (1) of (44) CNA certifications reviewed. (CNA #1). Findings include: Review of the facility policy titled, Nursing Services and Sufficient Staff, last reviewed [DATE], revealed the following: It is the policy of the facility to provide staff with appropriate competencies to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident . Record review of the Nurse Aide Registry with an inquiry date of [DATE] at 4:30 PM, revealed CNA #1's certification expired on [DATE]. An interview with the Staff Educator on [DATE] at 11:09 AM, confirmed that CNA #1's certification expired [DATE]. She stated that she accidentally missed the expiration date on the CNA log used to track certification dates. She acknowledged that allowing the CNA to work while her certification was expired was a violation of state and federal regulations. Record review of the time sheet for CNA #1 revealed that from [DATE] through [DATE], CNA #1 worked 15 days while her certification was expired. An interview with the Administrator (ADM) on [DATE] at 11:30 AM, confirmed that CNA #1's certification was expired and that the CNA had continued to work at the facility during that time. The ADM stated that the facility tracks CNA certification dates, but this particular lapse was overlooked. She confirmed CNA#1 should not have worked while her certification was expired. A phone interview with CNA #1 on [DATE] at 11:40 AM, revealed she was unaware that her certification had expired until she was notified by the ADM. She stated that she had recently moved and did not receive a renewal notice in the mail. She acknowledged she would be required to retest to regain her certification.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) status change was completed when a resident's original diagnosis was corrected to reflect the presence of a mental illness for one (1) of four (4) residents reviewed for PASRR. Resident #25.Findings included: In an interview with the Administrator (ADM) on 10/8/25 at 8:05 AM, she stated that the facility did not have a policy regarding submitting Status Change for PASRR. Record review of Resident #25's Intake Information dated 7/19/23, revealed in Section J-Disease Diagnoses that a mental illness was not included in the diagnosis section. Section M PASRR revealed that No was answered under the section PASRR Activity Required. Record review of the admission Record for Resident #25 revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder. Further review revealed that on 3/20/25, the resident's diagnosis list was updated to include Other psychotic disorder not due to a substance known physiological condition. Record review of the medical record revealed that the facility did not submit a Status Change following the correction of the resident's diagnosis to reflect a qualifying mental illness and there was no Level II evaluation was requested or completed. On 10/7/25 at 1:00 PM, the Social Worker (SW) confirmed that she did not complete a Status Change Request for Resident #25 because she was not aware of the diagnosis. She stated that she usually reviews the psychiatric Nurse Practitioner's notes to determine if a Status Change should be done. She verified the purpose of completing a Status Change is to ensure the resident is appropriate for the nursing home and may identify services that a resident with a mental illness may need. She agreed that a Status Change should have been completed for Resident #25. In a further interview with the ADM on 10/8/25 at 8:45 AM, she stated that the Minimum Data Set (MDS) nurse is responsible for coding resident diagnoses, and she did not correctly code Resident #25's diagnosis on admission. She stated the MDS nurse identified her error on 3/20/25 and corrected the diagnosis but did not notify the SW of the correction. She agreed the SW should have been notified so a Status Change could be submitted.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to ensure a resident had a safe and homelike environment as evidenced by a broken bathroom wall tile and a broken towel holder in the bathroom for one (1) of 67 residents' rooms observed. Resident #55Findings include: Review of the facility's policy titled, Safe and Homelike Environment dated 7/29/25, revealed, In accordance with residents' rights, the facility will provide a safe, clean comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. 'Environment' refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. 'Orderly' is defined as an uncluttered physical environment that is neat and well-kept . During an interview and observation on 10/6/25 at 10:44 AM, Resident #55 stated her towel holder had been broken since she moved in the room, and she would like to be able to use it. An observation revealed the left side of the towel holder was partially out of the wall and the tile was broken. The right side was secured in place, but there was no bar between the ends. An interview and observation on 10/7/25 at 2:45 PM, with the Director of Nursing (DON) revealed that it was her expectation that every area of the facility be in good repair and not a safety risk. She confirmed the facility failed to maintain the towel rack adequately and the broken tile was sharp and could cause an injury. During an interview on 10/7/25 at 2:50 PM, the Administrator confirmed that facility failed to maintain the resident's bathroom towel rack in safe and functioning condition. Record review of the admission Record for Resident #55 revealed the facility admitted the resident on 6/24/24 with diagnoses that included Hypertensive Chronic Kidney Disease and weakness. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/25 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated a moderate cognitive impairment.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from abuse including involuntary seclusion, verbal abuse and unreasonable confinement by staff members physically restraining a resident for one (1) of three (3) residents sampled. Resident #1. Findings include: Record review of facility policy titled, Abuse, Neglect and Exploitation, dated 3/17/23, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect , 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse . Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 'Verbal Abuse' means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Involuntary Seclusion refers to the separation of a resident from .his/her room .against the resident's will . During an interview with the Administrator on 11/20/24 at 9:15 AM, it was revealed that the incident occurred on 10/30/24 around 6:00 PM and was reported by Resident #3 to the Administrator the next morning on 10/31/24. She stated after viewing the video footage and interviewing residents and staff, it was determined that the resident was confined to her chair and made to stay in the lobby area and was not allowed to go to the bathroom by two staff members. An interview with Resident #3 on 11/20/24 at 12:25 PM, revealed she was in the lobby area when this incident occurred between Resident #1 and Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. She stated Resident #1 needed to go to the bathroom and LPN #1 held her in the chair and yelled at her and told her to stay in the chair and that she was not leaving. Then, RN #1 wrapped her arms around resident from behind and held her in the chair. They yelled at her and were telling her that they were going to send her out to the hospital. Resident #1 was moving a lot and trying to get them to let her go. Resident #3 stated, That really hurt me to see them treat her that way. I had to get out of there because I couldn't watch that. An interview with Resident #2 on 11/20/24 at 12:40 PM, revealed he also witnessed this incident in the lobby, and he reported it the next day. He stated it started when the resident told LPN #1 that she needed to go to her room to go to the bathroom, but LPN #1 told her she had just gone and not done anything, so she was not going back and to stay in her chair. The resident moved her chair towards the door several times, but LPN #1 brought her back to the lobby area each time. LPN #1 told another staff member to close the doors that led from the lobby to the hallway so Resident #1 could not leave. He stated LPN #1 took the resident's hands and held them together in front of the resident and tried to hold her arms on the resident's chest to keep her in her chair. She yelled at the resident to sit down, she was not going to her room, she was going to be sent out, and she was tired of her doing this. At that point, RN #1 came and held the resident from behind with her arms wrapped around the resident's shoulders and the resident's arms were crossed and she held her arms. The resident tried to get them to let go of her and go to the bathroom. He stated it was awful to watch, and he had never seen anything like that before with these nurses or other staff and both of these nurses seemed irritated, and the situation was out of control. An observation and interview with Resident #1 on 11/20/24 at 3:00 PM, revealed the resident sitting in her recliner in her room drinking water from her cup with jerky and uncoordinated movements. Resident #1 had a diagnosis of Huntington's disease; therefore she was extremely difficult to understand, but she continued to repeat each statement until she was understood. She stated she was in the lobby area and needed to go to the bathroom, but LPN #1 would not take her since she had just been. She attempted to propel herself to her room, but LPN #1 stopped her and pushed her back into the lobby. LPN #1 held her in the chair and yelled at her saying she was not going to her room, and she was getting sent to the hospital. Then, RN #1 held her from behind while she was sitting in her chair and would not allow her to move. She stated she had the right to go to the bathroom and to be held down was wrong and she did not like being treated that way. She denied any physical injury but stated she was emotionally bothered, and this made her angry and upset that they did this to her. She stated that the nurses sent her to the emergency room (ER) and she told the doctor in the ER that nothing was wrong with her that she just needed to go to the bathroom and they wouldn't allow her too. The resident confirmed that she was returned to the facility later that evening. During a phone interview on 11/20/24 at 3:45 PM, LPN #1 she stated Resident #1 was in the lobby area and was taken to the bathroom by a Certified Nursing Assistant (CNA) #5 and within a few minutes, she stated she needed to go to the bathroom again. CNA #5 was with another resident, and she informed Resident #1 that it would be a few minutes and the CNA would be back to take her to the bathroom. She stated the resident tried to propel herself to her room and she told her she could not go back by herself due to the risk of a fall. She stated Resident #1 got mad and was hitting and pushing and tried to throw herself out of the chair and she did hold her in the chair to keep her safe. She stated a resident does have the right to fall but she felt that it was her responsibility to keep that from happening if she could. She stated she should not have yelled at the resident or held her when she did not want to be held, but she did this to keep her safe, not to be malicious or mean. She stated she wished the situation had been handled differently, but she just did not want her to fall. LPN #1 confirmed that she was terminated from the facility related to this incident. A phone interview with CNA #1 on 11/20/24 at 4:05 PM, revealed she came up on the situation and the resident was yelling that she had to go to the bathroom and RN #1 was holding her from behind. CNA #1 did not witness the resident hitting or kicking but said it appeared to her that she was trying to free herself from being held. She stated she was shocked to see this and did not know what to think about it. During a phone interview with RN #2 on 11/20/24 at 4:15 PM, it was revealed that she and RN #1 were having shift report in the office, and they heard a big commotion and yelling so they went out to see what was happening. She stated LPN #1 said the resident was kicking and hitting and she needed help to hold her in her chair, so RN #1 put her arms around her from behind her to keep her from falling from the chair. She heard LPN #1 yelling at the resident that they were going to send her out and to sit down or you are going to fall. She felt they were trying to keep her safe and she did not think they meant for things to be that loud and out of control. A phone interview with CNA #2 on 11/20/24 at 4:45 PM revealed she had come into the lobby area and the lobby doors were closed and she heard the resident yelling that she needed to go to the bathroom and LPN #1 told her that she had just been to the bathroom and did not need to go again. She stated LPN #1 also cussed and yelled at the resident to calm down and she was not going to put up with this sh*t and that she was being sent out. CNA #2 observed that the resident was not combative but appeared to be trying to get loose from being held. She stated RN #1 was behind the resident and had her arms wrapped around her shoulders. She stated a CNA #3 came up and was holding her hands and talking calmly to the resident and the resident calmed down and RN #1 released her hold. She stated she had never seen anything like that, and the resident did not deserve for her caregivers to treat her that way in her home. During a phone interview on 11/21/24 at 9:45 AM, CNA #3 revealed the lobby doors were closed and when she walked through, she saw RN #1 holding the resident like a bear hug from behind and RN #1 said the resident had been hitting and kicking. RN #1 asked her to hold the resident's hands so she gently placed her hands over the resident's hands, and talked calmly to her and she calmed down and RN #1 released her hold on her. She stated the ambulance came and she was taken to the hospital. A phone interview with RN #1 on 11/21/24 at 10:00 AM revealed on the evening of the incident, she and the day nurse were in the office for shift change report and they heard a commotion and yelling in the lobby area. She and the day shift nurse went into the lobby area and heard LPN #1 and Resident #1 yelling loudly and LPN #1 told Resident #1 that she needed to calm down and she was going to be sent out to the hospital. LPN #1 told her the resident had been hitting and slapping all day and she asked her to help hold her in the chair so she would not fall out while she did the paperwork for the hospital transfer. She held her from behind around her shoulders like a bear hug to keep her from falling out of the chair and the resident tried to get loose. She stated the resident had a history of fighting and attacking staff and had been to the emergency room before for this. The resident told her she needed to go to the bathroom to poop but LPN #1 said she had already been and did not do anything. CNA #3 came and held her hands and talked to her and she calmed down and she stated she released the bear hug hold on her. The ambulance arrived and she was assisted onto the gurney and was taken to the hospital. She stated with the information she had received, her first concern was to keep this resident and others safe. She stated she made a judgement call based on the information she had received and in hindsight, the situation should have been handled differently and she should not have held her in her chair. She stated when she was in the situation, all she could think of was what to do to prevent a harmful fall. RN#1 confirmed that she resigned from the facility, prior to the facility terminating her. A phone interview with CNA #4 on 11/21/24 at 10:08 AM, revealed that she and CNA #1 came into the lobby and heard the commotion. RN #1 was holding the resident from behind and CNA #3 walked over to talk to the resident. She stated RN #1 and LPN #1 were screaming to sit down and you're not going anywhere. The resident yelled out and tried to get loose, but she did not see the resident kick or hit. As the resident calmed down and got quiet, she said she just needed to go to the bathroom. The ambulance arrived and she was taken to the hospital. An interview with RN #3 on 11/21/24 at 10:20 AM, revealed she had worked day shift and Resident #1 was agitated. After she ate her dinner in the dining room, she was taken to the lobby area. She stated LPN #1 was trying to calm her down and stated to the resident, We're not doing this and that she is Going to send her out. She stated she did not see the part of the incident where the resident was being held, but she knew the nurses and she did not believe they meant to cause her harm. Interview with CNA #5 on 11/21/24 at 3:45 PM revealed this was a hard situation to witness. She stated the resident was held in her chair by RN #1 and LPN #1 was cussing and yelling and telling her they were going to send her out to the hospital. She stated the resident was not fighting but was trying to get out of their grip. She stated it seemed like the nurses were frustrated and it turned into a bad situation. During an interview on 11/21/24 at 11:40 AM, the Director of Nursing (DON) stated they were notified of the incident by a resident the day after it occurred. She stated they watched the video and interviewed staff and residents. Resident #1 was cognitive and had the right to go where she wanted to go and no one would want a resident to fall, but a resident has that right. She stated Resident #1 was physically restrained and was kept from going where she wanted to go and doing what she wanted to do, therefore her rights were violated. She stated this incident was troubling to watch on the video and in the time frame they kept her from doing what she chose, the staff could have taken her to the bathroom. She confirmed the resident was verbally abused and was secluded to remain in the chair and was held in the chair by a staff member to prevent her from going to the bathroom. During an interview on 11/21/24 at 1:45 PM, the Administrator confirmed the resident was cognitive and had the right to make decisions on what she wanted to do and the resident was upset and angry that the staff confined her and kept her from going to the bathroom. She confirmed this violated her rights and that physical restraining of a resident is part of abuse and involuntary seclusion. On observation of the video with the Administrator on 11/20/24 at 1:40 PM, revealed on 10/30/24 at 6:01 PM, the resident was brought into the lobby. LPN #1 spoke to the resident at approximately 6:03 PM, then redirected her to the lobby in front of the TV at approximately 6:04 and 6:05 PM. At approximately 6:06 PM, a CNA took the resident to the restroom just outside the lobby area and returned to the lobby at approximately 6:14 PM. At approximately 6:20 PM, LPN #1 approached resident again and spoke to her and then about 6:21 LPN #1 redirected her back to the same area. At approximately 6:22 PM, Resident #1 began to roll herself backwards and LPN #1 approached and rolled her beside the exit area to B hall and the double doors were closed and LPN #1 appeared to speak with resident and touched her to keep her in place in her chair. At approximately 6:25 PM, RN #1 approached LPN #1 and resident and it appeared they talked and then RN #1 began to hold resident from behind. At 6:30 PM, while RN #1 was still holding resident, CNA #3 approached the resident and appeared to be speaking to the resident, RN #1, or both. At approximately 6:32 PM CNA #3 appeared to lay her hands over the top of Resident's hands and RN #1 released the resident. At approximately 6:33 PM, Emergency Medical Technicians arrived, and the resident was taken to the hospital by ambulance. The video verified the resident was not allowed to leave the lobby area by LPN #1 and then was held in her chair for almost eight (8) minutes by RN #1 and was not allowed to move from the area. The video verified what the witnesses had stated during their interviews to the State Agency (SA). The video did not have audio but from all the interviews and from the mannerisms of the staff in question it was determined there was yelling in part of this incident captured on the video footage. Record review of ER notes dated 10/30/24 revealed, .presents to the Emergency Department (ED) from the nursing facility due to aggression. Patient is alert and oriented times (x) 4 and states that she just wanted to go to the bathroom, and no one helped her. Record review of Resident #1's Admission Record revealed the facility admitted the resident on 1/7/21 with diagnoses that included Huntington's Disease. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/29/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Record review of Resident #2's Admission Record revealed the facility admitted the resident on 5/28/21. Record review of Resident #2's MDS with ARD of 11/8/24 revealed the resident had a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #3's Admission Record revealed the facility admitted the resident on 12/28/20. Record review of Resident #3's MDS with ARD of 9/24/24 revealed the resident had a BIMS score of 15 which indicated the resident was cognitively intact.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to report an allegation of abuse and involuntary seclusion within the time frame required for one (1) of three (3) allegations of abuse reviewed. Resident #1 Findings include: Record review of facility policy titled, Abuse, Neglect and Exploitation dated 3/17/23, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . During an interview with the Administrator on 11/20/24 at 9:15 AM, it was revealed that an allegation of abuse which occurred on 10/30/24 around 6:00 PM was reported to the Administrator by a resident on the morning of 10/31/24. The Administrator revealed this incident was investigated and was reported to the State Agency (SA) on 11/5/24 which did not meet the regulations requiring allegations of abuse to be reported within two (2) hours. She stated their investigation began on 10/31/24 and was substantiated for abuse and the employees involved were terminated. The Administrator confirmed that the facility had continued to investigate and gather statements from the witnesses and reported both nurses involved to the state board of nursing on 11/20/24. The Administrator stated that she was continuing to inservice staff on abuse and neglect and to notify her immediately if abuse or neglect was suspected and confirmed that the staff failed to do this initially. Interview with the Director of Nursing (DON) on 11/21/24 at 11:40 AM confirmed that when they were informed of the situation, they watched video, spoke with staff and residents, and investigation was initiated. The DON confirmed that the resident was physically restrained in her chair by another staff member which is a part of abuse. The DON stated that the video was only visual and had no auditory parts, but from interviews from the staff that witnessed the incident it was determined she was also verbally abused. She stated that the staff did not report this initially to her or the Administrator, but rather they were told by a resident the next morning about the incident that occurred. The DON confirmed that they waited until after the facility investigation was done and then reported it to the State Agency (SA) on 11/04/24 and she realized now that this should have been done in the time frame of 2 hours as required. On 11/21/24 at 1:45 PM the Administrator and the SA watched the video footage together and she confirmed this resident was cognitive, alert and had the right to make her own decisions on what she wants and that the staff restrained this resident and kept her from going to the bathroom and from the staff interviews gathered, she was also verbally abused by a staff member. This went against the resident's rights and physical restraining of a resident is part of abuse and the yelling and cussing and threatening to send her out gathered from interview was abusive as well. The Administrator stated that initially they just thought this was a customer service issue and not an abuse situation. Record review of Resident #1's Admission Record revealed the facility admitted the resident on 1/7/21 with diagnoses that included Huntington's Disease. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/29/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment.

