Every finding on record at Signature Healthcare at Jackson Manor Rehab and We

Based on interview and facility policy review, the facility failed to ensure residents were provided the opportunity and necessary assistance to exercise their right to vote in a primary election, which had the potential to affect all residents with the ability to vote residing in the facility. The findings include: Review of the facility's policy titled, Resident Rights, last reviewed 01/31/2026, revealed all residents had the right to be treated with respect and dignity and have those rights promoted and protected by the facility. Per review of the policy, residents were entitled to exercise their rights and privileges as residents, and as citizens of the United States, to the fullest extent possible. Further review revealed the facility was to make every effort to support each resident in exercising his or her rights. Review of the facility's policy titled, Voting, last reviewed 02/20/2025, revealed residents were to be assisted with voting as needed. The policy review revealed the Life Enrichment Director/Designee (Activities Director) was responsible for providing the County Board of Elections with a current list of residents who were registered voters. Per review the Life Enrichment Director/Designee was also responsible with requesting absentee ballot applications, obtaining signatures and other information necessary to complete the voting forms, and returning the completed forms to the Board of Elections in accordance with County Board of Elections guidelines. Review further revealed all eligible residents not registered to vote were given the opportunity to register, and absentee ballots obtained and completed by the resident and returned prior to the deadline for residents not wishing to vote at the polls. In addition, review of the policy revealed arrangements would be made for residents who wished to vote at the polls to be transported there. During an interview, on 05/20/2026 at 9:00 AM, the Activities Director stated she was not aware of the facility's policy regarding providing the residents with voting assistance. She reported she had not assisted any residents with voting in the 05/19/2026 primary election and was not aware of any residents who had voted in the primary. The Activities Director stated she did not know the process for requesting absentee ballots for residents. She further stated voting was a resident right and acknowledged it was important for residents to be able to exercise that right. During an interview, on 05/20/2026 at 9:05 AM, the Administrator stated he was unsure whether the Activities Department or Social Services Department was responsible for ensuring residents were offered the opportunity to vote. He reported he was unsure whether residents had voted in, or been offered the opportunity to vote in the 05/19/2026 primary election. The Administrator stated he expected the department responsible for residents' voting rights to know the process for ensuring that occurred. He said however, he was unsure what process had been followed for residents wishing to vote, and was unfamiliar with the facility's policy regarding providing resident voting assistance. In continued interview at 9:35 AM, after he retrieved the facility's Voting policy and reviewed it, the Administrator stated the Activities Department was responsible for ensuring residents were afforded the right to vote. He further stated he had not observed any residents voting or leaving the facility to go vote at the polls on 05/19/2026. The Administrator additionally stated that voting was a resident right and should not be impeded. During an interview, on 05/20/2026 at 9:10 AM, the Social Services Director (SSD) stated she had no role in residents' voting. She reported she had not assisted any residents with voting nor had she requested absentee ballots for residents to vote with. The SSD further stated voting was a right and residents should be able to exercise that right, with as much normalcy as possible. During an interview, on 05/20/2026 at 9:20 AM, Resident (R)41 stated he was a registered voter. He reported he would have definitely voted had he been given the opportunity to do so in the primary election. During an interview, on 05/20/2026 at 9:30 AM, R6 stated he would have definitely voted if he had been asked and given the opportunity. He further stated he would like to have voted. During an interview, on 05/20/2026 at 11:00 AM, R 23 stated, I usually vote but nobody offered. I like to always vote because I've voted all my life. Not voting bothered me. During an interview, on 5/20/2026 at 11:06 AM, R4 stated, I like to vote but nobody offered. I didn't vote this year because nobody asked me. I'm a strong Republican and I always want to vote. During an interview, on 05/20/2026 at 11:10 AM, R25 stated no one in the facility had mentioned the primary election, nor asked him if he would like to vote in it. During an interview, on 05/20/2026 at 11:15 AM, R2 stated no one had ever asked her about voting and she was not aware of an election happening recently. During an interview, on 05/20/2026 at 11:15 AM, R31 stated she had not been told about the primary election. She said no one in the facility had asked if she would like to vote. She further stated she would have voted if she had known she could have done that. During a follow-up interview, on 05/20/2026 at 11:20 AM, after reviewing the facility's, Voting policy, the Activities Director stated she had not completed the policy's requirements related to resident voting assistance. She said she had not sent a list of registered resident voters to the County Board of Elections, requested absentee ballot applications, or obtained signatures and information necessary to complete the voting forms. The Activities Director reported she had not offered eligible residents the opportunity to register to vote, or made arrangements for transportation for residents who wished to vote at the polls. She stated Step 6 of the policy, which was related to absentee ballots being completed and returned to the County Board of Elections, did not apply as no residents at the facility had voted in the 05/19/2026 primary election. The Activities Director stated she was unaware of the duties outlined in the facility's voting policy were her responsibility, until being questioned about the policy, by the State Survey Agency (SSA) Surveyor on 05/20/2026. She further stated she felt terrible that residents had been unable to vote and expressed concern that residents who had wanted to vote were not provided the opportunity to do so. During an interview, on 05/20/2026 at 11:25 AM, R44 stated he had not known about the primary election, and had not voted. He further stated he would have liked to have voted and would have done so had he known about it. During an interview, on 05/20/2026 at 2:29 PM, the facility's State Care Consultant (SCC) stated her expectation was for the residents' right to vote was not impeded. She reported the facility, could have done a better job of bringing it up regarding resident access to voting prior to the 05/19/2026 primary election. The SCC explained the residents' voting status should have been assessed on admission and residents wanting to vote offered assistance as needed. She further stated if residents requested assistance with voting, the facility was to provide support and she acknowledged the facility should make a bigger deal about it next time.

Based on observation, interview, record review and facility policy review, the facility failed to develop and implement a comprehensive care plan that included measurable objectives to meet a resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment for 5 of 24 sampled residents (Resident (R)1, R6, R7, R37, and R57).The findings include: Review of the facility policy titled, Comprehensive Care Plan last reviewed 01/31/2026, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident. Per review, the comprehensive person-centered care plan was to include measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs [NAME] were identified in the comprehensive assessment. Further review revealed the Comprehensive Care Plan was to be person-centered for each resident. 1). Review of R1's Face Sheet, located in the electronic health record (EHR), revealed the facility admitted the resident on 01/13/2026, with diagnoses of unspecified dementia, mood disturbance, dysphagia, and muscle weakness. Review of R1's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/06/2026, revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Continued review of the MDS revealed the facility also assessed R1 to require partial/moderate assistance with the Helper does LESS THAN HALF the effort. Further review revealed the facility additionally assessed R1 as requiring Helper lifts, holds, or supports trunks or limbs, but provides less than half the effort. Review of the 03/13/2026 Speech Language Pathology (SLP) evaluation for R1, revealed the SLP assessed the resident as needing assistance with feeding himself. Per review of the SLP evaluations dated 01/14/2026 and 02/02/2026, revealed the SLP noted R1 had macular degeneration and was dependent with feeding himself for food finding. Continued review of the 01/14/2026 and 02/02/2026, SLP evaluations revealed the SLP additionally assessed R1 to require drink set-up and finding drinks. Review of R1's Comprehensive Care Plan initiated on 01/21/2026, revealed the facility developed a problem area for R1 being at nutrition and/or hydration risk and as having altered nutritional needs related to pain and weakness. Per review, the problem was evidenced by trauma/stressor leading to admission diagnoses, leaving 25-50% of meals untouched at times, needing a therapeutic diet and mechanically altered diet. Continued review revealed the goal was for R1 to have no complications through the next review of 07/31/2026. Further review revealed the interventions included: meals as ordered by physician; medications as ordered; Registered Dietician (RD) to follow (the resident) as indicated; and supplements as ordered. However, further review revealed no documented evidence of R1 being dependent with feeding as per the SLP's evaluations, on the resident's care plan. Review of the facility's Profile Care Guide (guide for Certified Nurse Aides (CNA's) for R1 dated 02/02/2026, revealed an approach noted for them to set-up the resident's meals. Observation on 05/17/2026 at 12:16 PM, revealed R1 lying on his bed with the head of the bed (HOB) elevated, and his lunch tray sitting in front of him on the bedside table, with no staff nearby. Per interview, at the time of observation, R1 stated Am I going to sit here and starve? Someone needs to fucking feed me. Continued observation revealed R1's roommate was already eating from his lunch tray. Observation in the hallway revealed staff continued to pass residents' meal trays. Further observation at 12:30 PM, revealed CNA 2 went into R1's room to feed him. During an interview on 05/17/2026 at 12:32 PM, CNA 2 stated she did not normally work on R1's hall, but as far as she knew the resident was only fed by staff when he asked them to do so, due to him often refusing to allow staff to feed him. She reported she was not sure what R1's care plan said; however, noted his meal tray card did not denote R1 as dependent with meals. CNA 2 further stated the residents' Profile Care Guide was where she would look for residents' care needs. 