Based on observation, record review, staff and resident interviews and facility policy review, the facility failed to develop a care plan for Resident #10 related to chronic pain for one (1) of 18 residents reviewed. Findings include: Record review of facility policy titled, Comprehensive Care Plans with revision date of 3/10/23, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also revealed, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being, During an interview on 9/30/24 at 10:50 AM, Resident #10 stated that she has swelling in her left leg and at times it caused her to have pain in this leg. Record review of Resident #10's Care Plan revealed no care plan for pain was developed for this resident who had a diagnosis of Chronic Pain Syndrome. An interview with Registered Nurse (RN) #1 on 9/30/24 at 10:55 AM, revealed the resident had swelling in her leg which caused pain. She stated Resident #10 received scheduled Tylenol and a fluid pill as needed (PRN) for the swelling. During an interview on 10/1/24 at 2:00 PM, the RN Supervisor revealed the resident has pain in her foot and leg occasionally which improved when elevated. She stated she received Tylenol two times a day which generally controlled her pain and also has an order for a cream to use as needed. An interview with the Minimum Data Set (MDS) Coordinator on 10/2/24 at 9:40 AM, revealed she was the person responsible for the development of care plans which provided the staff the information of the needed care and preferences of each resident. She confirmed the resident had a diagnosis of chronic pain syndrome and was receiving a scheduled analgesic medication for her pain and confirmed she failed to develop a care plan for this resident's pain. During an interview on 10/2/24 at 2:00 PM, the Director of Nursing (DON) acknowledged Resident #10 had a diagnosis of chronic pain syndrome and received a scheduled analgesic medication two times each day. She confirmed a care plan for pain was needed to inform the staff of care that was desired and needed and since this resident had pain, a pain care plan should have been developed and confirmed that the facility had failed to do this. Record review of Resident #10's Order Summary Report revealed an order for Biofreeze External Gel 4% to apply to hands topically every four hours as needed for arthritis pain, Diclofenac Sodium External Gel 1% to apply to affected areas topically every 12 hours as needed for pain related to arthropathy, Tylenol Extra Strength 500 mg - give one tablet two times a day related to chronic pain syndrome and Tylenol 325 mg give 2 tablets every four (4) hours as needed for pain/discomfort. Record review of Resident #10's Admission Record revealed the facility admitted her on 5/10/24 with diagnoses that included Erosive Osteoarthritis, Arthropathy, and Chronic Pain Syndrome. Record review of Resident #10's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on observation, staff and resident representative (RR) interview and facility policy review revealed the facility failed to ensure residents were treated with dignity and respect as evidence by staff members calling the residents by their last name only and failing to use a salutation for two (2) of 18 residents sampled during this survey. Resident #2 and Resident #39. Findings Include Record review of the facility policy review titled, Promoting/Maintaining Resident Dignity with a revision date of 10/2/23 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Resident #2 A phone interview on 9/30/24 at 11:20 AM, with Resident #2's Resident Representative (RR) revealed he has complained numerous times to the Director of Nurses (DON) and Administrator regarding issues with his mother. He revealed he complained most recently about the way the aides call her by her last name only and do not use a salutation and they take personal phone calls while in her room, during times when they are changing and cleaning her. He stated that a week ago when he tried to file that complaint, the DON told him he was just hard to get along with and confirmed that he has never heard back from the facility regarding a resolution to any of his complaints. An interview on 10/02/24 at 8:56 AM, with Certified Nurse's Assistant (CNA) #1 confirmed that she does call some of the residents by their last name only and can see now how that might be disrespectful to the resident by not using a salutation. An interview on 10/2/24 at 3:00 PM, with the DON and the Administrator who confirmed they knew that some residents were called by their last names only and can see how that could appear as a dignity issue. The Administrator revealed the staff have been trained to address the residents as Mr. or Mrs. and she wasn't sure why they were doing this. Record review of Resident #2's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident was severely cognitively impaired. 41878 Resident #39 During an observation on 9/30/24 at 2:30 PM, it was noted that Resident #39 was in his wheelchair sitting by a window in the dayroom and the resident had called out to CNA #1 for assistance. As CNA #1 was walking towards him, she stated, You can't get no sugar, (resident's last name). Then she turned and walked away shaking her head and said, (resident's last name, resident's last name). An interview with CNA #1 on 10/2/24 at 9:00 AM, confirmed she called Resident #39 by his last name and acknowledged this could be seen as disrespectful since he had not told her that he preferred to be called by only his last name. During an observation and interview on 10/2/24 at 9:30 AM, CNA #2 was observed to be in the dayroom with Resident #39 and said, Hey (resident's last name). During the interview, CNA #2 acknowledged she called him by only his last name and thought he preferred that name since that was what everyone called him and she was not sure if he liked being called that or not. During an observation and attempted interview with Resident #39 on 10/2/24 at 1:55 PM, when asked his name and what he preferred to be called, it sounded like he said his first and last name together to both questions. Resident was difficult to interview since he had a BIMS of 4 which indicated he had severe cognitive impairment. During an interview on 10/2/24 at 3:00 PM, the DON and the Administrator confirmed they were aware that some residents were called by their last names only and could see how that could appear as a being disrespectful. The Administrator revealed that the staff know they should call them Mr. or Mrs. The record review of Resident #39's Admission Record revealed the facility admitted the resident on 10/30/23. Record review of Resident #39's MDS with ARD of 9/20/24, revealed a Brief Interview for BIMS of 4 which indicated the resident had a severe cognitive impairment.

Based on resident representative (RR) and staff interview, record review and facility policy review the facility failed to ensure a resident representative's grievance was resolved for one (1) of 18 residents reviewed, Resident #2. Findings Include Record review of the facility policy titled, Resident and Family Grievances with a revision date of 10/1/23 revealed under, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines .#12. The facility will make prompt efforts to resolve grievances. On 9/30/24 at 11:20 AM, during a phone interview with Resident #2's RR revealed he has complained numerous times to the Director of Nurses (DON) and Administrator regarding his mother. He revealed he complained most recently about the way the aides call her by her last name only and that they take personal phone calls in her room, while they are changing and cleaning her. He stated that a week ago when he tried to file that complaint, the DON told him he was just hard to get along with and confirmed that he has never heard back from the facility regarding a resolution to any of his complaints. An interview on 10/01/24 at 3:18 PM, with the DON and the Administrator confirmed that Resident #2's RR had made numerous complaints. The Administrator confirmed that they have never written any of his complaints up formally and included them on the grievance log. She stated that she usually just follows up and jots notes down and then calls him back. The DON stated we have not heard back from him, so we thought everything was ok. They both admitted that he came to the last care plan meeting a couple of weeks ago and complained about an aid cussing and talking loudly outside his mother's room. The Administrator confirmed she should have written these up so that they would have documentation of the grievances and what was done to resolve it and provided follow up back to the RR, but they had failed to do so. An interview on 10/02/24 at 2:53 PM, with Social Services confirmed she was aware that Resident #2's son had complained about stuff in the past. She stated that he always goes to either the DON or Administrator, but she had never been told to write it up as a formal grievance. Record review of the Grievance Summary Log for the past six (6) months revealed there was one grievance documented for Resident #2 and that was related to broken glasses and revealed no other grievances. Record review of Resident #2's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident was severely cognitively impaired.

Based on record review, staff interview, and facility policy review, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) Assessment for one (1) of 21 residents reviewed for MDS assessments. Resident #33 Findings include: A review of the facility policy titled Resident Assessment-RAI (Resident Assessment Instrument) with a revision date of 3/10/24 revealed, This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS. A record review of Resident #33's Admission Record revealed an admitted [DATE] and a discharge date of [DATE]. A record review of the Discharge Summary revealed Resident #33 was discharged home on 5/2/24. During an interview on 10/02/24 at 2:45 PM, the MDS Coordinator confirmed that Resident #33 was admitted to the facility on [DATE] and discharged home on 5/2/24. She revealed that she had, in error, omitted entering and transmitting the discharge MDS assessment for the Assessment Reference Date (ARD) of 5/2/24, which resulted in the assessment being not completed and transmitted over 120 days late.

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from accidents during a lift transfer by using the inappropriate lift for one (1) of 19 residents reviewed for investigations. Resident #53 Findings include: Record review of facility policy titled Modified Lifting Policy undated, revealed, (Proper name of nursing home) will provide a safe work environment for patient care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and patient injury. The policy also revealed, 1. Staff will follow the documented lifting protocol deemed appropriate for each resident. 2. Staff will utilize proper transfer/lifting/assistance procedures for each resident to include use of mechanical transfer devices or other lifting equipment or devices and by applying proper body mechanics. Record review of Physician's Order dated 6/16/23, revealed an order for x-ray of left shoulder related to acute pain. Record review of Patient Results of left shoulder x-ray from local hospital dated 6/16/23, revealed, Findings: Bone - There is a nondisplaced fracture involving the neck of the left humerus. There is no definite dislocation identified. There is mild angulation of the humeral head laterally. Intact AC joint. Record review of hospital records dated 6/16/23, revealed, [AGE] year-old female who presents from local nursing facility due to a humeral fracture. Patient says she was being helped to bed and she may have slipped somewhat but there is no significant fall or trauma. She has pain to her left shoulder with any attempts at movement. Denies any other complaints. Hospital records also revealed the aftercare instructions as Humerus Fracture, treated with immobilization. An interview on 8/8/23 at 11:55 AM, with Resident #53 revealed the staff was assisting her from her chair to her bed and their feet got twisted and she fell . Stated she was taken to the hospital due to a broken left arm but did not have to have surgery. She stated she wore a sling while it healed. An interview on 8/9/23 at 3:00 PM, with Resident #53 revealed she did not fall to the floor with this incident, but when she was on the stand-up lift, she stumbled when transferring to the bed. She stated she had pain in her arm, and she was given Tylenol. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 8/10/23 at 8:45 AM, revealed the resident was care planned for a full body total lift for transfers and it was changed to a sit to stand lift, and after her shoulder incident, she was changed back to a total lift. She printed off the previous care plans and noted on the care plans, only the [NAME] Lift (full body lift) was listed for transfers. She stated that the Vera Lift (sit to stand lift) had to be on the care plan at some point since she could see a resolved date for the Vera Lift after the resident's incident. She stated she is unable to locate the care plan that listed the sit-to-stand lift in the system. An interview with the Director of Nursing (DON) on 8/10/23 at 9:10 AM, revealed the resident was being transferred from her chair to the bed in a sit-to-stand lift by two (2) staff members and when the resident was placed in bed, she complained of her left arm and stated she had pain. She confirmed she investigated the incident and sent the information into the State Agency (SA) and from what she was able to determine the resident had a diagnosis of osteoporosis and it could have been a spontaneous type fracture. She was unable to determine any other cause of the injury. She stated the full body lift was now being used, but at that time she had been assessed for a sit-to-stand lift. When asked about that the care plan indicated that the full body lift was to be used for transfers, she responded that she is uncertain why that one is listed since she had been using the sit-to-stand lift and was able to bear some weight and was doing well with transfers. She pulled the assessment dated [DATE] and it revealed the resident required a full body lift/[NAME] Lift or other full mechanical lift and not a sit to stand lift. She stated she looked for another assessment or documentation for the change in lift type, but she was unable to find where another assessment was done. She stated the residents are assessed annually for the type of lift required. She confirmed the most recent assessment determined the need for the total lift, and at the time of the resident's injury, the wrong lift was used for her transfer. An interview with Minimum Data Set (MDS) Registered Nurse (RN) and the DON on 8/10/23 at 10:30 AM, revealed that after reviewing the Care Plan and Kardex for this resident, she had determined that at some point between 4/15/23 and 5/15/23, the Vera Lift (sit to stand lift) was added to the care plan since it shows up on the Kardex. She stated the information on the Kardex comes from the Care Plan, so it had to be added to the Care Plan for it to trigger on the Kardex. She stated from what can be determined on the Kardex/Care Plan, it appears that the sit-to-stand lift was added on 5/5/23 and removed on 6/16/23 (after the incident), and the full lift was put in on 1/5/22 and was never removed. The MDS RN stated she does not know why she added this lift, and it could have been a system error or improperly entered information. The DON stated she is not sure how far back the use of the sit/stand lift was being used, but she knew it was being used for a while before the injury occurred. The DON confirmed the most recent assessment was for a total lift, so, the total lift should have been the one used. She stated when the lift was changed from the full lift to the sit-to-stand lift, no assessment was done to ensure safety for the resident. She confirmed that prior to changing a resident to a more independent type of transfer device, an assessment should have been done to ensure the resident would be safe using this for transfers and the facility failed to do this assessment. An interview with Certified Nursing Assistant (CNA) #9 on 8/10/23 at 10:40 AM, revealed she had worked at the facility for about one and a half years and has worked with this resident often. She stated the staff use the Kardex to determine what lift to use, and this resident had the sit to stand lift listed. She stated that the resident was now using the full body lift for transfers. A phone interview with CNA #8 on 8/10/23 at 10:45 AM, revealed she was working with the resident when this incident occurred. She stated this was the first time she had worked with this resident. She stated she and another CNA used the sit-to-stand lift to transfer the resident from the chair to the bed that evening. She stated she wondered why the stand-up lift was being used since her left arm was weak. She stated they placed the resident in her bed and after she was lying down, the resident stated her left arm was hurting and would like some Tylenol. The nurse gave Tylenol, and her pain was eased. She stated she was unaware of anything that occurred during the transfer that would have caused an injury, but the next day an x-ray was done and showed a fracture. She stated the facility had trained her on lift use and she had done this job for [AGE] years. She confirmed that the resident's Kardex showed to use a sit-to-stand lift. During an interview on 8/10/23 at 10:40 AM, the Administrator confirmed the facility failed to use the lift the resident was assessed for. She confirmed the resident had an injury but could not confirm it was from the lift. Record review of Transfer/Lift assessment dated [DATE], for Resident #53 revealed, Instructions - An assessment should be made prior to each task if the resident has a varying level of ability due to medical reasons, fatigue, medications, etc. When in doubt, assume the patient cannot assist in the transfer/repositioning. Section A of assessment revealed, Ability to assist with transfer/positioning - The resident's level of assistance can best be described as - Dependent: resident requires more than 50% assistance by staff or is unpredictable in the amount of assistance offered. Section B of assessment revealed, Weight Bearing - Can the resident bear weight? No. Section C of the assessment revealed, Upper Extremity Strength - Does the resident have upper extremity strength to support his/her weight during transfer? No. Section G of the assessment revealed, Care Plan - After completing assessment, indicate transfer/repositioning needs below: How does the patient transfer to and from bed-chair, chair toilet, chair-chair, etc. - [NAME] Lift or other full mechanical lift - one or two person assist. Record review of Care Plan History revealed on 1/5/22, the [NAME] (full body) lift was listed. On 5/5/23, the Vera (sit-to-stand lift) was listed. On 6/16/20, the Vera Lift was resolved. Record review of Care Plan with review start date of 3/27/23, revealed the resident needed assistance with Activities of Daily Living (ADL) care and for transfers she was listed as Transfer: the resident is totally dependent on 2 staff for transferring and, the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Kardex Report for each month from 12/15/23 - 4/15/23, revealed, Transfer: the resident is totally dependent on 2 staff for transferring and Transferring: the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Kardex Report dated 5/15/23 and 6/15/23 revealed, Transfer: the resident is totally dependent on 2 staff for transferring and Transferring: the resident requires Mechanical Lift (Vera) with 1 or 2 staff assistance for transfers. Record review of Care Plan with review start date of 6/30/23, revealed the resident needed assistance with Activities of Daily Living (ADL) care and for transfers she was listed as Transfer: the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Electronic Medication Administration Record for June 2023 revealed the resident received the nightly dose of Tylenol on 6/15/23. The resident received the as needed dose of Tylenol on 6/16/23 at 5:11 AM and on 6/17/23 at 2:36 AM. The resident received her night dose of Tylenol each night but did not receive the as needed Tylenol any other time during the month of June. Record review of Resident #53's Admission Record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Wedge Compression Fracture of first and second Lumbar Vertebra, Hypertension, Cerebrovascular Disease, Muscle Weakness, Moderate Protein-Calorie Malnutrition, and Paroxysmal Atrial Fibrillation. Record review of Resident #53's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/20/23, revealed a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident is moderately cognitively impaired.

Based on staff interview, record review and facility policy review the facility failed to develop and implement a person-centered care plan for residents requiring assistance with Activities of Daily Living (ADL) (Residents #4, #6, #27, and #35), a resident requiring assistance with transfers using a lift (Resident #53), a resident with a diagnosis of Post-Traumatic Stress Disorder (Resident #47), and a resident requiring dental services and ADLs, (Resident #34) for seven (7) of 19 resident care plans reviewed. Findings included: Review of the facility policy titled, Comprehensive Care Plans with a revision date of 3/10/23, revealed, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #6 Record review of Resident #6's care plan revealed the resident's need for assistance with ADL's related to Hemiplegia resulting from a car accident. Interventions related to the care plan included fingernail care daily (if needed) and to check nail length and trim and clean as necessary. Record review of care plan revealed there were no interventions in place for shaving. On 8/8/23 at 2:30 PM, an observation and interview with Resident #6 revealed long and bushy facial hair on his face, chin, mustache, under the chin and jaws, on lower cheeks, and neck. He stated he liked having a mustache and a goatee, but he prefers to be clean-shaven on the rest of his face and neck. His fingernails were noted to be long, approximately 1/3 inch from the nailbed and he stated he would like for his fingernails and toenails to be trimmed since they were too long. He stated he had mentioned these things to someone on staff, but he was unsure who that was and stated he needed the staff's assistance at this time, but hoped he could eventually do these things independently. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 8/9/23 at 4:10 PM, stated the care plan should reflect the needs of the residents and the care on the care plan is transferred to the Kardex so the staff will know what care is required. She confirmed the facility failed to follow the care plan for the fingernail care daily (as needed) and to check nail length and trim and clean nails as necessary. The facility also failed to develop a person-centered care plan for the resident's preference for mustache/goatee and otherwise a clean-shaven face. An interview with the Director of Nursing (DON) on 8/10/23 at 9:40 AM, revealed the resident is cognitive and able to make his requests known. She stated his care plan should be reflective of his preferences and his preferences should be honored and confirmed the facility failed to do that when he was not groomed the way he preferred. Record review of Resident #6's Admission Record revealed the resident was admitted to the facility on [DATE]. His diagnoses included Hemiplegia, Personal History of Traumatic Brain Injury, Lesion of Ulnar Nerve, Left Upper Limb, Chronic Pain, Unilateral Primary Osteoarthritis of Left Knee. Record review of MDS with Assessment Reference Date (ARD) of 5/25/23, revealed a Brief Interview of Mental Status (BIMS) of 15 indicating resident was cognitively intact. Resident #53 Record review of Care Plan with an onset date of 3/27/23, revealed the resident needed assistance with ADL care and for transfers she was listed as Transfer: the resident is totally dependent on 2 (two) staff for transferring and the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Care Plan with review start date of 6/30/23, revealed the resident needed assistance with ADL care and for transfers she was listed as Transfer: the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Physician's Order dated 6/16/23, revealed an order for x-ray of left shoulder related to acute pain. Record review of Patient Results of left shoulder x-ray from local hospital dated 6/16/23, revealed, Findings: Bone - There is a nondisplaced fracture involving the neck of the left humerus. There is no definite dislocation identified. There is mild angulation of the humeral head laterally. Intact AC joint. The MDS Registered Nurse (RN) revealed in an interview on 8/10/23 at 8:45 AM, the resident was care planned for a total lift for transfers and it was changed to a sit to stand lift, and after her shoulder incident, she was changed back to a total lift. She printed off the previous care plans and noted on the care plans, only the [NAME] Lift (full body lift) was listed for transfers. She stated that the Vera Lift (sit to stand lift) had to be on the care plan at some point since she could see a resolved date for the Vera Lift after the resident's incident. She stated she is unable to locate the care plan that listed the sit-to-stand lift in the system, but she can see that it was resolved. An interview with the Director of Nursing (DON) on 8/10/23 at 9:10 AM, revealed the full body lift was currently being used, but for a period the sit-to-stand lift was being used. When asked about the care plan indicating the full body lift was to be used for transfers, she responded that she is uncertain why that one is listed since she had been using the sit-to-stand lift and was able to bear some weight and was doing well with transfers. She pulled the most recent lift assessment dated [DATE] and it revealed the resident required a [NAME] Lift or other full mechanical lift which is a full body lift and not a sit to stand lift. She stated the residents are assessed annually for the type of lift required. She confirmed the most recent assessment determined the need for the total lift, and at the time of the resident's injury, the wrong lift was used for her transfer. She confirmed the care plan was inaccurately developed for a brief time frame of the resident's stay and it was not being implemented properly since only a full body lift should have been used according to this resident's lift assessment. During an interview with MDS RN and DON on 8/10/23 at 10:30 AM, the MDS RN revealed that after reviewing the Care Plan and Kardex for this resident, she had determined that at some point between 4/15/23 and 5/15/23, the Vera Lift (sit to stand lift) was added to the care plan since it shows up on the Kardex. She stated the information on the Kardex comes from the Care Plan, so it had to be added to the Care Plan for it to trigger on the Kardex. She stated from what can be determined on the Kardex/Care Plan, it appears that the sit-to-stand lift was added on 5/5/23 and removed on 6/16/23 (after the incident involving the fracture of the left humerus), and the full lift was put in on 1/5/22 and was never removed. The DON confirmed the most recent assessment was for a total lift, so, the total lift should have been the one used. Record review of Resident #53's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses included Wedge Compression Fracture of first and second Lumbar Vertebra, Hypertension, Cerebrovascular Disease, Muscle Weakness, Moderate Protein-Calorie Malnutrition, and Paroxysmal Atrial Fibrillation. Record review of Resident #53's MDS with ARD of 6/20/23, revealed a BIMS of nine (9) indicating the resident is mildly cognitively impaired. Resident #4 Record review of Resident #4's care plans revealed a care plan indicating the resident needed assistance with bathing. An observation on 08/08/23 at 11:25 AM revealed that Resident #4 was sitting up in her wheelchair in the dining area with approximately 10 gray hairs in random areas of the chin and cheeks that were approximately 1 inch long. In an observation and interview on 8/8/23 at 4:30 PM with Certified Nurse Assistant (CNA) #11 confirmed that Resident #4 had several long hairs on her chin and cheeks that needed to be removed. She revealed she is unsure if she is supposed to shave the resident or use a tweezer to remove the hairs. She revealed that facial hair removal should occur when the resident gets a bath and that she does not recall being told which way to remove facial hair on female residents and has not ask, but admitted it needed to be removed. An interview on 8/9/23 at 4:20 PM with the DON confirmed that females should have facial hair removed during their bath unless they refuse, and that CNA's have been taught that. She confirmed that the residents care plan regarding ADL assistance had not been implemented properly. Record review of Resident #4's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Dementia and Need for Assistance with Personal Care. Record review of Resident #4's MDS with an ARD of 5/17/23 revealed in Section C a BIMS score of 04, which indicated the resident is severely cognitively impaired. This review revealed in Section G that the resident needed assistance from staff to complete Personal Hygiene and 'Bathing. Resident #47 Record review of Resident #47's medical diagnoses revealed an admitting diagnosis of Post Traumatic Stress Disorder (PTSD). Record review of Resident #47's care plans revealed the resident did not have a care plan regarding PTSD. During an interview on 8/9/23 at 11:45 AM with the MDS RN revealed that she is responsible for doing most all the care plans. She revealed that she discovered a few weeks ago that the resident had a diagnosis of PTSD even though she had been the one to code that diagnosis on the resident's MDS. She confirmed that she realized it was on her admitting diagnoses and stated, but that was just a history. She confirmed that the resident did not have a care plan regarding PTSD but should have and that she did not actually do this resident's care plans but sees now that she should have gone back and checked the record. When asked if she knew what triggered the resident's PTSD, she stated No. She confirmed that care plans direct care to make sure the resident gets all the care they need. When asked if a care plan would have helped the staff to know what triggers the resident she stated, Yes. On 8/9/23 at 1:36 PM, interview with the Licensed Social Worker (LSW) revealed that a care plan lays out the specific care provided for the residents. She confirmed that the resident needed a PTSD care plan. On 8/9/23 at 2:18 PM, interview with the DON stated that she did not realize that the resident had a diagnosis of PTSD on admission to the facility and confirmed that the resident should have had a care plan to address this diagnosis. Record review of Resident #47's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included PTSD. Record review of Resident #47's MDS with an ARD of 5/4/23 revealed in Section I that the resident had a diagnosis of PTSD and in Section C a BIMS of 11, which indicated the resident is moderately cognitively impaired. Resident #27 Record review of Resident #27's care plan revealed the Resident needs assistance with ADL related to (r/t) Dementia and physical limitations. Fingernail Care Daily (if needed) and (Resident's name) is to be gotten out of bed daily and dressed and brought out of her room. An observation on 08/08/23 at 10:50 AM, revealed Resident #27 was lying in bed with fingernails on bilateral hands were approximately one-half (1/2) inch long and jagged past the fingertips and a brown substance was under the nails. An observation and interview on 08/08/23 at 3:10 PM the DON confirmed that the nails were long and jagged and had a brown substance under her nails and it appeared as if they hadn't been cleaned in a while. In an interview on 08/09/23 at 4:00 PM with RN #1 revealed the resident has a special wheelchair for her, but we don't get her up every day, it's usually about two or three times a week. The SA inquired about Resident #27's ADL care plan and RN #1 confirmed after pulling the CNA Kardex that the resident is to be gotten out of bed daily and dressed and brought out of the room. RN #1 revealed I didn't know that was in her plan of care. RN #1 revealed the aides must click on it every day and document whether she was gotten up or not. An interview on 08/09/23 at 4:15 PM, with CNA #3 confirmed the plan of care was not being followed regarding getting the resident up daily. She revealed I didn't know it was in there. An interview on 08/09/23 at 4:35 PM, the DON confirmed Resident #27's care plan regarding nail care and getting the resident out of bed daily was not followed and it should have been. She revealed she wasn't aware of Resident #27 being out of bed daily but confirmed it was on the CNA's Kardex. An interview on 08/10/23 at 10:30 AM, with CNA #4 revealed she did document that she got Resident #27 up yesterday, but I documented in error and did not get her up. She revealed she wasn't aware that the resident needed to be up every day but confirmed that it did show up on the Kardex to be signed off daily. An interview on 08/10/23 at 10:40 AM, with CNA #5 revealed I think the last time she got up was sometime last week we haven't been getting her up every day. A record review of Resident #27's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that include Metabolic Encephalopathy, Unspecified Dementia, Peripheral Vascular Disease, and Generalized Anxiety Disorder. Record review of the MDS with an ARD of 07/20/23, revealed the resident is rarely/never understood which indicated the resident has severe cognitive impairment. Resident #34 A record review of the care plan for Resident #34, date initiated 7/10/23, revealed Focus: The resident needs assistance with ADL r/t (related to ) stroke .Interventions: BATHING/SHOWERING: The resident is totally dependent on 1 staff for bathing. Check nail length and trim and clean as necessary .PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance of 1 staff with personal hygiene and oral care . An observation on 8/08/23 at 2:18 PM, of Resident # 34 revealed long nails that measured approximately 3/8 inch in length from the tip of the fingers, with a brown substance underneath and raised brown patches on his tongue. An overpowering putrid (rotten) odor was present inside the room. The residents' teeth were observed to be in bad condition, with dark brown/black color to all the teeth and red, inflamed gums. An observation and interview with the DON on 8/08/23 at 3:20 PM, confirmed that Resident #34 had long dirty fingers nails, and raised brown patches on his tongue and it appeared that he had not received oral or nail care lately. An interview on 8/10/23 at 9:45 AM, with the MDS nurse confirmed that there was not a care plan developed for the resident's dental condition and that the staff was not aware of the problem with his teeth. She confirmed that the staff did not follow the care plan for cleaning and trimming the residents' nails and stated, If it's on there to be done, they are supposed to do it. She acknowledged nail care was part of the standard care the aides should provide. Record review of the Order Summary Report revealed an order dated 6/21/23, NPO (nothing by mouth) diet tube feeding texture related to Cerebral Infarction, Dysphagia. Also revealed an order dated 6/21/23, Enteral Feed Order every day and night shift Clean mouth with swabs. Record review of the Admission Record revealed Resident # 34 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified Dementia, Dysphagia, Hemiplegia and Hemiparesis Affecting Right Dominant Side and Gastrostomy Status. Review of the MDS with an ARD date of 6/27/23 revealed under section G, Resident #34 required total dependence for personal hygiene. Resident #35 Record review of Resident #35's care plans revealed, under, BATHING/SHOWERING: The resident requires extensive assist from 1 staff with bathing. Check nail length and trim and clean as necessary. HE HAS REQUESTED TO HAVE A SHOWER DAILY. An observation and interview on 08/08/23 at 11:07 AM, revealed Resident #35 stated that the facility was not bathing him but once a week. The resident revealed his bath day was yesterday, but he did not get one. The resident stated, I want my nails cut too. Observed long nails on both hands that measured approximately 3/8 inch in length. An observation and interview on 8/8/23 at 3:25 PM, with RN #2 confirmed that Resident #35 had long nails and it could cause skin injury. RN # 2 asked Resident #35 if he got a shower yesterday, and the resident replied, No, I didn't. She revealed that the resident was a diabetic, so she would have to cut his nails. An interview with the DON on 8/09/23 at 11:30 AM, revealed she had spoken with the aide assigned to the resident to give him a shower on Monday. She confirmed that the aide did not give the resident a shower. An interview with the DON on 8/9/23 at 11:32 AM, revealed she was not aware that Resident #35 was care planned for a daily shower. She stated, I didn't know. She confirmed that the resident had not been receiving daily showers routinely and agreed that the care plan was not followed. An interview with the MDS Nurse on 8/10/23 at 9:45 AM, revealed that the staff did not follow the care plan by not giving the resident a daily shower or provide needed nail care. She confirmed that the ADL had not applicable (N/A) documented, which revealed a daily shower had not been done. Record review of the August ADL bathing task for Resident #35 revealed under 8/01/23, 8/03/23, 8/04/23, 8/06/27, 8/07/23, and 8/08/23, Not Applicable (N/A) was checked indicating the resident did not receive a daily shower. Record review of the Admission Record revealed that Resident #35 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus, Major Depressive Disorder, Gastro-Esophageal Reflux Disease, Acquired Absence of Left Leg Below Knee and Acquired Absence of Right Leg Above Knee. Record review of the MDS with an ARD of 7/12/23 revealed under section C a BIMS score of 10, indicating Resident # 35 is moderately cognitively impaired. Also revealed under section G, the resident requires one-person physical assist with personal hygiene and is totally dependent for bathing.