2). Review of R6's Face Sheet revealed the facility admitted the resident on 10/16/2025, with diagnoses of Paraplegia, neuromuscular dysfunction of bladder, colostomy Status, and other artificial opening of urinary tract-chronic supra-pubic catheter. Review of R6's MDS Assessment, with an ARD date of 04/18/2026, revealed the facility assessed R6 as having a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Review of R6's Physician orders revealed an order dated 10/17/2025, to change the (colostomy) pouching system when leakage was noted or if the skin was sore or itching. Continued review of the 10/17/2025, Physician's order revealed the order noted to assess the site at stoma for signs/symptoms of infection, redness, or irritation. Further review of the Physician orders revealed an order dated 03/13/2026, to change the resident's supra-pubic catheter on the 13th of every month. Review of R6's care plan initiated on 10/16/2025, revealed the facility developed a problem for the resident as at risk for complications related to an indwelling catheter. Per review, the goal was for R6 to remain free of complications related to the use of the indwelling urinary catheter. Continued review revealed the interventions included: observing for abdominal pain; observing for change in urine; observing for retention; and to provide catheter care as needed. However, further care plan review revealed no documented evidence the facility developed and implemented interventions related to the type/size or changing of the supra-pubic catheter. 3). Review of R7's Face Sheet revealed the facility admitted the resident on 12/04/2025, with diagnoses of Alzheimer's Disease; unspecified dementia, moderate; and vascular dementia, severe. Review of R7's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of five out of 15, which indicated severe cognitive impairments. Review of R7's Nurse Progress Note dated 12/04/2025 at 4:19 PM, documented by Registered Nurse (RN) 5, revealed the resident had been wandering the halls looking for her family. Per continued review of the Note, a Secure Care (specialized monitoring device) bracelet was applied to R7's right ankle, the resident's Responsible Party (RP) and Physician were made aware of that information. Review of R7's Physician orders revealed an order dated 12/04/2025, to check the function of the wandering alert device daily. Observation of R7 on 05/17/2026, 05/18/2026, 05/19/2026, 05/20/2026 and 05/21/2026 revealed a monitoring device in place on the resident's right ankle at all times during the State Survey Agency (SSA) Survey. Review of R7's Care plan dated 12/04/2025, revealed the facility developed a behavioral problem dated 12/08/2026, for the resident being at risk for elopement due to exit seeking behavior. Per review, the goal was for R7 to remain safe within the (facility) environment. Continued review revealed the interventions included: alarm systems as appropriate; monitor for wandering triggers; observe for such behaviors such as verbal statements like, I'm leaving, packing belongings, and following visitors closely as they are exiting or pushing on exit doors. However, further review revealed no documented evidence regarding the wandering alert device placed on R7. 4). Review of R37's Face Sheet revealed the facility admitted the resident on 11/08/2023, with diagnoses of dementia, severe; gastrostomy; and dysphagia. Review of R37's MDS Assessment, with an ARD date of 03/27/2026, revealed the facility assessed the resident as having a BIMS score of six out of 15, which indicated severe cognitive impairment. Review of R37's physician orders dated 02/25/2026 revealed an order for foley catheter care twice daily, and to change foley catheter as needed. Review of R37's Care Plan revealed the facility developed a problem initiated on 01/21/2026, for R37 being at risk for potential complications related to an indwelling urinary catheter. Per review, the goal was for the resident to remain free of complications related to use of an indwelling urinary catheter. Further review revealed the interventions included: observing for abdominal pain; observing for changes in urine and for retention; provide catheter care as needed; and ensure correct anatomical placement of the resident's foreskin upon care. However, review further revealed no documented evidence of interventions related to the catheter size, care, or changing of the catheter. Review of R37's Care Profile for the CNA's revealed no specific care interventions to be provided for the resident's foley catheter. 5). Review of R57's Face Sheet revealed the facility admitted the resident on 07/02/2025, with diagnoses of vascular dementia with behaviors and hemiplegia of the left side. Review of R57's MDS Assessment, with an ARD of 10/09/2025, revealed the facility assessed the resident as having a BIMS score of 00 which, meaning the resident had been unable to complete the interview, indicating severe cognitive impairments. Review of R57's Physician orders revealed an order dated 07/05/2025, to check the function of the resident's wandering device daily. Further review revealed the order dated 07/05/2025, also revealed an order to check the placement of R57's wandering device every shift. Review of R57's Care plan initiated on 07/08/2025 revealed the facility developed a problem for R57's diagnosis of depression, and regarding the resident exhibiting tearfulness, and self-isolation. Per review, the goal was for R57 not to experience any adverse outcomes related to those diagnoses. Further review revealed the interventions included: one to one (1:1) visits with social services as needed; allowing R57 to express their feelings; consult with psychiatry/psychology as needed; and report signs and symptoms of depression. However, further review revealed no documented evidence of R57's wandering device on the care plan. Observation of R57 on 05/17/2026, 05/18/2026, 05/19/2026, 05/20/2026 and 05/21/2026, revealed a monitoring device in place on the resident's right ankle at all times during the State Survey Agency (SSA) Survey. During an interview, on 05/18/2026 at 10:35 AM, the MDS Coordinator stated care plans were collaborative, and all licensed nurses could update the care plans, in real time. The MDS Coordinator further stated care plans were reviewed during the facility's Interdisciplinary Team (IDT) meetings, where further updates were made as necessary. During an interview, on 05/18/2026 at 10:12 AM, the Staff Development Coordinator (SDC) stated for recurrent issues involving resident care; the residents' care plans should have been updated to reflect the care being provided. During an interview, on 05/21/2026 at 10:58 AM, the Interim Director of Nursing (DON) stated the residents' care plan were to be updated to reflect each resident's specific care. She said any change in resident, observed or noted by the CNA's, should be relayed to the nurse. The Interim DON explained the nurse would then put the changes and/or any orders in the resident's electronic health record (EHR). She reported all orders/changes were reviewed comprehensively by the IDT and the care plan updated accordingly. The Interim DON stated staff were made aware of changes in residents during report at shift change until the residents' care plan were updated. She further stated the orders for foley catheter, supra-pubic catheter might not be on the care plan as staff would follow the orders. In interview with the Interim Administrator on 05/18/2026 at 11:01 AM, he stated the facility's expectation was for resident care needs and instructions to be communicated through the resident's care plan or EHR. He further stated the care plans for the residents involved should have been updated to reflect the residents' care needs.

Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored in a safe and secure manner, with limited access for 1 medication room, and 1 of 1 medication carts. The findings include: Review of the facility's policy titled, Storage of Medication, dated 2007, revealed In order to limit access to prescription medication, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medication (such as medication aides) were allowed access to medication carts. Further review revealed medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by people with authorized access. Observation of the medication room on 05/17/2026 at approximately 9:39 AM, 10:56 AM, 11:42 AM, and 11:51 AM, the medication room was observed to be unlocked and unattended. Per observation, there was an unattended medication/treatment cart located inside the medication room that was also unlocked and unsecured. Further observation revealed multiple medication blister packs stored on top of the cart in view and readily accessible to residents, visitors, staff or other unauthorized individuals. During interview with Registered Nurse (RN) 2 on 05/17/2026 at approximately 9:56AM, she stated the medication room should be locked at all times. She said it should be locked due to wandering residents who could potentially go in the room, and that would be a safety hazard. RN 2 explained medication carts also should be locked at all times. She stated the facility's Emergency Box located on the floor was an infection control risk, and a fall hazard. When the State Survey Agency (SSA) Surveyor asked the RN about the door not closing and locking, she stated she did not know if maintenance had been notified of that. During interview with the Director of Nursing (DON) on 5/17/2026 at approximately 11:04, she stated the medication room should be locked at all times and if it was not, maintenance was to be notified immediately. She said it was her expectation for the medication room to be kept locked at all times. The DON reported the medications stored on top of the medication carts was to be put into medication carts and it locked as soon as possible. She further stated the issue identified should be corrected immediately, then staff should be educated and disciplinary action taken if needed. During interview with Licensed Practical Nurse (LPN) 3 on 5/17/2026 at approximately 11:45 AM, she stated The med room should be locked at all times because needles are in there and meds (medications) should not be out and residents may take medications that are not theirs. LPN 3 said there were a lot of safety hazards in there. She further stated she had never seen anyone in the medication room who was not supposed to be in there. During interview with the Regional Nurse Consultant on 05/17/2026 at approximately 12:28 PM, she stated, We are glad that you found that medication room was unlocked, the medication/treatment cart unlocked, and medications on top of the medication cart so that we may correct the problem. She reported it was the facility's expectation for the medication door to lock on it's own when someone exited the room. The facility's Consultant said the door was fixed now and should be working properly. She further stated staff would be educated on if the medication room door did not close upon exit, they should notify maintenance immediately. During interview with the Administrator on 5/17/2026 at approximately 12:39 PM, he stated the medication room should be closed and locked at all times. He said we should have notified maintenance, and educated staff immediately. The Administrator further stated the medication room not locking had never happened before now.