Based on observation, staff interview, record review and facility policy review the facility failed to provide necessary dental services to meet a residents dental needs for one (1) of 19 residents reviewed. Resident #34 Findings Include: Record review of the facility policy titled Dental Services with a revision date of 3/14/23 revealed, Policy: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care Policy Explanation and Compliance Guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment processes and are addressed in each resident's plan pf care. a. Oral/dental status shall be documented according to assessment findings. c. Referrals to dietician, speech therapist, physician, or dental provider shall be made as appropriate . On 8/08/23 at 2:18 PM, an observation of Resident # 34's room revealed he was observed lying in bed with his mouth open and eyes closed. An overpowering putrid (rotten) odor was present inside the room. The resident's tongue was observed with raised brown patches. The residents' teeth were observed to be in bad condition, with dark brown/black color to all the visible teeth and red, inflamed gums were observed. On 8/08/23 at 2:55 PM, an observation and interview with Nurse Assistant (NA) #2 confirmed that she smelled an odor upon entering the Resident's room and that there had been bad odor coming from his mouth since he was admitted to the facility a couple of months ago. She revealed that when he came to the facility, he had old food (debris) that was caked on his teeth. She stated, His lips have been chapped like that since he came from the other place. On 8/08/23 at 3:10 PM, an observation and interview with Registered Nurse (RN) # 1 confirmed that there was a foul odor in Resident # 34's room and stated, It's coming from his teeth. She revealed that the resident came from another facility and had an excessive amount of buildup on his teeth. RN #1 confirmed that the facility has not had the resident assessed for dental services that she knows of and she confirmed that she has not informed the physician of the odor or the condition of the resident's teeth. On 8/08/23 at 3:20 PM, during an observation and interview with the Director of Nursing (DON) , confirmed that the resident had come to the facility with his teeth and mouth in that condition and stated the odor was coming from his teeth. Registered Nurse (RN) # 1 revealed during an interview on 8/09/23 at 8:35 AM, that the aide had tried to brush Resident #34's teeth this morning and his gums began bleeding, and the resident became agitated and upset. On 8/09/23 at 4:00 PM, an interview with the DON confirmed after record review that the facility had not attempted to make Resident # 34 a dental appointment. She stated, No, we have not. She revealed that the resident came to the facility with his teeth in bad condition. She revealed that the facility used to have a dentist who came out to the facility, but no longer does. An interview with the Administrator (ADM) on 8/09/23 at 4:30 PM, revealed they have not tried to get Resident #34 a dental appointment. She revealed she was just made aware of the situation yesterday and stated, Naturally, we'll get that done for him. On 8/09/23 at 8:30 PM, an interview with Resident #34's Resident Representative (RR) via telephone, revealed she had discussed with the staff at the facility several times about getting some dental help for him. She stated, I told them to get his teeth extracted, if that's what it took. She revealed she had a conversation with the Social Worker (SW) on admission and was assured that he would get the dental care he needed. In an observation of Resident #34's teeth with the DON on 8/10/23 at 8:39 AM, confirmed the only actions taken by the facility since the resident was admitted was mouth care. She revealed that the facility was unable to look and determine what was going on with his teeth and revealed that the resident was a mouth breather and had an order for nothing by mouth (NPO) which causes his mouth to be drier. The DON described the resident's teeth as, dark buildup at the base of all teeth but stated she was unable to state that his teeth were decaying. She revealed that the resident's teeth were worse than that when he arrived at the facility. She confirmed that she did not see any broken or missing teeth. The DON described the resident's lower gums as Raw and stated, They probably just cleaned them, so they are irritated. She revealed that they have not made the physician aware of the oral/dental condition, and she stated, No, we have not made him aware, but he had assessed him. She revealed that the resident had not expressed pain associated with his teeth. The DON did not provide any documentation to support the residents' oral/dental status to the SA. On 8/10/23 at 8:50 AM, an interview with the Social Worker (SW) revealed that the resident was admitted from another facility and during her admission assessment with the RR dental care was never discussed. She revealed that the residents' Supplemental Security Income (SSI) does not pay for the dental company that the facility will be in contract with for dental care. Record review of Resident # 34's Progress Notes: dated 6/21/23 through 8/10/23 revealed no documentation regarding the residents' oral/dental concerns. Record review of Resident # 34's Nursing Admission Screening/History dated 6/21/23 revealed under, 6. MOUTH none of the boxes were checked to describe the resident's oral condition or history. Record review of the Admission Record revealed Resident #34 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified Dementia, Dysphagia, Hemiplegia and Hemiparesis Affecting Right Dominant Side and Gastrostomy Status. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/23 revealed under section L, None of the above were present which indicated Resident # 34 did not have any oral/dental status concerns. Also revealed under section C a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident is severely cognitively impaired.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to prevent neglect by failing to provide goods and services to a resident to ensure that the resident received the necessary Activities of Daily Living (ADL) and oral care for one (1) of 17 residents sampled. Resident #34. Findings Include: Record review of the facility policy titled Abuse, Neglect and Exploitation undated revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Policy Explanation and Compliance Guidelines: . 2. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . 6. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . An observation on 8/08/23 at 2:18 PM, of Resident # 34's room revealed the door was closed. The Survey Agent (SA) knocked and entered the resident's room, where he was observed lying in bed with his mouth open and eyes closed. An overpowering putrid (rotten) odor was present inside the room. The resident's tongue was observed with raised brown patches. The resident's teeth were observed to be in bad condition, with dark brown/black color to all teeth and red, inflamed gums. The resident's lower lip was raw, dry, and cracked with dried bloody patches. Long facial hair measured approximately 1/4 inch in length. The resident's nails were long, measuring approximately 3/8 inch in length from the tip of the fingers, with a brown substance underneath all the nails. The resident aroused to verbal stimuli and tried to communicate, but speech was low, unclear, and garbled. An observation and interview on 8/08/23 at 2:55 PM, with Nurse Assistant (NA) # 2 revealed she was working along with Certified Nurse Aide (CNA) # 1 to care for Resident #34. NA # 2 confirmed that she smelled an odor when she entered the resident's room and stated, Mm-hmm, it smells like body odor. She revealed that she had washed the resident up today and had put on deodorant but did not give him a complete bath. She confirmed that she had not shaved him and stated, I was scared to do that. She revealed that Resident # 34 had a bad odor coming from his mouth since he was admitted to the facility a couple of months ago. She revealed that when he came to the facility, he had old food (debris) that was caked on his teeth and stated, His lips have been chapped like that since he came from the other place. She revealed that she had been applying baby oil to the resident's lips because his family had requested her to do that, but she had not applied anything on his lips today. An observation and interview on 8/08/23 at 3:06 PM, with Certified Nurse Aide (CNA) # 1 revealed that the aides do not perform oral care for the residents with tube feedings and revealed that the nurses do it. She confirmed that they had not performed oral hygiene for Resident #34 today. An observation and interview on 8/08/23 at 3:10 PM, with Registered Nurse (RN) #1 confirmed that there was a foul odor in Resident # 34's room and stated, It's coming from his teeth. She revealed that they have worked on getting his teeth cleaner. She revealed that the resident came from another facility and had an excessive amount of buildup on his teeth. She revealed that the nurses and aides are both responsible for oral care on the resident and that oral care was part of the daily care that was supposed to be provided for the resident. RN #1 confirmed that the resident had raised brown patches on his tongue and a cracked lower lip with patchy areas of dried blood. She revealed that the aides should be using a lip moisturizer instead of baby oil to hydrate the lips. She confirmed that the resident's nails were long and dirty and stated, The aides can cut and clean the nails as long as the resident is not a diabetic, and he is not. She confirmed that the resident had long facial hair and stated, Yes, he is supposed to be shaved with his bath. The Survey Agent (SA) inquired who would be responsible for ensuring that all the needed care was provided for Resident #34, and she replied, Well, I guess that would be me. An observation and interview with the Director of Nursing (DON) on 8/08/23 at 3:20 PM, confirmed that Resident #34 had not been shaved, had long dirty fingers nails, and had a cracked lower lip with patchy areas of dried blood and raised brown patches to his tongue. She revealed that the aides and nurses are both responsible for the oral care and that the aides should be using a lip moisturizer on his lips, and he should be shaved daily. She revealed that the aides are responsible for cleaning the resident's nails and can cut them if the resident was not a diabetic. The DON revealed that the resident had come to the facility with his teeth and mouth in that condition and stated the odor was coming from his teeth. She confirmed that the resident had an excessive amount of buildup on his teeth. An interview on 8/09/23 at 8:35 AM, with Registered Nurse (RN) # 1 revealed that the aide had tried to brush Resident # 34's teeth this morning and his gums began bleeding, and the resident became agitated and upset. An interview with the Director of Nursing (DON) on 8/09/23 at 4:00 PM, revealed that the facility had not attempted to make Resident # 34 a dental appointment. She stated, No, we have not. She revealed that the resident came to the facility with his teeth in bad condition and stated that the facility used to have a dentist who came out to the facility, but no longer does. An interview with the Administrator (ADM) on 8/09/23 at 4:30 PM, revealed that it was the responsibility of the aides and the nurses to do oral care for Resident #34. She confirmed that the resident should be shaved, nails should be cleaned and trimmed, and the nurse should ensure that all the care was done. She stated, It is a concern. She revealed that they have not made the resident a dental appointment and revealed she was made aware of the situation yesterday with his teeth and the odor. An interview with Resident #34's Resident Representative (RR) on 8/09/23 at 8:30 PM, via telephone, revealed that she visited Resident #34 a couple of times a week. She revealed that she had witnessed a lack of oral hygiene and that she had discussed with the staff about getting some dental help for him. She stated, I told them to get his teeth extracted, if that's what it took. She revealed that she had a conversation with the Social Worker (SW) on admission and was assured that he would get the dental care needed. An observation of Resident #34's teeth with the Director of Nursing (DON) on 8/10/23 at 8:39 AM, confirmed the only actions taken by the facility since the resident was admitted was mouth care. She revealed that the facility was unable to look and determine what was going on with his teeth and revealed that the resident was a mouth breather and had an order for nothing by mouth (NPO) which caused his mouth to be drier. The DON described the resident's teeth as, Dark with dark buildup at the base of all his teeth but stated she was unable to state that his teeth were decaying. She revealed that she did not see any broken or missing teeth. The DON described the resident's lower gums as Raw and stated, They probably just cleaned them, so they are irritated. She revealed that they have not made the physician aware of the oral/dental condition and stated, No, we have not made him aware, but he had assessed him. The Survey Agent (SA) inquired if she could provide documentation to support the resident's dental status, and she replied, It should be there. The DON did not provide any documentation to support the residents' oral/dental status to the SA. An interview with the Social Worker (SW) on 8/10/23 at 8:50 AM, revealed that the resident was admitted from another facility and stated that during her admission assessment with the RR that dental care was never discussed. She revealed that the residents' Supplemental Security Income (SSI) does not pay for the dental company that the facility will be in contract with for dental care. Record review of the Order Summary Report revealed an order dated 6/21/23, NPO (nothing by mouth) diet tube feeding texture related to Cerebral Infarction, Dysphagia. Also revealed an order dated 6/21/23, Enteral Feed Order every day and night shift Clean mouth with swabs. Record review of Resident # 34's Nurse Progress Notes dated 6/21/23 through 8/10/23 revealed no documentation regarding the residents' oral/dental status. Record review of Resident # 34's Nursing Admission Screening/History dated 6/21/23 revealed under, 6. MOUTH none of the boxes were checked to describe the resident's oral condition or history. Record review of the Physician's Progress Notes dated 6/29/23 and 7/06/23 revealed no documentation regarding the condition of Resident #34's oral/dental status. Record review of the Admission Record revealed Resident # 34 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified Dementia, Dysphagia, Hemiplegia and Hemiparesis Affecting Right Dominant Side and Gastrostomy Status. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident is severely cognitively impaired. Also revealed under Section G, the resident requires total dependence for personal hygiene and revealed under Section L, None of the above were present which indicated Resident # 34 did not have any oral/dental status concerns.

Based on staff interviews, record review and facility policy review, the facility failed to accurately complete the oral/dental section of the admission comprehensive assessment on a resident with dental concerns for one (1) of five (5) residents reviewed for activities of daily living (ADL) care. Resident # 34 Findings include: Review of the facility policy titled Minimum Data Set (MDS) 3.0 Completion with a revision date of 3/10/23 revealed under, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Record review of the facility policy titled Conducting an Accurate Resident Assessment with a revision date of 3/29/23 revealed, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas .Policy Explanation and Compliance Guidelines: . 2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record 5. Information provided by the initial comprehensive assessment establishes baseline date for the ongoing assessment of resident progress. Record review of the admission MDS with an Assessment Reference Date (ARD) of 6/27/23 revealed under section L, None of the above were present which indicated Resident # 34 did not have any oral/dental status concerns. During an observation on 8/08/23 at 2:18 PM, of Resident # 34's room revealed the door was closed and as the room was entered it was observed that the resident was lying in bed with his mouth open and eyes closed. An overpowering putrid (rotten) odor was present inside the room. The resident's tongue was observed with raised brown patches and the residents' teeth were observed to be in bad condition, with dark brown/black color to all the teeth with red, inflamed gums. During an observation and interview with the Director of Nursing (DON) on 8/08/23 at 3:20 PM, revealed that the resident had come to the facility with his teeth and mouth in that condition and stated the odor in the room was coming from his teeth and confirmed that the resident had an excessive amount of buildup on his teeth. In an observation and interview with the Director of Nursing (DON) on 8/10/23 at 8:39 AM, of Resident # 34's teeth revealed she described the condition of resident's teeth as, Dark with dark buildup at the base of all his teeth, with his lower gums as, Raw and she stated, They probably just cleaned them, so they are irritated. An interview with MDS Nurse on 8/10/23 at 9:45 AM, confirmed there was not any documentation in Resident #34's medical record that revealed he had poor oral/dental status. She revealed, although the floor staff were aware of his dental condition, they did not document it or report it to her, so therefore, the MDS was not captured accurately, nor was a care plan developed. She revealed she reviewed all the medical record documentation including the admission assessment to accurately complete the MDS and the assessment should accurately reflect the resident's status to provide the best quality of care and it does not. Record review of Resident # 34's Progress Notes dated 6/21/23 through 8/10/23 revealed no documentation regarding the residents' oral/dental concerns. Record review of Resident # 34's Nursing Admission Screening/History dated 6/21/23 revealed under, 6. MOUTH none of the boxes were checked to describe the resident's oral condition or history. Record review of the Admission Record revealed Resident #34 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified Dementia, Dysphagia, Hemiplegia and Hemiparesis Affecting Right Dominant Side and Gastrostomy Status.

Based on observation, staff and resident interviews, record review, and facility policy review the facility failed to remove facial hair, bathe, shave, and perform nail and oral care for residents requiring assistance with their Activities of Daily Living (ADL) for five (5) of 19 sampled residents reviewed for ADLs. Resident #4, Resident #6, Resident #27, Resident #34, and Resident #35 Findings Include: Record review of the facility policy titled Activities of Daily Living (ADLs) with a revision date of 3/10/23 revealed under, Policy: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Also revealed under, Policy Explanation and Compliance Guidelines: . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Record review of the facility policy titled NAILS, CARE OF (FINGER AND TOE) undated revealed, BASIC RESPONSIBILITY: LICENSED NURSE PERFORMS THE PROCEDURE ON HIGH-RISK RESIDENTS. NURSING ASSISTANTS MAY PERFORM THE PROCEDURE IF THE RESIDENT IS NOT AT RISK FOR COMPLICATIONS OF INFECTION .PURPOSE 1. To provide cleanliness 2. To prevent spread of infection. 3. For comfort. 4. To prevent skin problems . Resident #6 An observation and interview with Resident #6 on 8/8/23 at 2:30 PM, revealed long and bushy facial hair on his face, chin, mustache area, under chin and jaws, on lower cheeks, and neck. He stated he liked having a mustache and a goatee, but he prefers to be clean-shaven on the rest of his face and neck. His fingernails were noted to be long, approximately 1/3 inch from nailbed and he stated he would like for his fingernails and toenails to be trimmed since they were too long. During an interview on 8/8/23 at 3:00 PM, Certified Nursing Assistant (CNA) #10 revealed the resident had excess facial hair on his lower jawbone, under his chin, and on his neck. She stated this resident had been in the hospital and had moved from another hall of the facility and has been back from the hospital for a few days. She stated it was the CNA's responsibility to ask what the resident prefers and to shave the residents and to trim the fingernails as the resident desired and she had failed to ask this resident. During an interview and observation on 8/8/23 at 3:15 PM, Registered Nurse (RN) #2 revealed that it is the nurses' responsibility to trim the toenails, unless a podiatrist is needed. She removed the resident's socks and revealed the toenails on the left foot are slightly long (less than 1/4 inch from nailbed to tip of nail). The toenails on the right foot were noted to be long with the big toenail being approximately 1/4 - 1/3 inch long and very jagged with part of nail being close to 1/3 inch long, then the other half of the big toenail about 1/4 inch long. Rough and jagged area between these two lengths of the big toenail were observed. She confirmed that the toenails should be kept smooth and short to maintain good nail care and prevent damage to skin and that his nails were too long and jagged to be safe or comfortable. She confirmed the resident prefers to be clean shaven and that he currently is not. She also confirmed that the resident's fingernails needed to be trimmed since the resident prefers them to be short. She stated that from his appearance, it had been several days since he had these things done. Record review of Resident #6's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses included Hemiplegia, Personal History of Traumatic Brain Injury, Lesion of Ulnar Nerve Left Upper Limb, Chronic Pain, Unilateral Primary Osteoarthritis of Left Knee. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/25/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating resident was cognitively intact. 44804 Resident #4 An observation on 08/08/23 at 11:25 AM revealed that Resident #4 was sitting up in her wheelchair in the dining area with approximately 10 gray hairs in random areas of the chin and cheeks that were approximately 1 inch long. An attempted interview with the resident revealed she was confused. An observation and interview on 8/8/23 at 4:30 PM with CNA #11 confirmed that Resident #4 had several long hairs on her chin and cheeks that needed to be removed. She revealed she is unsure if she is supposed to shave the resident or use a tweezer to remove the hairs. An interview on 8/8/23 at 4:38 PM, with CNA #12 confirmed that shaving is a part of bathing and stated, But I am not sure about female shaving, because I don't want to embarrass them by asking. CNA #12 was asked if a resident cannot determine if they need facial hair removed then how would she know if they need shaved, she revealed she is not sure about females but admitted that she would not want facial hair. An interview on 8/8/23 at 4:40 PM, with Registered Nurse (RN) #2 and RN #3 confirmed that female facial hair removal should occur when the resident is bathed unless they refuse. Record review of Resident #4's ADL care at this time with RN #3 revealed there was no documentation that the resident had refused any care. An interview on 8/9/23 at 4:20 PM, with the Director of Nurses (DON) confirmed that females should have facial hair removed during their bath time. Record review of Resident #4's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Dementia and Need for Assistance with Personal Care. Record review of Resident #4's MDS with an ARD of 5/17/23 revealed in Section C a BIMS score of 04, which indicated the resident is severely cognitively impaired. This review revealed in Section G that the resident needed assistance from staff to complete Personal Hygiene and 'Bathing. 46013 Resident #27 An observation on 08/08/23 at 10:50 AM of Resident #27 lying in bed with fingernails on bilateral hands approximately one-half (1/2) inch long and jagged past the fingertips and a brown substance was under the nails. An observation and interview on 08/08/23 at 2:55 PM with CNA #1 revealed, Resident #27 gets a bed bath daily and we do her nail care but today she was combative, and I didn't do her nails. She revealed we try and go back when she is calmer and see if she will let us do her nails. If she doesn't then we get the nurse to do them. CNA #1 confirmed her nails were long, jagged, and had a brown substance underneath them. An observation and interview on 08/08/23 at 3:10 PM with the DON revealed the aides are responsible for fingernail care which included trimming and keeping them washed and cleaned out. She revealed Resident #27 eats with her fingers and that her nails would require cleaning more frequently because of that. The DON confirmed that the nails were long and jagged and had a brown substance under her nails. A record review of Resident #27's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that include Metabolic Encephalopathy, Unspecified Dementia, Peripheral Vascular Disease, and Generalized Anxiety Disorder. A record review of the MDS with an ARD of 07/20/23, revealed the resident is rarely/never understood which indicated Resident #27 has severe cognitive impairment. 47874 Resident #34 An observation on 8/08/23 at 2:18 PM, of Resident # 34 revealed his tongue was observed with raised brown patches, lips were dry with dried bloody spots on the bottom lip and his teeth were observed to be in bad condition, with dark brown/black color to all teeth. Long facial hair measured approximately 1/4 inch in length and his nails were long, measuring approximately 3/8 inch in length from the tip of the fingers, with a brown substance underneath all nails. An observation and interview on 8/08/23 at 2:55 PM, with Nurse Assistant (NA) # 2 confirmed that she smelled an odor when she entered the resident's room and stated, Mm-hmm, it smells like body odor, and that she had washed the resident up today and had put on deodorant but did not give him a complete bath. She confirmed that she had not shaved him and stated, I was scared to do that. She revealed that when he came to the facility, he had old food (debris) that was caked on his teeth. She stated, His lips have been chapped like that since he came from the other place. She revealed that she had been applying baby oil to the resident's lips because his family had requested her to do that, but she had not applied anything on his lips today. An observation and interview on 8/08/23 at 3:10 PM, with Registered Nurse (RN) #1 confirmed that the nurses and aides are both responsible for oral care on the resident. She stated that this was part of the daily care that was supposed to be provided for the resident. She confirmed that the resident's nails were long and dirty and stated, The aides can cut and clean the nails as long as the resident is not a diabetic, and he is not. An observation and interview with the Director of Nursing (DON) on 8/08/23 at 3:20 PM, confirmed that Resident #34 had not been shaved, had long dirty fingers nails, and had an extremely dry, cracked lower lip with patchy areas of dried blood and raised brown patches to his tongue. She revealed that the aides and nurses are both responsible for the oral care, nail care and hygiene. An interview with the Administrator (ADM) on 8/09/23 at 4:30 PM, revealed that it was the responsibility of the aides and the nurses to do oral care for Resident #34 and stated, It is a concern. Record review of the Admission Record revealed Resident # 34 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified Dementia, Dysphagia, Hemiplegia and Hemiparesis Affecting Right Dominant Side and Gastrostomy Status. Record review of the MDS with an ARD date of 6/27/23 revealed under section C a BIMS score of 7, indicating Resident #34 is severely cognitively impaired. Also revealed under section G, Resident #34 requires total dependence for personal hygiene. Resident #35 An observation and interview on 08/08/23 at 11:07 AM, revealed Resident #35 revealed that the facility is only bathing him one time a week. lying in bed. The resident stated, I want to be shaved, and have my nails cut. An observation revealed long nails on both hands that measured approximately 3/8 inch in length, and facial hair approximately 1/4 inch. An observation and interview on 8/8/23 at 3:25 PM, with RN #2 confirmed that Resident #35 had long nails and facial hair and she asked him if he received a shower yesterday and the resident replied, No, I didn't. An interview with CNA # 6 on 8/09/23 at 11:10 AM, revealed the aides have a shower list that they keep at the nurse's station and that the resident was on the list for Monday, Wednesday, and Friday showers. An interview with RN #2 on 8/09/23 at 11:20 AM, confirmed that Resident # 35 did not get a shower on Monday and stated, I'm not sure why he didn't; I wasn't here. An interview with the Director of Nursing (DON) on 8/09/23 at 11:30 AM, revealed she had spoken with the aide assigned to Resident #35 and she confirmed that she did not give him a shower on Monday because every time she went in his room he was asleep so she didn't wake him up. Record review of the ADL bathing task for Resident #35 revealed under Monday 8/07/23, Not Applicable was checked. Record review of the Admission Record revealed that Resident #35 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus, Major Depressive Disorder, Acquired Absence of Left Leg Below Knee and Acquired Absence of Right Leg Above Knee. Record review of the MDS with an ARD of 7/12/23 revealed under section C a BIMS score of 10, indicating Resident # 35 is moderately cognitively impaired. Record review revealed under section G, the resident requires one-person physical assist with personal hygiene and is totally dependent for bathing.