Based on observation, interview, record review, and review of facility policy, the facility failed 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, which had the potential to affect all residents having their laundry and linens washed and dried by the facility, and all residents who smoked. The findings include: Review of the facility policy titled, Infection Prevention and Control Program revised 01/30/2026, revealed facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment. Continued review revealed, Facility infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the public alike. 1). Review of the facility policy titled, Folding and Distributing Linen revised 11/2018, revealed, All linen will be handled, folded, and distributed in a neat and orderly fashion. Review of the facility policy titled, Handling Clean Linen revised 11/2018, revealed, Linens that come out of the dryers must be folded as soon as possible to avoid wrinkling and creasing. Continued review revealed, Fold linen out of bin to keep infection control issues down. Review of the facility policy titled, Proper Operation of Dryers revised 11/2018, revealed, ensure the proper and safe operation of the dryers and provision of dry laundry to all residents and staff. Continued review revealed eight procedural steps in the policy, with step six noting, once the laundry is dry, remove it from the dryer and step seven being clean out the lint trap. Review of the Center for Disease Control and Prevention (CDC) guidelines revealed under the section titled, Laundry and Bedding- Guidelines for Environmental Infection Control in Health-Care Facilities revised 01/08/2024, it was noted Damp textiles should not be left in machines overnight. Observation on 05/17/2026 from 9:50 AM to 9:54 AM, of the facility's laundry room, revealed resident clothing and linens stored in the clean bin, uncovered, next to Dryer 2. Per observation, the uncovered bin had been pulled out from its designated area, with clothing and linen overflowing and falling onto the laundry room floor. Further observation revealed clothing had been left in Dryer 2. Continued observation revealed Dryer 1 and Dryer 2 had lint in the lint trays in the bottom of both dryers, with lint falling out of the lint trays. Observation revealed the designated folding table had multiple items of clothing and linen piled, unfolded, on its surface, resulting in the linens and clothing to overhang the table's edge and fall to the floor. Additional observation revealed clothing had been left in the front-loading washer which was semi-damp and almost dry to the touch. Further observation of the laundry area revealed the top loading washer had a load of towels and blankets left in it which was also semi damp and almost dry to the touch. Continued observation on 05/17/2026 from 9:55 AM to 9:57 AM, of the laundry room area revealed a bucket containing stagnant mop water with a soapy residue and visible debris, which included hair and dirt, present on the surface of the water. Observation revealed a used mop resting on the floor adjacent to the bucket, appearing damp. Per additional observation, a soiled linen container full of clothing items which prevented the container lid from fully closing; and soiled linens resting on top of the bin, outside of the designated bag that appeared damp. Further observation of the posted laundry staff schedule revealed laundry shifts were 11:00 AM to 6:00 PM daily. During interview on 05/17/2026 at 10:00 AM, concerning the lack of laundry room staff, Registered Nurse (RN) 2 stated, Nobody is here yet. I don't know if we have laundry staff on the weekends. During interview on 05/17/2026 at 10:35 AM, the Laundry Supervisor stated the clothes in the laundry bin were usually covered. The Laundry Supervisor said, I think its okay for clothes to be left in the washer overnight, but they probably shouldn't be because it could be a cross-contamination issue. The Laundry Supervisor further stated the dryer lint traps should be cleaned hourly. During interview on 05/17/2026 at 3:15 PM, the Regional Housekeeping Supervisor revealed housekeeping services were contracted through a healthcare services group. The Regional Housekeeping Supervisor said no clothing should be left in the dryer and the lint traps should be cleaned after each dryer use. The Regional Housekeeping Supervisor reported the laundry room should always look clean and there was a checklist placed in the laundry room for what was to be completed at the end of each shift before staff left. The Regional Housekeeping Supervisor further stated, in regards to infection control and laundry room training, that all training, including infection control, was done online at hire. 2). Observation on 05/18/2026 at 3:45 PM, revealed smoking aprons hanging in the open gazebo with no protection from weather elements or wildlife. Additional observation on 05/19/2026 at 7:45 AM, revealed the smoking aprons continued to be hanging in the open gazebo with no protection from weather elements or wildlife. During an interview with the Activities Assistant (AA) on 05/19/2026 at 8:07 AM, she stated smoking breaks were Mondays and Tuesdays at 10:00 AM, 2:00 PM, and 8:00 PM and Wednesday through Sunday the breaks were at 10:00 AM, 2:00 PM, and 6:00 PM. She said all residents who smoked were required to wear a shared smoking apron while smoking. The AA reported the residents' smoking aprons were routinely left hanging in both the open gazebo area and the enclosed smoking area for convenience between resident use. She explained the housekeeping/laundry department was responsible for sanitizing the aprons; however, she only performed a visual check to determine whether the aprons appeared clean and had no method to verify the aprons had been sanitized. The AA said smoking aprons that had not been sanitized properly could potentially cause a resident to become ill. She stated the smoking aprons had not been cleaned for months while remaining exposed outdoors to weather and wildlife. The AA further stated she personally would not want to wear a smoking apron that had not been washed/cleaned and had been exposed to the elements. She additionally stated she would not expect residents wanted to wear them either. During an interview with the Housekeeping Supervisor on 05/19/2026 at 8:12 AM, she stated the Activities Department was responsible for management of the residents' smoking aprons. She said the previous Activities Director had instructed the housekeeping department not to clean the smoking aprons. The Housekeeping Supervisor reported it had been months since the smoking aprons had been cleaned by housekeeping staff and she confirmed the aprons had remained hanging outside in the gazebo exposed to the elements during that time period. She further stated she would not want to wear a smoking apron that had not been properly sanitized or that had been stored outside exposed to weather conditions and wildlife. During an interview with the facility's Infection Preventionist (IP) on 05/19/2026 at 8:36 AM, she stated the facility utilized shared smoking aprons for residents to use. She reported the smoking aprons were expected to be cleaned monthly and as needed by Activities and Housekeeping staff as a group task; however, she was unable to identify a specific policy outlining the cleaning frequency for the aprons. The IP said the aprons should be stored inside the enclosed smoking building when not in use and acknowledged the aprons had been left outside in the gazebo exposed to the elements. She explained the shared resident-use items should be cleaned between each resident use. The IP stated the smoking aprons should be maintained in a clean and dry condition to reduce infection control risks and prevent contamination from moisture, weather exposure, and resident handling. She said the residents continued utilizing the aprons during the period in which they were not being routinely sanitized and acknowledged residents could be at risk for cross-contamination from use of shared equipment that had not been disinfected appropriately. The IP stated staff education regarding cleaning and storage expectations for shared resident-use equipment fell under the facility's shared equipment policy. She further verbally acknowledged oversight responsibilities related to ensuring infection control policies were followed would fall under me, housekeeping, and maintenance. In interview on 05/21/2026 at 9:40 AM, the Director of Nursing (DON) stated she expected all staff, even contracted staff, to adhere to the facility's infection control policies to promote a safe environment for residents. In interview on 05/21/2026 at 9:45 AM, the Administrator stated he was aware housekeeping must be trained during orientation; however, was unaware of who provided that training. He said he expected staff, including contract staff, to follow the facility's infection control policies and promote a safe and sanitary environment for residents. The Administrator further stated promoting a safe and sanitary environment for residents was a coordinated effort for all facility staff.

Based on observation, interview, and record review, the facility failed to maintain the confidentiality of resident clinical information for 1 of 24 sampled residents, reviewed for privacy, (Resident (R)37). The findings include: Review of the facility's policy titled, Resident Rights, last reviewed 01/31/2026, revealed residents had the right to privacy and confidentiality. Continued review of the policy revealed all residents had the right to be treated with respect and dignity and those rights were to be promoted and protected by the facility. The policy stated, the unauthorized release, access, or disclosure of resident information is prohibited. Further review revealed, all release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. Review of the facility's policy titled, Safeguard: Safeguarding and Storing Protected Health Information, last reviewed 06/12/2025, revealed Protected Health Information (PHI) was not to be intentionally or unintentionally used or disclosed in a manner that violated the privacy or confidentiality requirements. Per review, PHI shared or discussed was to be limited to the minimum amount necessary to accomplish the purpose of the use or disclosure. Continued review revealed documents containing PHI was to be stored appropriately to reduce the potential for incidental use or disclosure and should not be easily accessible to unauthorized staff or visitors. Policy review additionally revealed any documentation containing PHI was to be maintained in a manner that ensured security and accessibility only to authorized individuals. Review of R37's Electronic Health Record (EHR) face sheet revealed the facility admitted the resident on 11/08/2023, with diagnoses of unspecified dementia, severe, and cognitive communication deficit. Review of R37's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/08/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating the resident was severely cognitively impaired. Continued review of the MDS revealed the facility assessed R37 as dependent for personal hygiene, toileting hygiene, bathing, dressing, bed mobility, and transfers. Review further revealed the facility assessed the resident as not ambulatory due to medical condition or safety concerns and with impairment to both upper and lower extremities. Observation on 05/17/2026 at 12:13 PM, revealed a typed paper sign posted on the wall near the right side of R37s headboard visible to individuals entering the room. Continued observation revealed the typed sign was titled, Penis care (uncircumcised). Further review of the sign revealed it included written instructions stating, An uncircumcised penis has its foreskin intact .gently retract the foreskin during bathing and clean the penis well. It is very important to reposition the foreskin back over the head of the penis after cleaning. Otherwise, the foreskin can slightly squeeze the head of the penis, causing swelling and pain (paraphimosis). This needs medical care. During an interview, on 05/17/2026 at 2:05 PM, Certified Nursing Assistant (CNA) 2 stated she noticed the document hanging in the resident's room the previous weekend. She reported posting the sign was a dignity issue for R37, and she would never hang something like that up. During an interview, on 05/17/2026 at 2:25 PM, CNA 3 stated she noticed a document posted in the resident's room a couple of weeks ago, but the document posted in there today was different. She further stated the instructions should have been in the resident's care plan, not hung up for anyone to see. CNA 3 additionally said it was a privacy and dignity issue for R37. During an interview, on 05/17/2026 at 2:37 PM, Registered Nurse (RN) 2 stated the document should not have been hanging up for everyone entering R37's room to see. The RN further stated that information should have been updated in the resident's care plan. During an interview, on 05/18/2026 at 8:28 AM, RN 3 stated she had been working at the facility since January 2026, and