Based on resident and staff interviews, record review, and facility policy review the facility failed to deliver care and services for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 66 residents reviewed. Resident #47. Findings include: Review of the facility policy titled, Trauma Informed Care with an implementation date of 03/01/23 revealed, Policy .It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Record review of Resident #47's medical diagnoses revealed an admitting diagnosis of Post Traumatic Stress Disorder. An observation on 8/8/23 at 10:50 AM, revealed the resident lying in bed with the covers over her head and would not respond to the State Agent (SA) verbally. An interview on 8/9/23 at 8:15 AM with the Administrator stated, Where did you find PTSD on this resident (Resident #47)? SA informed her that it was listed on the resident's diagnosis, the Administrator stated, Oh, I missed that. She then stated that Resident #47 had a serious car accident where she was driving, and her daughter was killed. An interview on 8/9/23 at 1:25 PM, with Resident #47 revealed that she sees the nurse practitioner about some of her medicines, but she does not think they have ever talked about PTSD. Asked the resident if she recalled receiving a diagnosis of PTSD in the past the resident replied I'm not sure, I have so many. An interview on 8/9/23 at 11:45 AM with the Minimum Data Set (MDS) Registered Nurse (RN) revealed that she discovered a few weeks ago that the resident had a diagnosis of PTSD even though she had been the one to code that diagnosis on the resident's MDS. She revealed that she realized it was on her admitting diagnoses and stated, but that was just a history. When asked if she knew what triggered the resident's PTSD, she stated No. An interview on 8/9/23 at 11:45 AM, with the Behavioral Nurse Practitioner (NP) and MDS RN revealed that she discovered a few weeks ago that the resident had a diagnosis of PTSD even though she had been the one to code that diagnosis on the resident's initial MDS. When asked if she thinks the resident may have missed services since the diagnosis of PTSD was not addressed, she stated, I see what you mean about missing services, but I don't know her so I just can't say. MDS RN stated that the resident sees the Behavioral Nurse Practitioner monthly due to the residents past behaviors. She revealed that the resident has had angry outburst in the past and had to be sent to behavioral health facilities, but anger is normal in residents with Huntington's Disease. When the SA ask if the NP was aware of the PTSD diagnosis, she stated, I do not know, let's call her. A phone call interview at this time with the NP revealed that she was not aware that the resident had a diagnosis of PTSD. She admitted that she has access to the medical records and should have seen that diagnosis. She stated that she would have covered that with the resident when she came monthly, but since she wasn't aware, therefore it was never addressed. She revealed that she plans to return to the facility on Friday now that she knows about the PTSD diagnosis and address it with the resident to see if she needs a referral. An interview on 8/9/23 at 1:36 PM, with the Licensed Social Worker (LSW) revealed that she was not aware until recently that Resident #47 had a diagnosis of PTSD and therefore no trauma assessment had been completed. She stated that she was aware of the regulation regarding trauma informed care and now the facility covers it on admission, but since she did not realize the resident had that diagnosis then an assessment was not completed. She revealed that the resident had never talked about it and admitted that she had never asked the resident about it. An interview on 8/9/23 at 2:18 PM, with the DON stated that she did not realize that the resident had a diagnosis of PTSD on admission to the facility. She confirmed that no one had assessed the resident regarding what triggers her PTSD and that the facility failed to do that. An interview on 8/9/23 at 2:49 PM, with the Administrator confirmed that she did not know that Resident #47 had a diagnosis of PTSD on admission but does not think she missed any services while she has been at the facility. She confirmed that she does think they missed in planning her care and knowing her triggers. She stated that she was aware of the new regulation that came out in the Fall of 2022 that required the facility to do a trauma assessment on anyone with PTSD and admitted they should have assessed Resident #47, but no one realized she had that diagnosis. Record review of Resident #47's admission nursing assessment dated [DATE] revealed the resident had a diagnosis of PTSD. Record review of Resident #47's progress note dated 01/24/21 revealed the resident had an angry aggressive outburst with staff that required the resident to be sent out to a behavioral health facility and returned to the long-term care (LTC) facility on 2/5/21. Review of progress note dated 3/10/22 revealed the resident had to be sent to the emergency room for a psych evaluation following an angry aggressive outburst with facility staff and returned to the LTC facility on 3/15/22. Record review of Resident #47's Behavioral Medicine/Psychiatric assessment dated [DATE] revealed she was assessed by the NP on 3/15/21 following a return from a stay to a behavioral health facility regarding aggressive behaviors and a Behavioral Medicine Evaluation & Management Note dated 6/19/23 as the last assessment by the NP regarding psychiatric medication review that indicated the resident has periods of agitation that require redirection by staff. Record review of Resident #47's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Post Traumatic Stress Disorder (PTSD). Record review of Resident #47's MDS with an Assessment Reference Date (ARD) of 5/4/23 revealed in Section I that the resident had a diagnosis of PTSD and in Section C a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident is moderately cognitively impaired.

Based on observation, staff interview, facility policy review and record review, the facility failed to prevent the likelihood of the spread of infection as evidenced by failure to perform hand hygiene during the lunch tray pass in the west dining room and on east hall and while performing incontinent care for Resident #67 for two (2) of three (3) survey days. Findings Include: Review of the facility policy titled, Infection Prevention and Control Program dated April 2018 with no revision date revealed under Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and revealed under Policy Explanation and Compliance Guidelines: .# 4 Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty. b. Staff shall wash their hands before and after performing resident care procedures. Meal Tray Pass On 01/18/2022 at 11:55 AM, an observation of the noon meal tray pass for east wing rooms 119 through 134 revealed three (3) Certified Nursing Assistants (CNAs) did not utilize hand hygiene between residents while passing trays or returning to the tray cart. On 1/18/22 at 12:00 PM, an observation revealed that Certified Nurse Assistant (CNA) #1 in the west dining room did not perform hand hygiene in between resident's lunch tray delivery and set up. On 1/18/22 at 3:00 PM, an interview with CNA #1 revealed she was supposed to perform hand hygiene in between each tray she hands out to the residents and confirmed that she had attended hand hygiene in-services. CNA # 1 stated, I think I performed hand hygiene between each tray. On 1/18/22 at 3: 08 PM, an interview with Registered Nurse (RN) # 2 revealed that anyone passing out meal trays is supposed to use hand sanitizer or wash their hands with soap and water in between each tray to prevent the spread of germs. On 1/19/22 at 2:19 PM, an interview with the RN Infection Preventionist (RN-IP) confirmed that staff handing out meal trays should perform hand hygiene before and after touching the meal tray and the resident to prevent the spread of infection. The RN-IP revealed that staff had attended a hand hygiene in-service and the facility has a hand hygiene policy. RN-IP stated, I go out on the hall fairly often to verify that the staff is performing hand hygiene like they know to. Review of the facility in-services revealed the facility had a hand hygiene in-service on 1/14/21 that was attended by CNA #1. Incontinent Care On 1/19/2022 at 2:00 PM, an observation of CNA #2 and CNA #3 performing incontinent care for Resident #67 revealed that CNA #2 did not utilize hand hygiene between glove changes and after completing assisting CNA #3 with incontinent care. CNA #2 set up water and a snack within the residents reach without utilizing hand hygiene. CNA #3 initiated the incontinent care, for Resident #67 and did not change gloves or perform hand hygiene between cleaning the resident's perineal area and reaching into the clean rinse water with a clean cloth. CNA #2 removed a bag of dirty linen, a bag of dirty gloves and an incontinent brief without wearing gloves. On 01/20/2022 at 8:30 AM, an interview with RN #1 Staff Development Nurse revealed the staff should wash their hands before and after resident care, any time hands are visibly soiled, between dirty and clean, when performing resident care, and between each resident when passing meal trays. RN #1 reported she is the Staff Development Nurse and provides annual infection control in-services and intermittent should a problem occur. The Infection Preventionist /Infection Control Nurse performs infection control in-services. RN #1 reported we sometimes do return demonstrations for hand hygiene and donning/doffing Personal Protective Equipment (PPE). On 01/20/2022 at 8:55 AM, an interview with CNA #2 confirmed she was supposed to wash her hands or perform hand hygiene with the hand sanitizer, before and after resident care, when changing gloves, between dirty and clean and between tray pass for the residents. CNA #2 confirmed she did not utilize good hand hygiene practices when performing incontinence care on 01/19/2022 for Resident #67. CNA #2 confirmed she did not wash hands or use hand gel between changing gloves and only changed gloves once. She confirmed she did not wash her hands before setting up residents' snack and drink and carried out the trash and dirty linen bags without wearing gloves. Record review of physician Order Summery Report revealed Resident #67 to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/20/2022 at 9:30 AM, an interview with the Director of Nurses (DON ) revealed that infection control in-services are assigned to the staff, and they go online to complete. If we find a problem area, we will do a teachable moment on the hall. We do two formal in-services for infection control annually and the Dietitian performs any in-services pertaining to dietary or nutrition.

Based on observation, staff, and responsible party interview, record review, facility policy review, and Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo review, the facility failed to allow visitation for 44 of 71 residents in the west side of the building during an outbreak of COVID-19. Findings Include: Review of the facility policy titled, Interim COVID-19 Visitation Policy with no implementation or revision date revealed (Facility Proper Name) will restrict visitation of all visitors and non-essential health care personnel for the duration of the declared national and public health emergency related to COVID-19. Exceptions will be in accordance with current CMS directives and CDC recommendations, or as directed by state government (whichever is more stringent). Review of the Center for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo with a reference # of Ref: QSO-20-39-NH dated Revised 11-12-21 revealed under, Memorandum Summary Visitation is now allowed for all residents at all times. An observation on 1/18/22 at 10:00 AM, an observation revealed a notice on the front door of the facility that read, Visitation starts on Saturday at 12 noon and ends at 6 PM. On 1/18/22 at 10:38 AM, an interview with the Administrator stated that the notice on the front door was old and that she removed it. The Administrator revealed that they have been allowing visitors, but they must dress out with Personal Protective Equipment (PPE), especially in the West building since that is where our COVID-19 positive resident are residing. On 01/18/22 at 11:22 AM, an interview with Registered Nurse (RN) # 2 revealed that the facility had not allowed visitors on the west side for a good two weeks due to two of the residents testing positive for COVID-19. On 1/18/22 at 11:45 AM, an interview with the Director of Nurses (DON) confirmed that the facility had not allowed any visitors on the west side in about 3-4 weeks due to having positive COVID-19 residents. When questioned if the facility had reviewed the most recent QSO memo from CMS regarding allowing visitors during a COVID-19 outbreak, the DON stated that she had told them we were supposed to allow visitors into the building and had always thought that it was a bad thing to not allow families to come into the facility. On 01/18/22 at 03:09 PM, an interview with Resident # 27's Responsible Party (RP ) revealed she has not been allowed to come in the west side of the facility to visit her mother for at least two weeks. Resident # 27's RP revealed that the facility called and notified her that the facility was in an outbreak again and had to be shut down for visitors and she could only call her mother on the phone to check on her. Resident # 27's RP stated, I called to check on Mother this afternoon and the staff that answered the phone told me I could come visit her now. On 1/19/22 at 2:19 PM, an interview with Registered Nurse-Infection Preventionist (RN-IP) confirmed that visitation was restricted during their current COVID-19 outbreak, but families could come for compassionate care visits. The RN-IP revealed that the staff called all the resident's families to notify them of the COVID-19 outbreak and that visitation was shut down. The RN-IP revealed that families could come for compassionate care visits only, but the families may not have known they could come for a compassionate care visit, because we did not specifically tell them that. The RN-IP revealed that the Administrator received the CMS-QSO memos, and she denied any knowledge of the most recent update on 11/12/2021 by CMS regarding no restriction on visitation. The RN-IP revealed they would begin calling all families now to inform them they could come to visit. On 1/19/22 at 4:15 PM, an interview with the Administrator revealed that visitation was restricted in the West building where the COVID positive residents were, but not in the East building. The Administrator confirmed she received the CMS QSO memos, reviews them, and keeps a copy. On 1/20/22 at 8:45 AM, an interview with Licensed Practical Nurse (LPN) # 1 revealed that Resident # 27 does not speak. LPN # 1 revealed that all the resident's benefit from visiting with their family and friends; they just need it. LPN # 1 stated that when the facility is shut down for visitation, then the staff must be their everything and as hard as we try, we are not able to give them the same kind of attention that a family member could. On 1/20/22 at 10:45 AM, an interview with the Administrator revealed that the policy titled, Interim COVID-19 Visitation Policy was implemented at the beginning of COVID-19, so it would have been around 2/2020 or 3/2020 and confirmed that she believes allowing visitors to visit the residents is important. Record review of the Resident #27's Face Sheet revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Resident #27's nurse's note dated 1/3/2022 revealed the nurse documented that she spoke with the RP (RP's name). Notified that we have new COVID positive cases at facility, and there will be no visitation for 2 weeks. Also notified that if resident has a decline in her condition, they will be allowed to visit. Record review of the resident's Minimum Data Set with an Assessment Reference Date of 8/24/21 revealed Resident #27 had Brief Interview of Mental Status Score (BIMS) of 2, indicating that the resident has a severe cognitive deficit.