the document had been hanging up, for a while. She reported she did not think the document should have been hung up in the resident's room, and instead should have been in R37's EHR or the care plan updated with that information. During an interview, on 05/18/2026 at 10:35 AM, the MDS Coordinator stated care plans were collaborative documents and could be updated in real time by licensed nursing staff. He reported bedside signs should not be used to communicate a resident's care needs and confirmed residents' care instructions should be documented in the resident's care plan. The MDS Coordinator explained it was his understanding signs of the nature hung in R37's room, should not be posted in residents' rooms. He further stated, I don't know why anyone would have thought putting signs up is the answer. During an interview, on 05/18/2026 at 10:12 AM, the Staff Development Coordinator (SDC) stated a document that had previously been posted in R37's room had been taken down. She reported she believed she knew which nurse (RN 4) had posted the document and believed the nurse posted it because staff were not providing the care needed correctly to the resident. The SDC stated however, the document should not have been hung up in R37's room. She further stated for recurrent issues involving resident care, the resident's care plan should have been updated to reflect the care necessary that was being provided, instead of hanging a document up. During an interview, on 05/18/2026 at 10:13 AM, the Interim Director of Nursing (DON) stated the facility had addressed the document being posted in the resident's room previously. She said however, it keeps being hung up because the nurse (RN 4) became frustrated as she thought staff were not providing R37's care correctly. The Interim DON further stated the sign should not have been posted. She additionally said education had been provided to staff regarding the concern of posting the sign, and staff should have been aware not to post such a document again. During an interview, on 05/18/2026 at 11:01 AM, the Interim Administrator stated he was not aware the resident-specific penis care instructions had been posted at the head of the resident's bed until it was brought to his attention earlier in the day. He said nursing staff intended the posting to communicate care instructions related to R37's care; however, he had not authorized such a posting. The Interim Administrator verbally acknowledged he was unable to identify who had directed staff to place the sign in the resident's room. He explained the facility's expectation was for residents' care needs and instructions to be communicated through the resident's care plan in the EHR, rather than being posted at bedside. He stated there were less intrusive methods available to communicate a resident's care needs and said the care plan should have been updated to reflect R37's penis care needs. The Interim Administrator further stated the posting of the sign was not a common facility practice. He additionally said resident-specific care information was typically maintained in the resident's medical record or care plan. During an interview, on 05/20/2026 at 2:28PM, the facility's State Care Consultant (SCC) stated posting a document titled, Penis care (uncircumcised) in plain view of others, at a resident's bedside was inappropriate. The SCC said there were alternative methods available to communicate R37's resident's care needs, including use of a nursing order or updating the resident's care profile. The SCC reported resident-specific personal care information should be communicated in a manner that maintained the resident's dignity and privacy. The SCC explained staff education regarding care should be provided privately, such as one-to-one or in a group setting, rather than through the visible posting of that information in a resident's room. The SCC further stated publicly posting genital care instructions for a cognitively impaired resident raised concerns for the resident related to dignity, privacy, and confidentiality. During an interview, on 05/20/2026 at 2:01 PM, Family Member (F) 7 stated no one from the facility had contacted her to request permission to hang any documents up in R37's room regarding his care needs. Telephone (Phone) interview was attempted on 05/19/2026 at 10:48 AM, with RN 4; however, was unsuccessful, and a voicemail message was left for a return call. Additional phone interview calls were placed to RN 4 on 05/20/2026 at 9:58 AM and again on 05/20/2026 at 1:17 PM, with no answer and a voicemail message again left. No return telephone calls or responses to the voicemail messages were ever received from RN 4.

Based on interview, facility policy, document and investigation review, the facility failed to ensure alleged violations involving abuse were reported to the appropriate state agency in accordance with the facility's policy and regulatory requirements for 2 of 3 residents sampled for abuse out of the total sample of 24 residents, (Resident (R)46 and R12). The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of property, last reviewed 01/31/2026, revealed all alleged violations including abuse, neglect, exploitation, mistreatment, and misappropriation of resident property were to be immediately reported. Policy review under the, Reporting/Response and Reporting Guidelines, revealed every stakeholder (staff member) shall immediately report any allegation of abuse, and any abuse allegation must be reported to the State within two hours from the time the allegation was received. Review of the facility's document titled, Summary of Investigation, dated 03/04/2026, revealed resident to resident physical contact noted involving R12 and R46. Per review of the Summary the residents (R12 and R46) were separated and resident assessments completed. Further review revealed staff interviews were conducted, and R46 was placed on one to one (1:1) observation. In addition, the Summary of Investigation further documented, State Reported/Time (if applicable) was noted as N/A (not applicable). During an interview on 05/19/2026 at 4:00 PM, The Nurse Consultant stated the event had been an accident, and that was why the incident was not reported to the State agency. During an interview on 05/21/2026 at 9:00 AM, Registered Nurse (RN) 5 stated R46 had been leaving the day room (on 03/04/2026) aggressively, and the resident's wheelchair hit R12's chair. RN 5 further stated R46 then swung her hand striking R12 in the arm. During an interview on 05/21/2026 at 9:15 AM, RN 6 stated R46 had been exhibiting behaviors when he arrived (to work) that morning (on 03/04/2026). He reported he attempted to intervene and redirect R46 multiple times without success. RN 6 said he escorted R46 to the day room; however, R46 remained there only a couple of minutes. He stated while exiting the day room R46's wheelchair struck R12'S chair, and R46 then open handedly struck R12 on the arm. RN 6 further stated he then escorted R46 to the opposite side of the nurse's station and remained 1:1 with R46 until the Emergency Medical Services (EMS) personnel arrived. During an interview on 05/21/2026 at 9:30 AM, the Social Services Director (SSD) stated she witnessed R46 (on 03/04/2026) agitated and swinging her arms in the direction of R12, striking R12 in the left arm. During an interview on 05/21/2026 at 9:50 AM, the Interim Assistant Director of Nursing. (ADON) stated upon arrival (to work) on 03/04/2026, nursing staff informed her of the incident between R46 and R12. She said staff informed her RN 6 was providing 1:1 supervision of R46 while awaiting EMS to arrive to transport R46 to the hospital for further evaluation. During an interview on 05/21/2026 at 10:00 AM, the Interim Administrator stated he had not been employed at the facility on 03/04/2026, as Administrator when the incident involving R12 and R46 occurred. He said he did not assume the Administrator role until 04/17/2026. The Interim Administrator reported he expected staff to report all allegations and evidence of abuse, neglect, and misappropriation in accordance with the facility's policy and procedures. He further stated he would ensure reportable incidents were reported to the State Agency as required ongoing. The Interim Administrator acknowledged the previous Administrator had been responsible for the administrative oversight of the facility at the time of the incident involving R46 and R12. Telephone (Phone) attempts were made on 05/20/2026 at 4:00 PM and 05/21/2026 at 9:30 AM, and 05/21/2026 at 10:20 AM to interview the previous Administrator about the 03/04/2026 incident involving R46 and R12, and the reporting requirements. However, the attempts were unsuccessful, as the previous Administrator did not answer or return the telephone call after a voicemail was left.

Based on interview, record review, and review of the facility's investigation policies, the facility failed to ensure a thorough investigation of an alleged abuse incident was completed in accordance with its policies and investigation guidelines for 2 of 3 residents sampled for abuse out of the total sample of 24, (Resident (R)46 and R12). The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised last reviewed 01/31/2026, revealed the Facility Administrator retained ultimate responsibility to oversee and complete investigations and draw the conclusions regarding the nature of the incident. Further review of the policy under the section titled, Investigation Guidelines revealed investigations were to include interviews of involved persons, complete and thorough documentation, and determination of the root cause. In addition, policy review revealed the investigations were also to include implementation of corrective action consistent with the investigative findings. Review of the facility's document titled, Summary of Investigation, dated 03/04/2026, regarding an incident involving R46 and R12, documented resident interviews, staff interviews, resident separation, resident assessment, provider notification, family/responsible party notification, one to one (1:1) observation, and transfer to the emergency room for further evaluation. Review of the investigation summary revealed, State Reported Date/Time (if applicable): N/A was noted. Continued review revealed the facility failed to document: a final investigative determination; what the substantiation status had been; or an investigative conclusion regarding the nature of the incident. Further revealed the facility also failed to ensure the investigation was thoroughly completed, with a root cause determined, or with final investigative findings documented in accordance with the facility policy and investigation guidelines. Additionally, review of the Summary of Investigation under the nursing documentation revealed the evaluation status had been noted as, N/A: Event still open. Review of the Summary of Investigation documentation dated 03/04/2026, noting R46 exhibited escalating behaviors, including agitation, aggression, and unsuccessful redirection attempts. Per review, R46 made contact with R12 resulting in a red mark on R12's left upper arm. Further review revealed resident separation had been initiated, R46 had been placed on 1:1 observation, and emergency medical services (EMS) had been contacted to transport the resident to the hospital for further evaluation. In interview on 05/19/2026 at 4:00 PM, the Regional Nurse Consultant stated the incident involving R46 and R12 on 03/04/2026 had been considered an accident. The Regional Nurse Consultant further stated The Summary of investigation and R12's skin assessments was all she had because it was an accident and a thorough investigation was not warranted and that was why the incident had not been reported to the State Agency. During an interview on 05/21/2026 at 9:50 AM, the Interim Assistant Director of Nursing. (ADON) stated upon arrival (to work) on 03/04/2026, nursing staff informed her of the incident between R46 and R12. She stated staff informed her RN 6 was providing 1:1 supervision of R46 while awaiting EMS to arrive to transport R46 to the hospital for further evaluation and that the Administrator/Abuse Coordinator was present and aware of the situation that morning. During an interview on 05/21/2026 at 10:00 AM, With the current Administrator stated he had not been employed as Administrator at the facility on 03/04/2026 when the incident involving R46 and R12 occurred. He said he expected facility staff to report all allegations and evidence of abuse, neglect, and misappropriation in accordance with facility policy and procedure. The Administrator further stated he would ensure reportable incidents were reported to the State Agency as required ongoing. Telephone (Phone) interview was attempted with the previous Administrator on 05/20/2026 at 4:00 PM, on 05/21/2026 at 9:30 AM, and on 05/21/2026 at 10:20 AM, related to the incident involving R46 and R12 on 03/04/2026, and regarding the reporting requirements. However, all attempts were unsuccessful and a return call from the previous Administrator was never received.

Based on observation, interview, and facility policy review, the facility failed to ensure current and accurate menus were posted for resident review, which had the potential to affect all residents consuming their meals from the facility's kitchen.The findings include: Review of the facility policy labeled, Menus, revised 09/2017, revealed menus were planned in advanced to meet resident nutritional needs and identify meals and food items being served. Per policy review, menus were to be periodically reviewed and posted in the dining service department, dining rooms, and resident care areas. Observation, on 05/17/2026 at 9:38 AM, revealed menus were not posted in all designated resident dining areas. Additional observation revealed menus posted throughout the facility contained dates of 05/04/2026, 05/05/2026, 05/6/2026, and 05/22/2026 which was incorrect and therefore, the meal information was inaccurate meal. During an interview on 05/17/2026 at 11:30 AM with Resident (R)32 she stated she had received meals that were not what was listed on the menu she was provided or informed she would be receiving for her meal on multiple occasions. During an interview, on 05/17/2026 at 10:00 AM, the Interim Dietary Manager stated it was her responsibility to print and update the menus posted in the resident care areas. She reported the posted menus had not been updated to reflect the current day's meals because, she had not gotten a chance to post them. She further stated the menus were supposed to be posted the night before, and it was important for the residents to know what meals the facility was having. The Interim Dietary Manager additionally stated it was important for the menus to have the correct dates on them, so the residents were not confused. During an interview on 05/21/2026 at 10:30 AM, the Administrator stated staff were expected to follow the facility's policies and procedure regarding menu posting and accuracy.

Based on observation, interview, and review of facility policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety to prevent contamination and maintain sanitary conditions, with the potential to affect all residents receiving food from the kitchen.The findings include: Review of the facility policy titled, Meal distribution: Infection control considerations revised 09/2017, revealed meal service and warewashing practices were to follow infection control guidelines to minimize contamination and transmission of infectious agents. 1). Review of the facility policy titled, Food storage: Cold foods revised 04/2018, revealed all time/temperature control for safety (TCS) foods, frozen and refrigerated, were to be stored in accordance with Food and Drug Administration (FDA) food code guidelines. Further review revealed freezer temperatures were to be maintained at 0 Fahrenheit (F) or below; and all foods were to be stored wrapped, or in covered containers, labeled and dated, and arranged to prevent cross contamination. Review of the facility policy titled. Food: Preparation revised 09/2017, revealed dining service staff were responsible for food preparation procedures that avoided contamination. Per review, food was to be maintained at appropriate temperatures, and TCS foods held greater than 24 hours maintained at 41 F or less. Further review revealed food was to be labeled and dated with a prepared date and a use by date. Observation of the walk-in freezer, on 05/17/2026 at 9:45 AM, revealed the freezer's thermometer registered above 0 F, which was within the yellow CAUTION range, and there was condensation present around the thermometer. Per observation, condensation was dripping from around the freezer fan inside the walk-in freezer. Continued observation of the walk-in freezer revealed one box of chicken patties and one box of breaded chicken tenders stored in their original boxes/containers with the flaps and plastic packaging inside the box, opened, uncovered, and exposed to potential cross-contamination. Observation of the walk-in refrigerator, on 05/17/2026 at 9:55 AM, revealed a tray of 11 peanut butter sandwiches, two baggies of cooked chicken tenders, banana pudding, mandarin oranges, cooked chicken breast, and fruit salad not labeled or dated. Observation during a follow up visit to the kitchen on 05/18/2026 at 11:00 AM, revealed the walk-in freezer thermometer remained above 0 F, and within the yellow CAUTION range. Continued observation revealed a secondary thermometer had been placed inside the walk-in freezer, which read 11 F. During an interview, on 05/17/2026 at 10:05 AM, the Interim Account Manager (also the Dietary Manager) stated the walk-in freezer was in defrost mode and that was the reason the temperature was above 0 F and the reason for the condensation. She reported the external digital thermostat located outside the freezer door had not worked for some time and that maintenance had just been notified of that information. She further stated the opened, food should be closed and sealed, so nothing contaminates it. During an interview, on 05/17/2026 at 10:10 AM, Dietary Aide (DA) 5 stated the unlabeled food located in the walk-in refrigerator had just been prepped and placed in there and I was headed back to label it. During an interview, on 5/18/2026 at 11:00 AM, The Regional Kitchen Manager stated she placed another thermometer in the walk-in freezer. She further stated she had put in a work order for maintenance regarding the walk-in freezer's thermometer. 2). Review of the facility policy titled, Manual Warewashing revised 09/2017, revealed cookware, dishware, and service ware were to be manually washed and sanitized. Further review revealed the cookware, dishware, and service ware were to be stored appropriately prior to use or storage. Observation on 5/17/2026 at 9:35 AM, revealed serving plates stored on a plate warmer uncovered and exposed; while dietary staff completed deep cleaning activities, creating the potential for cross contamination. Observation, during a follow up visit of the kitchen, on 5/18/2026 at 3:27 PM. revealed serving plates again stored on a plate warmer uncovered and exposed, creating the potential for cross contamination During an interview, on 05/17/2026 at 10:00 AM, the Interim Account Manager (also the Dietary Manager) stated plates in the plate warmer should be covered to protect them from contaminants which might fall on the surface area of the plates where food was placed. The Interim Account Manager stated facility staff were deep cleaning. She further stated if anything fell on the uncovered plates it could make residents sick, and said, I'm just slacking today. In interview on 5/18/2026 at 3:27 PM, the Regional Kitchen Manager stated those plates should not be uncovered. During an interview with the Maintenance Director on 5/18/2026 at 4:00 PM, he stated maintenance received and completed work orders submitted in a timely manner. He further stated he just spoke with the Regional Kitchen Manager regarding the walk-in freezer's thermometer. During an interview with the Administrator on 5/21/2026 at 10:30 AM, he stated he expected kitchen staff to keep a clean and sanitary environment. He reported he expected the kitchen staff to make sure serving plates remained clean and protected from debris. The Administrator said he also expected kitchen staff to ensure food items were properly stored, dated and labeled in accordance with the facility's policy and procedure. In addition, he further stated he expected maintenance work orders to be submitted in a timely manner.

Based on observation, interview, and review of facility policy, the facility failed to maintain sanitary conditions related to the storage and disposal of garbage and refuse waste to prevent the development of odors, pests, and potential contamination.The findings include: Review of the facility's policy titled, Environmental Services (EVS) Operations Policy Manual, undated, revealed Healthcare Services Group (a contracted vendor providing housekeeping and environmental services for the facility) was committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors. Review of the facility's policy titled, Dispose of Garbage and Refuse, undated, revealed all garbage and refuse was to be collected and disposed of in a safe and efficient manner. The policy further revealed the Dietary Manager would coordinate with the Director of Maintenance to ensure the area surrounding the exterior dumpster area was maintained in a manner free of rubbish and other debris. Review of the facility's position description titled, Plant Operations Director, undated, revealed the Plant Operations Director was responsible for ensuring facility grounds were properly maintained in accordance with facility policies and state and federal regulations. 1). Observation on 05/17/2026 at 10:05 AM, of the exterior service area adjacent to the kitchen entrance, revealed 19 cigarette butts scattered across the concrete walkway immediately outside the doorway. Observation on 05/19/2026 at 7:20 AM, of the exterior service area adjacent to the kitchen entrance, revealed six cigarette butts scattered across the concrete walkway and in the grass immediately outside the kitchen doorway. In an interview on 05/18/2026 at 10:50 AM, Dietary Aide (DA) 5 stated staff should not have smoked outside the kitchen door. The DA further stated however, staff sometimes did that. In an interview on 05/18/2026 at 11:00 AM, Regional Kitchen Manager 1 stated staff were not permitted to smoke outside the kitchen door and that a designated smoking area was available for staff to use. Regional Kitchen Manager 1 stated, in regards to the cigarette butts outside the kitchen entrance, she did not know who the cigarette butts belonged to; however, she had instructed staff not to smoke in that area. In an interview on 05/19/2026 at 7:20 AM, Regional Kitchen Manager 2 stated staff should not have been smoking near the kitchen entrance. Regional Kitchen Manager 2 further stated it was not healthy for cigarette smoke to enter the kitchen where resident meals were being prepared. 2). Observation on 05/17/2026 at 10:10 AM, of the facility's exterior refuse storage area revealed three large blue refuse dumpsters, with six lids on each, positioned in the paved parking lot adjacent to the facility. Per observation, four of the dumpsters' lids were observed to be in an opened or partially opened position. Closer observation revealed refuse bags and cardboard waste visible above the rim of all three dumpsters, preventing the lids from closing completely. Additional observation revealed loose trash bags placed on top of the closed lids of one dumpster. Continued observation revealed the dumpsters were located in an open outdoor area accessible from the facility's parking lot; with the contents of the dumpsters visible from the exterior due to the lids being opened or unable to fully close over the accumulated refuse present in them. In an interview on 05/17/2026 at 10:10 AM, the Interim Dietary Manager stated the lids to the refuse dumpsters should remain closed to prevent pests from being attracted to the garbage. The Interim Dietary Manager stated if pests were attracted to the refuse area, they could potentially enter the facility and pose a health and safety risk to the residents. In an interview on 05/17/2026 at 10:13 AM, the facility's Interim District Manager stated the lids to the refuse dumpsters were to remain closed when not in use. She said having the dumpster lids opened could attract rodents and other pests to the refuse area. The Interim District Manager further stated pests attracted to the garbage area could potentially enter the facility, creating health and safety concerns for residents and staff. In an interview on 05/20/2026 at 3:00 PM, the Administrator stated it was his expectation for facility staff to keep the refuse dumpster lids closed and to follow all facility policies. He further stated the purpose of keeping the lids closed was to maintain a clean and sanitary environment for residents. In an interview on 05/20/2026 at 3:20 PM, the Maintenance Director stated he monitored the garbage refuse area and corrected overflowing refuse or opened lids when he was at the facility. He stated he was the only person in his department and if he was not at work for some reason, he was not sure if other staff checked the area. The Maintenance Director further stated he did his best to maintain a clean and homelike environment for residents but could not be everywhere at once.