Based on observation, staff interview, record review and facility review, the facility failed to ensure a resident received the appropriate treatment in order to maintain a resident's highest practical level of well being for one (1) of five (5) residents reviewed for behavior symptoms. (Resident #6). This resulted in the Immediate Jeopardy that began on 08/07/13 when Resident #6 touched the upper leg of Resident #1 and attempted to touch Resident #1's breast. On 11/14/13, Resident # 6 was witnessed by Housekeeper (HSKP) #1 to touch Resident #1's breast. The facility's failure to provide appropriate treatment and services to maintain Resident #6's wellbeing which resulted in the likelihood of Resident #1 and other female residents to be sexually abused. This resulted in Immediate Jeopardy that began on 08/07/13. The facility was notified on 03/12/14 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AoC) was received on 03/14/14 which alleged removal of the Immediate Jeopardy (IJ) on 03/14/14. The State Survey Agency determined the IJ was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.2 (F319) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings Include: A review of the facility policy entitled, "Resident's Rights," with no review date, revealed the following, "Each resident in (name of facility) has, at least, the right to: To receive adequate and appropriate health care and protective services." A review of "Report of Incident", undated, and signed by the Director of Nursing (DON) revealed on 08/07/2013 at approximately 5:30 pm, Resident #6 rolled his wheel chair up to Resident #1 and put his hand on her upper leg; a visitor walked thru the lobby and Resident #6 backed his wheelchair away from Resident #1. When the visitor left the area Resident #6 again rolled up to Resident #1 and tried to touch Resident #1's breast. Resident # 1 pushed his hand away and shook her finger at him. Resident #6 rolled back away from Resident # 1. Staff entered lobby and took Resident # 6 to his room and put him to bed. This report confirmed that the visitor that entered the lobby reported the incident between Resident # 1 and Resident # 6 to administration, and the videotape was reviewed. Interview with LSW on 03/11/14 at 4:00 PM, LSW stated, "He (Resident #6) has become more reclusive in that chair, less animated but the family said he was like that, very seldom will he engage his family." LSW stated, "He says he is fine," regarding Resident #6 being in stationary chair during the day. LSW stated, "I ask him every couple of weeks, I ask him do you need anything?" During interview with Resident Care Coordinator (RCC) on 03/13/14 at 12:30 PM, RCC stated, "When he first came in he was ambulating and trying to get out, he still will when he is in that wheelchair." RCC revealed that Resident #6 was "trying to get out to go home." Resident #6 was observed on 03/11/14 at 2:50 PM, sitting in stationary chair in west lobby of facility asleep with legs stretched out in front of him. An attempted interview with Resident #6, on 03/12/14 at 9:23 AM, Resident #6 was seated in stationary chair in West Lobby. Resident #6 stared ahead, turned face in direction of name when called but no attempt at verbal response, and then closed his eyes. Observation of Resident #6 on 03/12/14 at 2:36 PM, revealed Resident #6 sitting in stationary chair with legs out stretched, and eyes closed. During interview with the Director of Nursing (DON) on 03/11/14 at 2:15 PM, DON revealed prior to 08/07/13, Resident #6 had not touched another female resident, but had been inappropriate with CNA's (Certified Nurse Aides). DON confirmed Resident #6 had been grabbing CNA's breasts. DON confirmed that Resident #6 was not sent for any mental health evaluations following the 08/07/14 incident with Resident #1. DON stated, " We discussed inappropriate behavior with him, and he agreed that it was inappropriate. " DON stated that behavior towards staff has improved. A review of the written statement by Housekeeper (HSKP) #1 and interview with HSKP #1 on 03/12/14 at 1:30 PM, revealed on 11/14/13 HSKP #1 observed Resident #6 grab Resident #1's breast. HSKP #1 reported this incident to the Licensed Social Worker (LSW) and Activity Director (AD) at the observation of the incident. Interview with Activity Director (AD) on 03/11/14 at 5:10 PM, confirmed she was serving as Social Service Director when Resident #6 was admitted to the facility. AD confirmed Resident #6 had no occurrences of inappropriate sexual touching on admission to the facility. AD confirmed on 06/23/13, Resident #6 was seen by staff going in female resident's room across the hall from his room. AD confirmed Resident #6 was sent for a mental health evaluation following this incident. During an interview with The Chief Nursing Officer (CNO) from inpatient psychiatric unit on 03/12/14 at 2:41 PM, CNO confirmed she was completing assessment for Resident #6 to be admitted for treatment. CNO stated "very limited with assessment," due to Resident #6 nodding, shaking head and giving "a few uncomfortable looks at times." CNO stated "we are going to look more into his depression and not his behaviors." During interview with Physical Therapy Assistant (PTA) on 03/13/14 at 12:15 PM, PTA stated, "When he first came in, we worked with him, then he went to the hospital and he wouldn't work with us at all when he came back. He was walking from lobby to dining room with assistance and with a rolling walker, when returned from hospital he refused to walk or talk." PTA further revealed Resident #6 would speak with family but refused to speak with staff. PTA stated, "He could walk now if he wanted to but refuses." PTA relayed he is unaware of any clinical reason why Resident #6 could not walk. PTA stated, "When he first started sitting in that chair in the lobby, he seemed to enjoy it now he just seems to sleep." During an interview with Resident #6's Responsible Party (RP) on 03/13/14 at 3:35 PM, RP confirmed when Resident #6 was admitted to the facility, he was able to walk and was receiving therapy. RP stated, "He was getting where he didn't want to walk." RP confirmed unsure of reason Resident #6 refused to walk and revealed she had spoken with Resident#6 concerning his refusal. RP confirmed Resident #6 had no prior history of inappropriately touching other residents at previous facility. Interview with CNA #5 on 03/14/14 at 9:45 AM, CNA #5 stated, "He seems depressed to me." CNA #5 stated, "I've talked to the other aides about him being depressed but not to the DON or social worker. " Interview with Physician #1 on 03/14/14 at 11:25 AM, Physician #1 confirmed that he oversees Resident #6's care. Physician #1 stated that Resident #6 had, "lack of motivation to do much." Physician #1 stated, "He has not had an increase in his depressive symptoms that would warrant a medication adjustment." Physician #1 confirmed awareness of Resident #6's sexually inappropriate behavior, and stated, "they watch him. He is quite comfortable in the living room. He has gotten less aggressive there." Review of Resident #6's Progress Notes by Physician #1 revealed on 08/31/13,"SUBJECTIVE & OBJECTIVE: There was a concern of increasing depression, for which reason the patient had his [MEDICATION NAME] dose increased. There was a challenge of the patient being sexually inappropriate at times. He had been managed at (name of facility) for this. He is being watched closely to make sure he does not have spells of increasing inappropriateness or agitation." and "ASSESSMENT & PLAN: 1. Neuropsychiatric- The patient has advanced dementia. He also likely has ongoing depression. We will continue to monitor him closely for inappropriate behavior. It is really difficult at this time to manage this, because this can be a personality problem that he had even before he became demented. I have reviewed his medications, and I see nothing here that would cause him to have increasing [MEDICAL CONDITION], except for his [MEDICATION NAME]. However, he does need the [MEDICATION NAME] for his [MEDICAL CONDITION] reflux disease. I have already decreased the use of this medication to see if this will help with regard to the patient ' s mentation." Review of Resident #6's Progress Notes by Physician #1 revealed the following entry dated 11/30/13," He has had no agitation or inappropriate behaviors since he has been comfortably placed in chair where he can watch TV without any distractions" and "ASSESSMENT & PLAN: 2. Neuropsychiatric- The patient's depression and dementia are likewise stable." A review of Resident #6's quarterly social note for 09/27/13 revealed, "He sits with his head down, not communicating with others. He appears to struggle with some depressive issues but this has not been verbalized by staff, identified by behaviors and body language. Nursing staff reports that he struggles frequent sleep issues and has some increased sleeping." A review of "social concern" dated 10/21/13, revealed, "It was reported to SW (Social Worker) that (Resident #6) had made advances (kept reaching at her private area of her body) toward a CNA while she was trying to change him during last rounds of the night. SW spoke with (Resident #6) about the incident. He did not deny or agree to the report. SW discussed inappropriate behaviors and the negative consequences that occur when those behaviors are present. He shook his head and acknowledged that he understood the discussion." A review of Resident #6's quarterly social note for 12/20/13, revealed, "He can be very difficult to arouse when others are attempting interaction with him. This may be an avoidant behavior displayed by (Resident #6). (Resident #6) sits with his head down, not communicating with others. He appears to struggle with some depressive issues AEB (as evidenced by) behaviors and body language. Nursing staff reports that he struggles with frequent sleep issues and has some increased sleeping." No documentation was noted of plan to address these concerns in social service notes. A review of Resident #6's March 2014 Physician Orders revealed Resident #6 received [MEDICATION NAME] 40 milligrams (mg) daily for [MEDICAL CONDITION] beginning on 08/09/13. A review of Resident #6's Medication Administration Record [REDACTED]. Resident #6 admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux, [MEDICAL CONDITION], Hypopotassemia, and Chronic Sinusitis. Review of Resident #6's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/13 revealed Resident #6 was moderately impaired with decision making and had a total staff assessed mood score of 03. Resident #6 did not have any physical behaviors symptoms directed towards others within quarterly assessment period. Review of Resident #6's most recent MDS with an ARD of 09/20/13 revealed Resident #6 was moderately impaired with decision making and had a total staff assessed mood score of 06. Resident #6 did not have any physical behaviors symptoms directed towards others within quarterly assessment period. Review of Resident #6 MDS with an ARD of 12/19/13 revealed Resident#6 was moderately impaired with decision-making and had a total staff assessed mood score of 05. In addition, Resident #6 did not have any physical behaviors symptoms directed towards others within quarterly assessment period. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on observation, resident record review,incident report review, interview and facility policy review, the facility failed to ensure residents were free from sexual abuse for one (1) of eight (8) sampled residents for abuse (Resident #1) when review of the incident report by the Director of Nursing (DON) detailed Resident #1 being touched on the upper leg by Resident #6, and Resident #6 attempting to touch Resident #1's breast on 08/07/13. On 11/14/13, Resident #6 was witnessed grabbing Resident #1's right breast by Housekeeper #1. The facility's failure to ensure Resident #1 was free from abuse resulted in the Immediate Jeopardy that began on 08/07/13. These incidents resulted in Resident #1 being sexually abused with the likelihood of Resident #1 and other female residents in the facility being sexually abused. An acceptable credible Allegation of Compliance (AoC) was received from the facility on 03/14/14 which alleged removal of the IJ on 03/14/14. The State Survey Agency determined the Immediate Jeopardy (IJ) was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.13 (F223) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings include: Review of facility policy entitled, "Abuse Prevention/Reporting Policy and Procedure," with a reviewed date of 11/23/11, revealed the following: "POLICY Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friends or other individuals." This policy further stated, "Sexual Abuse: Touching the resident in an intimate or suggestive manner, making sexual comments or allowing another resident to do so." Interview with Licensed Social Worker (LSW) during initial tour on 03/11/14 at 10:35 AM-11:30 AM, LSW revealed Resident #6 ambulated with a wheelchair, and Resident #6 had sexually touched Resident #1 on two occasions, "three months apart." Review of "Report of Incident", reported to the State Agency, undated, and signed by Director of Nursing (DON) documented, the following: On 08/7/2013 at approximately 5:30 PM Resident #6 and Resident #1 were sitting in lobby on the West side in their wheelchairs. Resident #6 (male), rolled his wheelchair up to Resident #1 (female) and put his hand on her upper leg. A visitor walked through the lobby and Resident #6 backed his wheelchair up away from Resident #1. During an interview with the DON on 03/11/14 at 2:15 PM, the DON explained once the visitor reported the incident on 08/07/13, the facility Administrator and DON reviewed the video tape. The video revealed when the visitor left the area, Resident #6 again rolled up to Resident #1 and tried to touch her breast. Resident #1 pushed his hand away and shook her finger at him. This time he rolled back away from her. The report then revealed staff entered the lobby and took Resident #6 to his room and put him to bed. The facility report of the incident documented that Resident #1 received no injury and did not voice any complaints. There was no documented evidence of Resident #1 being assessed by the facility staff following the incident on 08/07/13. Review of Resident #1 nurse's notes dated 08/07/13 revealed the following: "Male resident was observed touching this resident (Resident #1) inappropriately-male resident removed from area" and was signed by DON. Following the 08/07/13 incident of sexual abuse, Resident #1 received no changes in care. Resident #6 was to be in common areas when out of bed, placed in stationary chair for staff supervision when not in dining room, activities or bed, and received every 15 minute visual checks by staff. On 11/14/13, a second incident of sexual abuse of Resident #1 by Resident #6 was documented by Housekeeper #1 . Review of a written statement by Housekeeper (HSKP) #1, dated 11/14/13, revealed, "I heard (Resident #1) saying, 'NO, NO, NO." That's when I looked up and saw (Resident #6) reach over and grab her right breast. He did not see me and I said stop, then he backed up in his wheelchair. I reported it to (Activity Director) and (Licensed Social Worker)." Interview with HSKP #1 on 03/12/14 at 1:30 PM, HSKP #1 stated, "I was standing in the kitchenette at the West Lobby. (Resident #1) and (Resident #6) were alone in the lobby, in their wheelchairs. I heard her saying, "no, no, no." It (verbalization) sounded scared like. Their chairs were facing each other, and she was trying to back up. It looked like they (wheelchairs) were locked up. He reached out and twisted her breast, like handful of her breast. I yelled (made a negative sound for Resident #6 to stop) and he took his hand away. I was looking for someone, (LSW) and (AD) was right there, so I went and told them what happened. (AD) took Resident #6 and (LSW) took Resident #1, separated them. (LSW) asked me to write the statement." During interview with LSW on 03/11/14 at 4:00 PM, LSW confirmed being informed of Resident #6 touching Resident #1's breast on 11/14/13 by HSKP #1. LSW confirmed that she spoke with Resident #1 immediately after being informed of this incident by HSKP #1. LSW confirmed written statement, dated 11/14/13, in which LSW documented that she (LSW) did not observe Resident #1 to have emotional trauma following the 11/14/13 incident with Resident #6. LSW stated, "I went to (Resident #1) her body language was clear, she seemed in control of her situation." LSW confirmed that she did not follow up with Resident #1 any further on 11/14/13 following the incident. LSW confirmed that Resident #1 did not recieve any follow up counceling services, and stated, "She didn't have any counseling. She was forthright with him and did not victimize herself." During interview with LSW on 03/12/14 at 9:15 AM, LSW confirmed Licensed Practical Nurse (LPN) #1 was the nurse that she informed of Resident #6 touching Resident #1's breast on 11/14/13. LSW confirmed she reported this incident to Licensed Practical Nurse (LPN) #1 when it occurred. Review of signed statement, dated 03/12/14,by LPN #1 revealed, "I, (LPN #1) had no knowledge of the events on 11/14/13, until I was asked about it from (DON)". A review of a signed statement, dated 03/14/14, and signed by the DON confirmed the following, "I was not notified of the incident which occurred on 11/14/13 between (Resident #6) and (Resident #1) when the housekeeper saw (Resident #6) touch (Resident #1)'s right breast. I became aware of this incident on 03/12/14." Review of a signed statement by the Administrator, dated 03/14/14, revealed, "I, (Administrator), was not informed of the Nov. 14, 2013 incident. I was made aware of this incident on 03/12/14". Review of written statement by Activity Director (AD), dated 11/14/13, revealed, "Reported by housekeeper (name of housekeeper) that (Resident #6) had grabbed (Resident #1) breast. I went into the lobby- he (Resident #6)was backing away from her. I asked what he was doing, he nodded at me. I asked if he knew he was doing wrong (and) he (Resident #6) nodded yes again. Aide was called (and) he(Resident #6) was put in his chair (stationary chair) out of w/c (wheelchair)." During interview with AD on 03/11/14 at 5:10 PM, AD confirmed she was aware of the 08/07/13 incident with Resident #1 and Resident #6 but was not involved in the planning process. AD confirmed on 11/14/13, HSKP #1 told LSW and AD, "Hey, hey this man's trying to touch this lady." AD confirmed upon finding Resident #1 and Resident #6, Resident #6 was seated in wheelchair in the West Lobby. AD stated, "an aide (CNA) came through and we set him in a regular chair (armchair)." AD further stated, "I asked him: Do you know this was wrong, he shook his head yes. Are you going to do this anymore? He shook his head no." AD stated of Resident #1 on 11/14/13, "She was good that day she was with herself (clear cognition)." A review of Resident #1 and Resident #6 nurse's notes revealed no documentation of 11/14/13 incident or the potential for continued sexual abuse by Resident #6. Observation on 03/11/14 at 11:30 AM revealed, Resident #1 was seated in a stationary chair in the West Lobby. Resident #6 was seated in a stationary chair next to Resident #1 with one small coffee table separating the two chairs. Resident #1 had a walker on the right side close to her chair. Observation on 03/12/14 at 9:23 AM, Resident #1 was observed seated in stationary chair in West Lobby, with her walker in front of her. Resident #6 was seated in a stationary chair also with a small coffee table between them. No staff were observed in the West Lobby, despite Resident #6 being on visual checks every fifteen minutes. The facility transferred Resident #6 to an inpatient psychiatric program on 03/12/14. Interview with Resident #1 on 03/13/14 at 11:45 AM, revealed Resident #1 smiled, attempted speech but verbalizations were unclear. Resident #1 did say, "Ok," in response to general questions of wellbeing and nodded to name of daughter, but did not attempt to answer any other questions, simply pointed out of window. Resident #1 Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION], Dementia without Behavioral Disturbances, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. Record review of Resident #1 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/13, and 09/28/13 revealed Resident #1 had moderately impaired decision-making ability. Resident #6 Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses', which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux, Depression, Hypopotassemia, and Chronic Sinusitis. Review of Resident #6's MDS with an ARD of 09/20/13, prior to the incident on 11/14/13, revealed Resident #6 was moderately impaired with decision making; functional status of extensive assistance of one(1) person, and to use walker and wheelchair for ambulation. The MDS assessment stated Resident #6 had no physical behaviors directed towards others listed. LSW completed the behavior and cognitive pattern assessment of this MDS. Review of Resident #6 MDS with an ARD of 12/19/13 revealed Resident #1 was moderately impaired