Based on observation, interview, and facility policy review, the facility failed to ensure provision of a safe, functional, sanitary, and comfortable environment for residents which had the potential to affect all residents residing in the facility. The findings include: Review of the facility's policy titled, Resident Rights, last reviewed 01/31/2026, revealed all residents were to be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Further review revealed the facility was to make every effort to support each resident's rights to assure the resident was always treated with respect, kindness, and dignity. Review of the facility's, Plant Operations Director job description, version 03/2021, revealed the Plant Operations Director (Maintenance Director) was responsible for maintaining the building, equipment, and utilities in good working order. Per review, the Plant Operations Director was also responsible for ensuring the facility was properly maintained in accordance with the facility's policies and state and federal regulations. Continued review of the job description revealed the responsibilities additionally included supervising the overall maintenance operation of the facility, maintaining the building in good repair and keeping it free of hazards. Further review revealed other responsibilities of the Plant Operations Director included performing monthly maintenance checks of the building, grounds, and facility, and completing routine maintenance and repair work as needed. Review of the facility's, Plant Operations Staff job description, version 05/2022, revealed Plant Operations Staff were responsible in assisting the Plant Operations Director with maintaining the building, equipment, and utilities in good working order and ensuring the facility was properly maintained in accordance with the facility's policies. Continued review revealed the Staff responsibilities also included maintaining the building in good repair and free of hazards, completing monthly maintenance checks of the building, grounds, and facilities, and performing routine maintenance and repair work as needed. Review of the facility's, EVS (Environmental Services) Operations Policy Manual, undated, revealed the facility was committed to providing a safe, clean, and hygienic environment for residents in accordance with regulatory guidance and industry best practices. The policy further revealed the Environmental Services Department provided housekeeping and laundry services in a manner that met the physical and social needs of residents. Observation on 05/17/2026 at 10:33 AM, in the primary shower room, revealed the shower floor contained multiple floor tiles along the wall perimeter were cracked, chipped, and missing pieces, with exposed substrate visible beneath the broken tiles. Continued observation revealed patching material was present in multiple areas where floor tiles had deteriorated or were no longer intact. Further observation revealed cracked floor tiles near the entrance to the shower area and additional damaged tile surfaces extending into the back corner of the shower room. Observation on 05/17/2026 at 10:37 AM, in the secondary shower room, revealed a section of wall tile above the tub was broken and missing, with exposed foam backing material visible through the opening. Continued observation revealed a discoloration and water staining surrounding the ceiling ventilation grill, extending outward onto the ceiling surface. Further observation revealed floor tiles that were cracked, chipped, and missing pieces, with exposed substrate visible beneath the broken tiles. Additionally, observation revealed the lighting in the secondary shower room was pulsing between bright and dim. Observation, on 05/17/2026 at 12:15 PM, in resident room A-06, revealed the laminate countertop surrounding the sink in the bathroom was separated and broken at the front left corner, exposing the underlying composite material beneath the surface. Continued observation revealed damage to the flooring near the base of the resident's bed, including a torn area with black underlying material visible through the opening. Observation, on 05/18/2026 at 4:30 PM, outside resident room C-09, revealed the resident room window had three pieces of black tape of varying lengths applied to the exterior surface of the glass. Per observation, a crack was faintly visible beneath the tape near the upper portion of the covered area. Further observation revealed the black tape was unevenly layered across the damaged section of the window, creating a visibly patched appearance. Observation, on 05/19/2026 at 10:00 AM, in resident room C-03, revealed a brown discolored area on the ceiling above bed A. Per observation, the area appeared irregular in shape and was visibly noticeable above the resident's bed. During the observation, the Maintenance Director measured the discolored area and stated it measured approximately 17 inches wide by 37 inches long. During an interview on 5/17/2026 at 11:30 AM, R32 stated there was a hole in her closet wall exposing water lines and a shut off valve. The resident reported being concerned that bugs, mice, and snakes could enter through those openings. She said she had observed mice coming from the closet area once before. R32 explained there were multiple white patches on her wall throughout the room and expressed a desire for the room to be painted one color. The resident stated, This is my home, and I want it to look like a home. She also reported that water leaked from her air conditioning unit sometimes. During the interview, R32 requested the State Survey Agency (SSA) Surveyor observe her closet area. Observation of R32's closet revealed a hole in the closet wall exposing water lines and a shut-off valve. Observation of R32's room further revealed multiple white patches on the wall throughout the room that were visibly different in color from the surrounding wall areas. During an interview, on 05/17/2026 at 10:32 AM, Registered Nurse (RN) 2 stated the cracked tiles in the primary shower have been like that for a while and she had been told they were put on a list. She said she had not personally reported the cracked tiles to the maintenance department or facility administration; however, she was aware the tiles had not been repaired. RN 2 reported the broken tiles could allow water to penetrate beneath the surface, weakening the floor structure, and creating the potential for mold growth. She stated, we wouldn't want mold in a place like this, the residents are compromised and that would be bad. RN 2 stated the flickering light in the shower room had also, been like that for a while and described it as giving a horror movie effect. She further stated the flickering light could affect residents' perception and potentially increase their risk of falls. During an interview, on 05/18/2026 at 5:00 PM, Resident (R)41 stated he had notified multiple staff at the facility of his window blinds not opening and closing correctly and the issue still had not been resolved. He said if he was able to fix the blinds himself, he would and they would have already been fixed. R41 further stated he really enjoyed looking at the pond across the road from his room, and had not been able to do that since the blinds had been broken and not opening correctly. During an interview on 05/20/2026 at 3:20 PM, the Maintenance Director stated he did his best to maintain a clean and homelike environment for residents; however, he was the only person in his department and could not be everywhere at once. He reported uneven tiles could create fall risks for residents and the raised laminate would be difficult to effectively clean and disinfect due to the uneven surface. The Maintenance Director verbally acknowledged the condition could create the potential for germs to remain present creating an infection control issue. He stated he would address the laminate on the sink immediately, because it was a quick fix that would only take a few minutes. However, observation on 05/20/2026 at 4:20 PM and 05/21/2026 8:35 AM and 11:30 AM, revealed the laminate surrounding the sink in the resident's bathroom had not been repaired. During an interview on 5/21/2026 at 10:20 AM, the Interim Assistant Director of Nursing (ADON) stated a homelike environment was what the facility wished for all residents. The Interim ADON further stated they expected maintenance work orders to be handled properly and be completed in a timely manner. During an interview on 5/21/2026 at 10:30 AM, the Interim Administrator stated residents were expected to have a clean, comfortable, and personalized living environment that felt like home. He said staff were expected to submit maintenance work orders, upon identification of any environmental concerns. The Interim Administrator reported maintenance staff were expected to complete those work orders in a timely manner in accordance with the facility's policy and procedures. He further stated he had spoken with a couple of residents regarding their concerns and was working on addressing those concerns to make the environment more homelike for them.