with decision-making. In addition, Resident #6 did not have any physical behaviors symptoms directed towards others listed within quarterly assessment period. Resident #6 needed one (1) person physical assistance with functional status, and a walker and wheelchair for ambulation. LSW the completed behavior and cognitive pattern for this Resident Assessment Instrument (RAI). The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on resident records review, incident report review, interview, and facility policy review, the facility failed to thoroughly investigate, and report allegations of sexual abuse for one (1) of eight (8) residents reviewed for abuse, (Resident #1) when the facility failed to thoroughly investigate and protect residents when Resident #6 touched the upper leg of Resident #1 and attempted to touch Resident #1's breast. A second incident of sexual abuse occurred on 11/14/13 Resident #6 was observed touching Resident #1's breast and the incident was not reported to the administrator or state agency and was not thoroughly investigated. The facility's failure to investigate, report, and protect residents resulted in Resident #1 being inappropriately touched with the likelihood of ongoing potential for other female residents to be at risk for sexual abuse. Immediate Jeopardy (IJ) was identified on 03/12/14 and was determined to begin on 08/07/13. The facility was notified on 03/12/14 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AoC) was received on 03/14/14 which alleged removal of the IJ on 03/14/14. The State Survey Agency determined the Immediate Jeopardy (IJ) was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.13 (F225) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings include: Resident #1 A review of the facility's policy entitled, "Abuse Prevention/Reporting Policy and Procedure", reviewed by the Administrator on 11-23-11, revealed the following: "The facility management is required to accept all allegations of abuse and conducted a complete investigation including reporting to proper authorities. The Administrator and the D.O.N. will conduct an investigation of any alleged abuse/neglect in accordance with state law. The results of the investigation will be provided to the proper authorities as per state regulations, in addition to the Quality Assessment & Assurance Committee, Attending Physician, Resident and family members within 5 days of the reported incident." Record review revealed on 11/14/13, Housekeeper (HSKP) #1 observed Resident #6 touch Resident #1's right breast. Upon this observation, she immediately reported the incident to the Licensed Social Worker (LSW) and Activity Director (AD). The LSW and AD separated the two residents. During interview with the Director of Nurses (DON) on 03/11/14 at 2:50 PM, the DON revealed she was unsure if the 11/14/14 incident was reported to the Attorney General's Office and/or to the Mississippi State Department of Health. DON stated, "I may not have because there was not an injury." DON confirmed that Resident #6 was not supposed to be in a wheelchair unattended and stated, "Whatever CNA had him should have been chastised." However, DON was unable to recall, which CNA was assigned to Resident #6 on 11/14/13 and could not recall what follow up (if any) took place regarding the incident. DON confirmed that statements written by LSW, HSKP #1 and AD did not document time of occurrence. DON revealed that she "could not find complete investigation" for 11/14/13 incident with Resident #1 and Resident #6. During interview with LSW on 03/11/14 at 4:00 PM, LSW confirmed being informed of Resident #6 touching Resident #1's breast on 11/14/13 by HSKP #1. LSW confirmed that she spoke with Resident #1 immediately after being informed of this incident by HSKP #1. LSW confirmed written statement, dated 11/14/13, in which LSW documented that she (LSW) reported incident to the nurse on duty. Interview with LSW on 3/12/14 at 9:15 am, LSW said that Licensed Practical Nurse (LPN) #1 was nurse the she informed of Resident #6 touching Resident #1's breast on 11/14/13. Also said, she reported this incident when it occurred to LPN #1. LPN #1 revealed on 03/12/14 at 9:35 AM, during an interview, that no one had reported incident involving Resident #6 touching Resident #1's breast on 11/14/13 to her. LPN #1 stated, "They didn't. I would have stopped what I was doing and called the doctor and reported it to (DON) and (Administrator), but no one told me. I would have documented it in my notes." Review of signed statement by LPN #1, dated 03/12/14, revealed, "I, (LPN #1) had no knowledge of the events on 11/14/13, until I was asked about it from (DON)" Review of signed statement by DON, dated 03/13/14, revealed "On 3/11/14 I asked, (LPN #1), if she had any knowledge of an incident on 11/14/13, concerning (Resident #1) and (Resident #6)." Review of the "Investigative Report" dated 03/12/14 provided by the DON, revealed, "It was reported that on 11-14-13 (Resident #6) was observed in the lobby in his wheelchair by (HSKP #1), housekeeper, rolling over to (Resident #1) who was also sitting in a wheelchair in the lobby. (HSKP #1) stated that he rolled over to (Resident #1) and grabbed her rt. (right) Breast. She further stated (Resident #1) told him, "no, no" and backed away. The incident was reported to the Activity Director and the Social Director. Both the Activity Director and the Social Director stated the nurse on duty was notified. The nurse on duty, (LPN #1), stated she was never notified of the incident, no notation was found in the nurses notes. The family was not notified and neither was the Physician. The Director of Nurses not the Administrator were notified as policy states". This investigative report further stated, "When questioned by the director of nurses, the housekeeper stated, 'She never told the director of nurses not the administrator of the incident'. When questioned by the administrator the social services director and the activity director stated that they "thought" they told the Director of Nurses the following day. Neither stated they told the administrator of the incident". Interview with the DON on 03/12/14 at 8:50 AM revealed the (LSW) gave a statement to her (DON), provided yesterday (03/11/14), concerning the 11/14/13 incident with Resident #6. The DON stated, "I am not sure that I was even told. I don't recall that at all." The DON confirmed the administrator was not informed of the sexual abuse by Resident #6 to Resident #1, no investigation was completed, and the incident was not reported to the appropriate agencies per policy. A review of a signed statement by DON dated 03/14/14 revealed the following, "I was not notified of the incident which occurred on 11/14/13 between (Resident #6) and (Resident #1) when the housekeeper saw (Resident #6) touch (Resident #1)'s right breast. I became aware of this incident on 03/12/14." Interview with the Administrator on 03/12/14 at 10:10 AM revealed, "The DON does the investigation, she gets statements, she notifies the AG (Attorney General), MSDH (Mississippi State Department of Health), and the administrator." Administrator acknowledged that she is not involved in the investigation process, "most of the time." Administrator stated that Resident #6 had only exhibited sexually inappropriate behavior, "one time in August. I think he touched a ladies arm." Review of a signed statement by the Administrator, dated 03/14/14, revealed, "I, (Administrator), was not informed of the Nov. 14, 2013 incident. I was made aware of this incident on 03/12/14." A review of Resident #1 and Resident #6's records revealed no documentation of reporting of Resident #6 inappropriately touching Resident #1's breast as witnessed by Housekeeper (HSKP) #1 on 11/14/13. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION], Dementia without Behavioral Disturbances, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. Record review of Resident #1 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/13, and 09/28/13 revealed Resident #1 to have moderately impaired decision-making ability. Record review revealed Resident #6 admitted to the facility on [DATE] with diagnoses', which included [MEDICAL CONDITION], , [MEDICAL CONDITION] Reflux, Depression, Hypertension and Chronic Sinusitis. Review of Resident #6's MDS with an ARD of 09/20/13 and 12/19/13 revealed Resident #6 was moderately impaired with decision making. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on observation, record review, staff interview and facility policy review, the facility failed to implemented their polices for the prevention and identification of sexual abuse of residents, as evidenced by one (1) of eight (8) sampled residents reviewed for abuse (Resident #1) being touched inappropriately by another resident (Resident #6) on two (2) separate occasions. The was for one (1) of 16 Residents reviewed (Resident #1). On 08/07/13, Resident #6 who had exhibited past inappropriate behavior, touched the upper leg of Resident #1 and attempted to touch Resident #1's breast. On 11/14/13, Resident #6 was observed touching Resident #1's breast by Housekeeper #1. The facility's failure to implement the facility policy for abuse resulted in Resident #1 being inappropriately touched with the likelihood of ongoing potential for other female residents to be at risk for sexual abuse. Immediate Jeopardy (IJ) was identified on 03/12/14 and was determined to begin on 08/07/13. The facility was notified on 03/12/14 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AoC) was received on 03/14/14 which alleged removal of the IJ on 03/14/14. The State Survey Agency determined the Immediate Jeopardy (IJ) was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.13 (F226) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings Include: Resident #1 Review of facility policy entitled, "Abuse Prevention/Reporting Policy and Procedure," with a review date of 11/23/2011, revealed the following: Prevention Residents identified by staff as being self-injurious or exhibiting abusive behavior, which requires professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate to insure safety and consistency of care. Identification The facility Quality Assessment & Assurance Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the directions of the investigation/intervention, through analysis of systems, audits and reports." Interview with Licensed Social Worker (LSW) during initial tour on 03/11/2014 at 10:35 AM-11:30 AM, LSW stated that Resident #6 had sexually touched Resident #1 on two occasions, "three months apart." A review of nurses' notes for Resident #6 revealed on 06/23/13 at 6:00 AM, LPN #1 documented, "Late entry for 6/23/13 5:30 PM, Resident was spoken to by this nurse about staying in lobby D/T (due to) not staying out of Rm (Room) #18. Resident shook his head 'NO' and began to propel w/c (wheelchair) towards short hall. This nurse stopped him brought him back to the lobby. Spoke with him again about inappropriateness of going to other residents room without invitation by them. I asked him did he understand he was not to go in another resident's room (without) permission he nodded 'yes' (and) began to smile. This nurse asked why he was going in there did he feel like he knew these ladies he nodded, "no" (and) then pointed (at) this Nurses crotch area (and) smiled. I asked him if that's why he was going in there (and) he nodded 'yes' (and) smiled. I asked him if that's why he was going in there (and) he nodded 'yes' (and) smiled. This nurse again began to explain that this was inappropriate (behavior) (and) he smiled (and) nodded 'yes." Interview with Certified Nurse Aide (CNA) #1 on 03/14/14 at 10:30 AM, revealed that CNA #1 witnessed Resident #6 attempting to go in Room # 18 on 06/23/14. CNA #1 confirmed that Resident #6 did not touch any of the females inappropriately. CNA #1 confirmed that upon seeing Resident #6 attempt to go into room [ROOM NUMBER], she notified LPN #1, and informed Resident #6 he did not need to go into room [ROOM NUMBER]. Review of the discharge summary from the local psychiatric inpatient facility revealed, Resident #6 was sent to inpatient psychiatric program on 06/24/13 related to entering female residents rooms and making inappropriate gestures to LPN #1 on 06/23/14, and returned to the facility on [DATE]. Resident #6 was placed on visual monitoring when out of bed by staff. Review of "Report of Incident", undated, and signed by Director of Nursing (DON) revealed on 08/07/13 at approximately 5:30 PM Resident #6 put his hand on Resident #1 upper leg and tried to touch her breast. The incident was reported by a visitor that observed both residents, and then administration reviewed the camera footage. A record review of Resident #1 nurse's notes dated 08/07/13 documented the following: "Male resident was observed touching this resident inappropriately-male resident removed from area" and signed by the Director of Nursing (DON). Interview with the Director of Nursing (DON) on 03/11/14 at 2:15 PM, DON stated that prior to 08/07/13 incident with Resident #1, Resident #6 had "never grabbed or touched another resident, but he had been inappropriate with CNAs (Certified Nursing Assistants)." DON confirmed that Resident #6 was not sent out of the facility for any follow up evaluation after incident with Resident #1 on 08/07/13. No changes in care where made for Resident #1. Resident #6 continued on visual monitoring by staff, with every fifteen minute observations despite identification of sexual behaviors towards others, Resident #1. Review of written statements by the Housekeeper (HSKP) #1, Activity Director (AD), and Licensed Social Worker (LSW) dated 11/14/2013, revealed that Resident #6 was again witnessed touching Resident #1. Review of written statement by Housekeeper (HSKP) #1, dated 11/14/13, revealed, she heard Resident #1 saying no, and looked and observed Resident #6 grab Resident #1 right breast. HSKP #1 reported the observation to the LSW and AD. Interview with HSKP #1 on 03/12/14 at 1:30 PM, HSKP #1 confirmed Resident #6 grabbed Resident #1 breast on 11/14/13 and it was reported to the LSW and AD. A review of Resident #1 and Resident #6's record revealed no documentation of Resident #6 inappropriately touching Resident #1's breast on 11/14/13. No changes in care were made for Resident #1 and Resident #6. A review of the DON's signed statement, dated 03/14/2014, revealed, "I was not notified of the incident which occurred on 11/14/2013 between (Resident #6) and (Resident #1) when the housekeeper saw (Resident #6) touch (Resident #1)'s right breast. I became aware of this incident on 03/12/14." A review of the signed statement by the Administrator, dated 03/14/14, revealed, "I, (Administrator), was not informed of the Nov. 14, 2013 incident. I was made aware of this incident on 03/12/14." Interview with Physician #2 on 03/14/2014, at 10:26 AM, Physician #2 confirmed he served as the medical director for the facility, and part of the Quality Assurance Committee. Physician #2 stated regarding 08/07/2013 incident, "I can't recall that I was called, they say they have documented that they called me." Physician #2 confirmed that he was called on 03/12/2014 by the DON and informed of the 11/14/2013 incident between Resident #1 and Resident #6. Record review revealed the facility admitted Resident #1 on 07/19/12 with diagnoses, which included [MEDICAL CONDITION], Dementia without Behavioral Disturbances, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Record review of Resident #1 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/2013 and 12/27/2013, revealed Resident #1 had moderately impaired decision-making ability. Record Review revealed the facility admitted Resident #6 on 03/28/13 with diagnoses', which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux, Depression, and Chronic Sinusitis. Review of Resident #6's MDS with an ARD of 09/20/13 and 12/19/13 revealed Resident #6 was moderately impaired with decision making. Resident #6 had no physical behaviors directed towards others. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on record review, incident review, interview, and facility policy review, the facility failed to provide social services to meet the safety, and psychosocial wellbeing for two (2) of 12 sampled residents reviewed,(Resident #1 and Resident #6). This resulted in the Immediate Jeopardy that began on 08/07/13 when Resident #6 touched the upper leg of Resident #1 and attempted to touch Resident #1's breast. On 11/14/13, Resident # 6 was witnessed by Housekeeper (HSKP) #1 to touch Resident #1's breast. The facility's failure to provide necessary social services for Resident #1 resulted in the likelihood for Resident #1 and other female residents to be sexually abused. Immediate Jeopardy (IJ) was identified on 03/12/14 and was determined to begin on 08/07/13. The facility was notified on 03/12/14 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AoC) was received on 03/14/14 which alleged removal of the IJ on 03/14/14. The State Survey Agency determined the Immediate Jeopardy (IJ) was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.15 (F250) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings include: Resident #1 A review of the facility policy entitled, "Social Service Department," with no effective date, revealed, "Purpose: To provide social services staff with a reference, as a role of the social service department in the facility, and the organization of that department." This policy further stated, "EXAMPLES OF MEDICALLY RELATED SOCIAL SERVICES: Providing or arranging provision of needed counseling services Through the assessment and care planning process, identifying and seeking ways to support residents' individual needs and preferences, customary routines, concerns and choices Finding options that most meet the physical and emotional needs of each resident Finding options which most meet their physical and emotional needs. CONDITIONS WARRANTING SOCIAL SERVICES: Inappropriate sexual behavior; f. Depression h. Difficulty with personal interaction and socialization skills;" A review of the job description for, "Social Service Director," signed by Licensed Social Worker (LSW) on 08/05/2013, revealed the following responsibilities: Development and implementation of social care plans, resident assessments and discharge planning to meet the needs of the facility, the residents and their families. Assist in developing for each resident a preliminary and comprehensive assessment and written care plan that identifies the emotional and social problems and/or needs of the resident and the goals to be accomplished for each problem and/or need identified. monitor social services to ensure that residents' emotional and social needs are met Monitor Resident behavior. Report any problems concerning resident's, family members, continued: to the Administrator/DON (Director of Nursing) immediately." A review of "Report of Incident," with no date, and signed by Director of Nursing (DON) documented on 08/07/13 Resident #1 was observed by a visitor touching the upper leg of Resident #1. After the visitor left the lobby, Resident #6 attempted to touch Resident #1's breast, when Resident #1 pushed his hand away and shook her finger at him. Staff intervened and removed Resident #6 from lobby area. The observations on "Report of Incident" were reviewed by videotape by the Director of Nursing (DON) and Administrator after report made by visitor. A review of the "Investigative Report", dated on 3/12/14, documented on 11/14/13 Housekeeper (HSKP) #1 observed Resident #6 touch Resident #1's breast. HSKP #1 reported this to the LSW and AD. LSW and AD stated LPN #1, who was on duty the night of the incident, was notified, however, LPN #1 denied being informed of incident and no documentation was found in nurses notes. LSW and AD confirmed to DON they "thought" they had informed the DON the following day, but neither informed the Administrator. A review of social service notes for Resident #1 and Resident #6 revealed no documentation by social services of contacting the families of the residents involved, following the 11/14/13 incident of sexual abuse. A review of Resident #6's record revealed no documentation of LSW addressing any alternatives to Resident #6 being placed in stationary chair to prevent Resident #6 from engaging in sexually inappropriate behavior with other female residents. During an interview with LSW on 03/11/14 at 4:00 PM,LSW stated of Resident #6 following the 11/14/13 incident, "I just reiterated him being in the chair." LSW stated Resident #6 had become, "more reclusive in that chair, less animated. LSW confirmed she was unaware if the physician was called for either resident following the 11/14/13 incident. Resident #6 was admitted to the facility on [DATE] with diagnoses', which included Alzheimer's disease, Hypertension, Esophageal Reflux, Depression, Hypopotassemia, and Chronic Sinusitis. Review of Resident #6 MDS with an ARD of 12/19/13 revealed Resident #1 was moderately impaired with decision-making. Resident #1 A review of Resident #1's complete plan of care revealed no documentation to address sexual abuse by Resident #6, as identified by the LSW, on 08/07/14 and 11/14/14. No documentation was found to support Resident #1 was being monitored or observed for adverse reactions from sexual abuse on 11/14/13. During an interview with LSW on 03/11/14 at 4:00 PM, LSW confirmed she did not provide any counseling to Resident #1 following either incident of abuse on 08/07/13 and 11/14/13. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Dementia without Behavioral Disturbances, Depressive Disorder, Hypertension and [DIAGNOSES REDACTED]. Record review of Resident #1 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/13, and 09/28/13 revealed Resident #1 to have moderately impaired decision-making ability. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on observation, resident record review,incident report review, and facility policy review, the facility failed to provide accurate assessments for a resident with behaviors, (Resident #6). This was for one (1) of five (5) sampled residents for behavior symptoms when review of the incident report by the Director of Nursing (DON) detailed Resident #1 being touched on the upper leg by Resident #6, and Resident #6 attempting to touch Resident #1's breast on 8/7/13. On 11/14/13, Resident #6 was witnessed grabbing Resident #1's right breast by Housekeeper #1. The facility's failure to provide a complete and accurate assessment of Resident #6's behaviors of inappropriately touching Resident #1 on 08/07/13 and 11/14/13, resulted in the Immediate Jeopardy that began on 08/07/13. These incidents resulted in Resident #1 being sexually abused with the likelihood of Resident #1 and other female residents in the facility being sexually abused. The facility was notified on 03/12/14 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AoC) was received on 03/14/14 which alleged removal of the Immediate Jeopardy (IJ) on 03/14/14. The State Survey Agency determined the IJ was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.20 (F278) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings include: A review of the facility policy with no name or revision date revealed, "PROCESS: I. Assessment and Plan of Care Process b) Resident Assessment Instrument (RAI)- within 14 days of admission; quarterly, annually and with a significant change of condition". Interview with Licensed Social Worker (LSW) during initial tour on 03/11/14 at 10:35 AM-11:30 AM, LSW confirmed that Resident #6 had sexually touched Resident #1 on two occasions, and stated that the incidents occured "three months apart." Review of the "Report of Incident", undated, and signed by Director of Nursing (DON) documented: On 8/7/2013 at approximately 5:30 PM Resident #6 and Resident #1 were sitting in lobby on the West side in their wheelchairs. Resident #6 (male), rolled his wheelchair up to Resident #1 (female) and put his hand on her upper leg. A visitor walked through the lobby and Resident #6 backed his wheelchair up away from Resident #1. Upon visitor leaving lobby, Resident #6 attempted to touch Resident #1's breast. Resident #1 pushed Resident #6's hand away and shook her finger at him. These observations were confirmed upon review of the videotape by the Administrator and the DON, after the visitor reported the incident. A second incident of inappropriate sexual behavior towards Resident #1 was documented by Housekeeper (HSKP) #1, Licensed Social Worker (LSW) and Activity Director (AD) on 11/14/13. Interview with HSKP #1 on 03/12/14 at 1:30 PM, HSKP #1 confirmed observation of Resident #6 touching Resident #1's breast on 11/14/13 while Resident #1 was in West Side Lobby with Resident #6, without the presence of staff. HSKP #1 confirmed that she reported observation to the Licensed Social Worker (LSW) and Activity Director (AD). During interview with LSW on 03/11/14 at 4:00 PM, LSW confirmed knowledge of 08/07/13 incident of Resident #6 placing hand on upper leg of Resident #1 and confirmed being informed of Resident #6 touching Resident #1's breast on 11/14/13. Review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/20/13, which was completed following the incident on 08/07/13 with Resident #6 inappropriately touching Resident #1, revealed Resident #6 was moderately impaired with decision making. The MDS assessment stated Resident #6 had no physical behaviors directed towards others listed. Review of the electronic staff signatures on the 09/20/13 MDS revealed the LSW completed the behavior and cognitive pattern assessment of this Resident Assessment Instrument (RAI), and assessment did not reflect inappropriate sexual behaviors by Resident #6 during this assessment period. Review of Resident #6 MDS with an ARD of 12/19/13 , which was completed following the incident on 11/14/13 with Resident #6 inappropriately touching Resident #1,revealed Resident #1 was moderately impaired with decision-making. Resident #6 did not have any physical behaviors symptoms directed towards others listed within the quarterly assessment period. Review of the electronic staff signatures on the 09/20/13 MDS revealed the LSW completed the behavior and cognitive pattern assessment of this Resident Assessment Instrument (RAI)and assessment did not reflect inappropriate sexual behaviors by Resident #6 during this assessment period. Record review revealed Resident #6 admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux, Depression, Hypopotassemia, and Chronic Sinusitis. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on staff interview, record review and facility policy review, the facility failed to develop a comprehensive care plan for residents related to (A) psychological needs following an unsolicited sexual advance as evidenced by Resident #6 was observed touching the upper leg and attempting to touch Resident #1's breast on 08/07/13, and touched Resident #1 breast on 11/14/13, and (B) antidepressant use and [MEDICAL CONDITION] as evidenced by Resident #6 receiving an antidepressant and a [DIAGNOSES REDACTED]. for two (2) of 16 residents reviewed for care plans (Resident #1 and Resident #6). The facility's failure to develop a comprehensive care plan for Resident #1 related to psychological needs following an unsolicited sexual advance and Resident #6 related to antidepressant use and [MEDICAL CONDITION] resulted in the likelihood of other residents being placed in a situation which could lead to serious harm. This resulted in Immediate Jeopardy that began on 08/07/13. The facility was notified on 03/12/14 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AoC) was received on 03/14/14 which alleged removal of the Immediate Jeopardy (IJ) on 03/14/14. The State Survey Agency determined the IJ was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.20 (F279) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings include: Resident #1 A review of the facility policy with no name or revision date revealed, "Purpose: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment." Review of "Report of Incident", signed by the Director of Nursing (DON) revealed the following, on 08/07/13 Resident #6 was observed with his hand on Resident #1 leg and trying to touch her breast. Review of written statement by Housekeeper (HSKP) #1, dated 11/14/13 acknowledged Resident #6 grabbed Resident #1 right breast. Review of Resident #1's complete plan of care revealed no evidence of a care plan following the incident on 08/07/13 between Resident #1 and Resident #6, to address Resident #1 being inappropriately touched by Resident #6. Interview with Licensed Social Worker (LSW) on 03/11/14 at 4:00 PM, LSW confirmed no care plan was developed to address Resident #1 being at risk for abuse by Resident #6 following incidents of inappropriate touching on 08/07/13 and 11/13/14. A record review revealed Resident #1 admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION], Dementia without Behavioral Disturbances, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. A record review of Resident #1 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/13 and 12/27/13 revealed Resident #1 had moderately impaired decision-making ability. Resident #6 A review of Resident #6's Physician orders revealed Resident #6 received 40 MG (milligrams) of [MEDICATION NAME] daily for [MEDICAL CONDITION]. This treatment order was started on 08/09/13. A review of Resident #6's care plan revealed no plan of care to address Resident #6 ' s [DIAGNOSES REDACTED]. Resident #6 admitted to the facility on [DATE] with diagnoses', which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], and Hypopotassemia. Review of Resident #6's Minimum Data Set, (MDS) with an Assessment Reference Date, (ARD) of 12/19/13 revealed moderately impaired with decision-making. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on staff interview, record review, and facility policy review, the facility failed to update and revise Resident #6's care plan to include appropriate interventions to address sexually appropriate behavior after Resident #6 was observed grabbing Resident #1 right breast on 11/14/13. This is for one (1) of sixteen records reviewed. The facility's failure to update and revise Resident #6 care plan after Resident #6 was observed grabbing Resident #1 right breast on 11/14/13 resulted in the likelihood of Resident #1 and other female residents to be sexually abused. This resulted in Immediate Jeopardy that began on 08/07/13. The facility was notified on 03/12/14 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AoC) was received on 03/14/14 which alleged removal of the Immediate Jeopardy (IJ) on 03/14/14. The State Survey Agency determined the IJ was removed on 03/15/14. The Scope and Severity for the IJ at 42 CFR 483.20 (F280) was lowered to a "D" while the facility develops and implements a plan of correction for the deficient practice. Findings include: Resident #6 A review of the facility policy with no title or date of revision, revealed, "STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs" and "III. Conducting the Interdisciplinary Care Plan Meeting e) the team should attempt to make care plan goals measurable, attainable, and resident specific and easy to understand. Disciplines responsible for actions should be documented." Interview with LSW on 03/11/14 at 4:00 PM, LSW confirmed incident on 11/14/13 between Resident #1 and Resident #6. LSW confirmed the care plan team did not meet after incident on 11/14/13 to address Resident #6 touching Resident #1. LSW stated, "It was a working care plan (Resident #6 care plan for 08/07/13 incident), we just had a breakdown because he wasn't put back in the chair." A review of Resident #6's care plan revealed, "08/08/13 (Resident #6) is making unwanted sexual advances to female residents and staff at times." Approaches to this problem included, "Consult with MD (medical doctor) regarding behaviors and potential medical or psychological interventions. Refer to Social Worker to discuss behaviors with resident and with family. Protect uninterested residents from sexual advances, Remind resident of appropriate group behavior, Verbal intervention: Redirect firmly when behaviors occur." The most recent approach was dated 10/08/13, and stated, "To remain in common areas when OOB (out of bed). Visual checks q15 (every 15) minutes." This care plan was reviewed on 10/02/13 and 12/31/13. Review of Resident #6's care plan revealed that no revisions were made following the 11/14/13 incident of Resident #6 inappropriately touching Resident #1 breast. Reviews of written statement by Housekeeper (HSKP) #1 dated 11/14/13, revealed HSKP #1, witnessed Resident #6 reach over and grab her right breast. A record review revealed Resident #6 admitted to the facility on [DATE] with diagnoses', which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux, Depression, Hypopotassemia, and Chronic Sinusitis. A review of Resident #6's most recent MDS with an ARD of 09/20/13 and 12/19/13 revealed Resident #6 had moderately impaired with decision-making capability. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/14/14. Review of the AOC revealed the facility implemented the following: 1) On 03/12/14, Resident #6 was transferred to an inpatient psychiatric unit for evaluation of inappropriate sexual behavior. 2) On 03/12/14, an investigation was initiated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) into the non-reported sexual abuse that occurred on 11/14/13. 3) On 03/12/14, the DON informed Physician #2 and the families for Resident #1 and Resident #6, of Resident #6 inappropriately touching Resident #1 on 11/14/13. 4) On 03/12/14, the Licensed Social Worker (LSW) attempted to interview Resident #1 for sexual abuse evaluation. Resident #1 was unable to recall details of the sexual abuse on 11/14/13. 5) On 3/12/14, the Resident Care Coordinator (RCC), DON, Registered Nurses (RN) #1, RN #2, RN #3, and RN #4 educated all working employees: RN's, Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Housekeeping Attendants (HA), Dietary Department (DD), Maintenance Director (MD), Office Personnel (OP), and Therapy Department (TD), on sexual abuse recognition, protection and reporting. No employee will be allowed to work until completion of this inservice. Sexual abuse education was added to the new employee orientation and annual in-service calendar. 6) On 3/12/14, thirty-three of forty-four female residents were interviewed by the LSW and Activity Director (AD) to determine if any residents were aware of unreported inappropriate sexual touching. There were no reports of inappropriate sexual touching. The eleven female residents that were un-interviewable received body audits, including Resident #1, which were completed by RN #5 and RN #6. The DON, NHA and RCC conducted chart audits to identify documentation of suspected possible sexual abuse. 7) On 3/12/14, the Medical Records Registered Nurse (MRRN) interviewed all working employees related to unreported sexual abuse. No employee reported any observed inappropriate sexual behavior. No employee will be allowed to work until completing the sexual abuse questionnaire. 8) On 03/13/14, the NHA in-serviced the LSW on the Sexual Abuse Policy as well as the LSW's responsibility for reporting, protection and providing emotional support following any allegations of sexual abuse. The LSW received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the LSW was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 9) On 3/13/14, the NHA in-serviced the AD on the Sexual Abuse Policy as well as the AD's responsibility for reporting, protection, and providing emotional support following any allegations of sexual abuse. The AD received a written disciplinary action for "non-reporting." The facility submitted a clarification statement which confirmed the AD was actually inserviced by the NHA on 03/12/14, prior to conducting resident interviews. 10) On 3/13/14, the Business Office Manager (BOM) contacted employees, not in attendance, to inform them that they would not be able to work until sexual abuse questionnaire and in-service were completed. 11) On 3/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits by the social worker, then monthly for six months, by the AD and LSW, to observe resident for any " unexplained changes in emotion or cognition. " 12) On 3/14/14, the facility added sexual abuse information to the abuse policy is to be given to residents and families during the admission process by the AD. 13) On 3/14/14, the facility implemented the procedure for the Resident Abuse Questionnaire to be completed during the Resident Assessment Instrument (RAI), during the Minimum Data System (MDS) schedule (admission, quarterly, annually), and when allegations of abuse are reported. The MDS-RN will inform the DON of any allegations of sexual abuse. 14) On 3/14/14, the Quality Assurance Committee (QAC) met and reviewed AOC plan to prevent resident-to-resident sexual abuse from occurring. The plan was discussed and accepted. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of Resident #6's record revealed that on 03/12/14, Resident #6 was transferred to an inpatient psychiatric facility. 2) Review of the facility's investigation report revealed the non-reported incident of sexual abuse on 11/14/13 was initiated by the DON on 03/12/14. 3) Record review for both residents revealed the Physician and family were notified of incident on 11/14/13. 4) Record review for Resident #1 revealed the LSW met with Resident #1 on 03/12/14 concerning incidents of sexual abuse in 08/07/13 and 11/14/13. Resident was unable to verbalize details of incidents of sexual touching by Resident #6. 5) Review of the facility's documentation for in-services, revealed all employees in attendance on 03/12/14 were in-serviced on sexual abuse recognition, protection, and reporting. Review of the new employee orientation packet revealed sexual abuse education was added to orientation information. Interview with thirty-five of the facility's seventy-three employees across all disciplines confirmed in-services and questionnaires were implemented with no negative findings. 6) Review of the facility's documentation for interviews, revealed that thirty-three female residents were interviewed by the LSW and AD on 03/12/14. All responses to interview were reviewed. No reports of inappropriate sexual touching were revealed during these interviews. There were no reports of inappropriate sexual touching. Review of the body audits for the eleven non-interviewable female residents, including Resident #1, which were completed by RN #5 and RN #6, revealed no signs of sexual abuse. Chart audits, conducted by the DON, NHA and RCC were reviewed and found to identify no suspected sexual abuse. 7) Review of the facility's documentation revealed between 03/12/14 and 03/14/14, an employee questionnaire was conducted on all employees (except seventeen employees who will not be allowed to work until completed), concerning any observed and unreported sexual abuse, as well as what is considered sexual abuse and how it is to be reported. 8) Review of disciplinary action documentation revealed the LSW received written disciplinary action on 03/13/14. Interview with LSW confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the LSW completed the in-service on the sexual abuse and reporting by the NHA. 9) Review of disciplinary action documentation revealed the AD received written disciplinary action on 03/13/14. Interview with AD confirmed in-service provided by NHA. Review of the facility's documentation of in-services' revealed that on 03/12/14, the AD completed the in-service on the sexual abuse and reporting by the NHA. 10) Review of the facility's documentation confirmed that the BOM contacted seventeen employees to inform them of not being allowed to begin work until sexual abuse questionnaire and sexual abuse in-services were completed. 11) Review of Resident #1's care plan revealed on 03/13/14, Resident #1's care plan was updated to include one time a week for eight-week visits, then monthly for six months, by the AD and LSW, to observe resident for any "unexplained changes in emotion or cognition." This care plan further included weekly skin assessments for Resident #1. Any changes in skin assessments, emotion or cognition are to be reported to the DON for investigation. 12) Review of the facility checklist for resident admissions, revealed the "Abuse Prevention/Reporting Policy and Procedure" was added to the admission checklist of information to be given to residents/families. 13) Review of the "Resident Interview-Abuse Questionnaire" confirmed questions regarding sexual abuse will be asked during RAI/MDS assessments. 14) Review of the facility's Quality Assurance(QA) Meeting documentation, revealed on 03/14/14 the QA meeting was held with the DON, PCC,LSW, Physician #2 (Medical Director), NHA, and AD in attendance. Interview with the Medical Director confirmed that the meeting was held on 03/14/14 with discussion of the incident and AOC plan.

Based on staff interview, record review, policy review, and complaint investigation findings, the facility failed to prevent an accident for Resident #1. Findings for one (1) of four (4) residents reviewed for accidents. Findings include: Resident #1 Record Review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/04/12, reveals a Basic Interview for Mental Illness Score (BIMS) of 06 (moderately impaired). On 2/12/13 at 11:30 a.m., review of complaint investigation MS was performed. It revealed that on 5/6/12 at 4:30 a.m., Licensed Practical Nurse (LPN) #1 applied a hot pack to Resident #1's right knee. After 15 minutes, the hot pack was removed and a 2cm round red area with a blister had formed on Resident #1's right knee. During facility investigation on 5/8/12, (name of physician) was interviewed and stated that she was notified of incident and that LPN #1 requested an order for [REDACTED]. (Name of physician) also stated she told LPN #1 that she would not give her an order because she did not order the treatment in the first place. She further stated that she did not know why LPN #1 would do that without consulting her first. Interview with Director of Nursing on 2/13/13 at 2:00 p.m., confirmed that LPN #1 performed a treatment on a resident without a physician's orders [REDACTED].