Based on record review, interview, facility document, policy review, and review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within 14 days after the assessments were completed for three (Resident (R)12, R34, and R47) of three sampled residents reviewed for resident assessments. The findings included: A facility policy titled, Resident Assessment, revised on 09/15/2023, revealed, 15. The Assessment Coordinator will be responsible for ensuring that all required resident assessments are completed and submitted in accordance with current federal and state guidelines outlined in the RAI manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, effective 10/2024, indicated, under the Comprehensive Assessments section, The MDS must be transmitted (submitted and accepted into iQIES) electronically no later than 14 calendar days after the care plan completion date (V0200C2 + 14 calendar days). In addition, review of the Non-Comprehensive Assessments and Entry and Discharge Reporting section revealed that, The MDS must be transmitted (submitted and accepted into iQIES) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). 1. A Resident Face Sheet indicated the facility admitted R12 on 10/28/2015 and most recently readmitted the resident on 08/29/2023. Review of an annual MDS, with an Assessment Reference Date (ARD) of 02/27/2025 revealed R12's assessment was signed as complete by the MDS Coordinator on 03/10/2025. A Final Validation Report, dated 04/30/2025 at 9:22 AM, revealed the annual MDS assessment was not submitted until 04/30/2025. The Final Validation Report indicated, Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment (A0310A equals 01, 03.04, or 05). During an interview on 05/02/2025 at 10:49 AM, the MDS Coordinator reviewed R12's MDS assessment and confirmed the assessment was not transmitted timely, and he was not sure why. 2. A Resident Face Sheet indicated the facility admitted R34 on 09/17/2024 and most recently readmitted the resident on 12/18/2024. A quarterly MDS, with an ARD of 03/25/2025, revealed R34's assessment was signed as complete by the MDS Coordinator on 04/09/2025. A Final Validation Report, dated 05/01/2025 at 11:44 AM, revealed the quarterly MDS assessment was not submitted until 05/01/2025. The Final Validation Report indicated, Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment. During an interview on 05/02/2025 at 10:44 AM, the MDS Coordinator reviewed R34's MDS assessment and stated the assessment was not transmitted timely as it should have been transmitted by day 14 after completion. He stated he was not sure why the MDS was not transmitted timely other than that he was new and still learning. 3. A Resident Face Sheet indicated the facility admitted R47 on 12/11/2024. A discharge MDS, with an ARD of 01/21/2025, revealed R47's assessment was signed as complete by the MDS Coordinator on 01/27/2025. A Final Validation Report, dated 04/30/2025 at 9:31 AM, revealed the discharge assessment was not submitted until 04/30/2025. The Final Validation Report indicated, Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment. During an interview on 05/02/2025 at 10:55 AM, the MDS Coordinator reviewed R47's MDS assessment and confirmed the assessment was transmitted late. During an interview on 05/02/2025 at 5:16 PM, the Administrator revealed he expected all MDS assessments to be completed and transmitted timely according to the most recent RAI manual.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three (Resident (R) 107, R21, and R53) of 15 sampled residents. MDS data was not coded accurately, in accordance with instructions from the Resident Assessment Instrument (RAI) User Manual, related to fall history, antipsychotic use, and/or discharge status. Findings included: A facility policy titled, Resident Assessment, revised on 09/15/2023, revealed, 1. The Resident Assessment Instrument User Manual version 3.0 will be utilized for all items coded on Minimum Data Set (MDS) assessments., Care Area Assessments (CAA) development, Care planning, MDS scheduling, submission, modifications, and Medicare regulations. The policy continued, 6. Assessment data will/may be collected from sources including the resident's medical record, interview with the resident and/or resident representative, observations, assessment tools including PASRR Level II determination and the Preadmission Screening & Resident Review (PASRR) evaluation, facility electronic medical records, and from other healthcare professionals with knowledge of the resident to ensure the assessment accurately reflects the resident's status. 1. A Resident Face Sheet indicated the facility admitted R107 on 04/17/2025. Review of an admission MDS, with an Assessment Reference Date (ARD) of 04/24/2025, identified that R107 had not had any falls since admission/entry, reentry, or their prior assessment. However, review of an Event Report revealed R107 sustained a fall on 04/23/2025 at 4:02 PM, while attempting to get up unassisted. During an interview on 04/30/2025 at 9:42 AM with the MDS Coordinator and the Clinical Reimbursement Consultant (CRC), the MDS Coordinator stated R107's MDS should have indicated the resident had a fall with minor injury. The CRC confirmed the resident's fall was not captured in the MDS and should have been recorded as a fall with minor injury. During an interview on 05/02/2025 at 5:13 PM, the Administrator stated R107's fall on 04/23/2025 should have been captured in the resident's MDS assessment. 2. A Resident Face Sheet indicated the facility admitted R21 on 09/02/2020, and most recently readmitted the resident on 08/11/2021. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of paranoid personality disorder; major depressive disorder, and schizophrenia. a. Review of R21's 12/2024 Medication Administration History revealed documentation that the resident received Seroquel 25 milligrams (mg) in the morning on 12/07/2024, 12/08/2024, 12/10/2024, 12/11/2024, and 12/12/2024 and received Seroquel 100 mg at bedtime on 12/07/2024, 12/08/2024, 12/09/2024 and 12/13/2024. Review of R21's quarterly MDS, with an ARD of 12/13/2024, revealed the resident took an antipsychotic medication during the last seven days or since admission/entry or reentry if less than seven days. However, under section N0450. Antipsychotic Medication Review, the MDS was marked, 0. No- Antipsychotics were not received, which indicated the resident did not receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever was more recent. b. Review of R21's 03/2025 Medication Administration History: 03/01/2025 - 03/31/2025 revealed documentation that the resident received Seroquel 25 mg in the morning on 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025 and 03/14/2025 and received Seroquel 100 mg at bedtime on 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, and 03/14/2025. Review of R21's quarterly MDS, with an ARD of 03/14/2025, revealed the resident took an antipsychotic medication during the last seven days or since admission/entry or reentry if less than seven days. However, under section N0450. Antipsychotic Medication Review,' the MDS was marked 0. No- Antipsychotics were not received, which indicated the resident did not receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever was more recent. During an interview on 04/30/2025 at 9:52 AM with the MDS Coordinator and the CRC, the MDS Coordinator stated R21's MDS related to the Antipsychotic Medication Review should have indicated the resident routinely received antipsychotic medications. He stated it was an oversight when he was reviewing the resident record. The CRC confirmed the MDS assessments were coded incorrectly. During an interview on 05/02/2025 at 5:15 PM, the Administrator stated he expected the MDS Coordinator to review the resident's entire medical record and complete MDS assessments accurately. 3. A Resident Face Sheet indicated the facility admitted R53 on 02/07/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of unspecified displaced fracture of the first cervical vertebra. Review of a physician's order, dated 02/21/2025, revealed an order for R53 to discharge home with home health services. Per the Resident Face Sheet, the resident discharged home with home health services on 02/28/2025. Review of a Resident Progress Notes, dated 02/28/2025 at 12:16 PM, also revealed R53 discharged home with home health services. Review of the discharge MDS, with an ARD of 02/28/2025, revealed it documented R53's discharge status as 04. Short-Term General Hospital, rather than a discharge to home. During an interview on 05/02/2025 at 10:47 AM, the MDS Coordinator stated R53's discharge location documented in the MDS was inaccurate, confirming that the resident discharged home with home health services and did not discharge to the hospital. He stated it was a mistake and the MDS should have been coded as 12, for home under care of organized home health service organization, not 04, for a short-term hospital. During an interview on 05/02/2025 at 1:29 PM, the Director of Nursing (DON) stated R53's MDS assessment was inaccurate. He stated the MDS should have been coded to identify the resident discharged home with home health services, not to a short-term hospital. He stated his expectation was for MDS assessments to be completed accurately. During an interview on 05/02/2025 at 5:15 PM, the Administrator stated he expected all MDS assessments to be completed accurately. He stated R53's MDS discharge assessment was inaccurate and should have reflected that the resident discharged home and not to a hospital.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an environment that was free from verbal abuse involving one (1) of eighteen (18) sampled residents (Resident #7). On 08/02/2023, Resident #8 entered Resident #7 room and cursed at Resident #7. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, effective 05/27/2016, revealed it was the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or state laws which involved abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property are investigated, and reported immediately to the facility administrator, the state survey agency, and other appropriate state and local agencies in accordance with federal and state law. Continued review of the facility's policy revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which included verbal abuse, sexual abuse, physical abuse, mental abuse, and abuse facilitated or enabled through the use of technology. Additional review of the policy revealed verbal abuse was defined as the use of any oral, written, or gestured language that included any threat, or any frightening, disparaging, or derogatory language, to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability. Review of the facility investigation, dated 08/02/2023, revealed Resident #8 rolled his/her chair into Resident #7's room and cussed at Resident #7 and Resident #7 became upset. Continued review of the facility investigation revealed the allegation was unsubstantiated due to neither resident had willful intent to do harm. Additional review of the facility investigation revealed the incident was reported to the Ombudsman, DCBS, and OIG on the day of the incident and five days later for the final report. Review of Resident #7's Admission Record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses to include Unspecified Dementia without behavioral disturbance and Unspecified Mental Disorder due to known physiological condition. Review of Resident #7's Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had been assessed by the facility as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #7's Comprehensive Care Plan (CCP) initiated on 11/20/2023 revealed Resident #7 was at risk for psychosocial harm related to stress following an unexpected environmental change with a goal to include the resident would have minimal to no alterations in mood and behavior. Interventions included discuss with Resident #7 any concerns or fears he/she may have as needed. Continued review of Resident #7's CCP revealed Resident #7 was at risk for Activities of Daily Living (ADLS) related to unspecified dementia with a goal to include the resident would express satisfaction with daily routine and leisure activities. Interventions included to provide materials of interest (craft supplies and puzzles) as well as playing gospel and country music initiated 08/03/2023. Review of Resident #7's Progress Note dated 08/02/2023, entered by Registered Nurse (RN) #2, revealed Resident #8 rolled into Resident #7's room and cussed at him/her and Resident #7 became upset. Review of Resident #7's Skin assessment dated [DATE] no skin issues were observed after the incident. Review of Resident #7's Progress Note dated 08/03/2023, entered by Director of Nursing (DON), revealed Resident #7 was upset when Resident #8 wandered in his/her room. Review of Resident #7's Psychiatric Progress Note dated 08/09/2023, entered by Advanced Registered Nurse Practitioner (ARNP) #1, revealed Resident #7 had no documented behaviors since the incident on 08/02/2023 and no new recommendations documented. Review of Resident #7's Safety Check Logs dated 08/02/2023, 08/03/2023, and 08/04/2023 revealed Resident #7 continued on every fifteen (15) minute checks after the incident. Observation of Resident #7 on 12/19/2023 at 9:34 AM, 12/20/2023 at 1:46 PM, and 12/21/2023 at 11:40 AM revealed Resident #7 was calm with clean, neat appearance, well-groomed, no foul odor, and no behavioral outbursts were observed. Continued observations revealed Resident #7 stayed in his/her room and worked on puzzle books, sewing crafts, and watched TV. During an interview with Resident #7 on 12/19/2023 at 9:27 AM, he/she stated he/she did not want Resident #8 in his/her room so he/she shooed (Resident #7 made a hand gesture to leave) Resident #8 out of his/her room. Resident #7 did admit he/she made contact with Resident #8's leg, but stated he/she was just trying to get Resident #8 out of the room as Resident #8 was cussing and fussing. Review of Resident #8's Admission Record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses to include Unspecified Dementia with behavioral disturbance and Unspecified Depression. Review of Resident #8's Quarterly MDS dated [DATE] revealed Resident #8 had been assessed by the facility as having a BIMS) score of four (4) out of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #8's Comprehensive Care Plan (CCP) dated 02/05/2021, revealed focus of behaviors; cursing at others, hitting at others; and making incoherent noise initiated on 05/25/2023 with a goal to include Resident #8's behaviors would not result in disruption of others environment. Interventions included place dog picture on door initiated on 11/10/2021, offer to play favorite music initiated on 02/05/2021, increase involvement in activities initiated on 11/10/2021, Social Service Director (SSD) to follow up for any mood changes initiated on 08/22/2022, use diversional activities initiated on 11/09/2021, assisting resident away from other residents initiated on 08/03/2023, observe for unmet needs and offer toileting, food, fluids, and offer to lay down for rest periods initiated on 08/03/2023, and psych consult on next routine visit initiated on 08/03/2023. Review of Resident #8's Progress Note dated 08/02/2023, entered by Registered Nurse (RN) #2, revealed Resident #8 rolled into Resident #8's room and cussed at him/her and Resident #8 became upset. Review of Resident #8's Skin assessment dated [DATE] no skin issues were noted after the incident. Review of Resident #8's Psychiatry Progress Note dated 08/09/2023 revealed Resident #8 was pleasantly confused with labile mood and intermittent behaviors. Continued review of the progress note revealed Resident #8 was not a danger to self or others and no new recommendations was documented. Review of Resident #8's Safety Check Log dated 08/02/2023, 08/03/2023, and 08/04/2023 revealed Resident #8 continued on every fifteen (15) minute checks after the incident. Observation on 12/19/2023 and 12/20/2023 revealed Resident #8 was up in broda chair with clean, neat appearance, well-groomed, no body odor, and confused. Resident #8 was observed to be sitting by the nursing station making incoherent sounds. Due to Resident #8's cognitive status, the resident was not able to discuss the incident that occurred on 08/02/2023. During an interview with Medical Director (MD) on 12/15/2023 at 3:34 PM, she stated she had Resident #7 as a resident. The MD stated she was made aware of the resident-to-resident allegations whenever she was the acting MD of the residents. The MD stated Resident #7 had a brain injury as a child and he/she could be quite funny at times. The MD stated due to Resident #7's cognition, he/she would not be able to do something willful to another resident. The MD stated she would expect the facility staff to follow the policies and to protect the residents from abuse. During an interview with former Social Services Director (SSD) #2 on 12/20/2023 at 9:15 AM, she stated she was the SSD during the incident between Resident #7 and Resident #8. SSD #2 stated Resident #7 liked to stay in his/her room a lot and Resident #7 and Resident #8 knew each other prior to them coming to the facility. SSD #2 stated Resident #8 wandered around the facility and he/she had good days and bad days. SSD #2 stated Resident #8 was sitting in the doorway of Resident #7's room cursing, and Resident #7 started yelling for him/her to get out of his/her room. SSD #2 stated she did the follow up with the previous administrator, but she could not remember her name. SSD #2 stated care plan was updated to move Resident #8 to another part of the facility and she did psychosocial assessment for 3 days after the incident. SSD #2 doesn't remember any other incident between the residents. During an interview with SSD #1 on 12/21/2023 at 11:57 AM, she stated if she suspected abuse between 2 residents, she would separate the residents immediately and report to charge nurse. She stated she would then report the incident to the administrator. She stated Resident #8 was seen monthly by psychiatry for any behaviors but could be seen weekly if needed. SSD #1 stated the types of abuse are physical, sexual, emotional/mental, verbal, neglect, and misappropriation and she would expect the staff to follow the policies and to protect all residents from abuse. She stated staff being more involved with the residents by trying to distract or divert from the behavior by walking with the resident, talking to the resident, taking residents to scheduled activities, and watching TV with the residents. SSD #1 stated these techniques were good to prevent the behaviors. During an interview with Certified Nursing Assistant (CNA) #3 on 12/20/2023 at 10:31 AM, she stated she Resident #7 and Resident #8 knew each other prior to both admissions to the facility. CNA #3 stated Resident #8 was in his/her wheelchair and in the doorway of Resident #7. CNA #3 stated she heard cursing and went to investigate but RN #2 was already there and separating the residents. CNA #3 stated Resident #8 was doing his/her usual yelling like always and was known to curse at others in the past. CNA #3 stated if she suspected abuse or witnessed abuse, then she would make sure the residents were separated and safe and would go report the abuse to her charge nurse. During an interview with RN #2 on 12/20/2023 at 1:43 PM, she stated she had worked at the facility for about 7 or 8 years. RN #2 stated Resident #8 wheels him/herself up and down the hallway most days. RN #2 stated she was helping another resident at the nursing station when she heard an oh and she went to check it out. RN #2 stated Resident #8 was in his/her wheelchair in doorway of Resident #7's room cursing at Resident #7. She stated Resident #7 was making a shoo motion (gestured with hand to leave) at Resident #8. RN #2 stated she did not witness physical contact between the two residents. RN #2 stated she separated both residents and checked both residents for injuries. RN #2 stated she did not see any injuries on either resident. RN #2 stated Resident #8 had occasional behaviors of fussing and cussing at staff. RN #2 stated she reported the incident immediately to the Director of Nursing (DON) after assessing both residents for injuries. RN #2 stated staff moved Resident #8 to another wing of the facility and Resident #8 was placed on 1:1 monitoring. RN #2 stated Resident #7 just did not want Resident #8 in his/her room and was usually never mean and usually pleasant to everyone. RN #2 stated abuse training included types of abuse, first thing to do if you suspect abuse, how to report abuse, and what to do if you suspect abuse. RN #2 stated if abuse was suspected she would remove the alleged abuser from the scene, ensure residents were safe, and report immediately to the administrator who was the abuse coordinator in the facility. During an interview with the DON on 12/21/2023 at 1:16 PM, she stated she remembered the incident between Resident #7 and Resident #8. The DON stated Resident #7 was placed on 1:1 monitoring, both residents were separated, and psychiatry services was consulted to evaluate both residents. The DON stated abuse training occurred after any resident-to-resident altercation or after any abuse allegation in the facility. The DON stated it was her expectation for all staff to follow the facility policies and to protect the residents from abuse. During an interview with the Administrator on 12/21/2023 at 1:54 PM, she stated she had been the administrator in the facility since August 2023. The Administrator stated she encouraged the use of redirection after resident-to-resident altercations, and she knew Resident #8 liked to talk about clothes. The Administrator stated the Interdisciplinary Team (IDT) met and discussed all resident-to-resident altercations in the next stand up meeting after an incident occurred in the facility. The Administrator stated the IDT discussed what happened and what the plan was moving forward. The Administrator stated the Quality Assurance Performance Improvement (QAPI) team would cover all abuse allegations in an ad hoc QAPI meeting after an incident occurred and during the routine monthly meeting after the incident. The Administrator stated QAPI met to discuss the reportable and what interventions need to be put into place or if anything needed to be changed or revised from the incident. The Administrator stated it was her expectation for staff to follow abuse policy and any staff who violated the policy would be written up.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resident received a written notice, including the reason for the change, before the resident's room or roommate in the facility had been changed for one (1) of eleven (11) sampled residents (Resident #4). Record review and staff interview revealed Resident #4 had a roommate for eight (8) days during the month of March 2022. Additionally, Resident #4 was private pay from 11/03/2021 to 03/21/2022. The findings include: Review of the facility policy titled, Resident Rights,updated 04/17/2023, revealed the facility recognized the basic right for each resident to participate in decisions, voice grievances, and have the facility respond to those grievances. Record review revealed the facility admitted Resident #4 on 08/25/2021 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Rheumatoid Arthritis, Muscle Weakness, Cognitive Communication Deficit, Dementia, Delirium, Anxiety, and Encephalopathy. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment, dated 03/03/2022, revealed the facility did not assess the resident's Brief Interview for Mental Status (BIMS) score. However, review of the Admission MDS assessment, dated 09/01/2021, revealed the resident was assessed to have a BIMS score of eight (8) out of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #4's COVID Test, dated 03/10/2022, revealed the resident was COVID positive. Review of Resident #4's Progress Note, dated 03/14/2022, revealed the family had been notified the resident would have a roommate during COVID related to not having enough COVID rooms for the resident to remain in a private room. Continued review revealed no documented evidence to support the family had been notified in writing Resident #4 would have a roommate nor had the resident or family been given a choice to have another resident moved into the Private Room with Resident #4. Review of Resident#4's Notes Report, dated 04/12/2022, revealed the business office took eight (8) days from private rate for Resident #4 not being in a private room during COVID, per the Administrator. A new statement was sent to the Administrator and Assistant Business Office Manager to send to the family. Review of Resident #4's Facility's [NAME] Statements for November 2021 through March 2022 revealed Resident #4 had been billed at a semi-private room rate of two-hundred and thirty-two dollars ($232) daily for eight (8) days. Resident #4 no longer resided in the facility. Interview with Family Member #4, on 04/20/2023 at 10:58 am., revealed when they had window visit the resident on 03/12/2022, the resident was in a private room. Per interview, when the family had another window visit on 03/13/2022, the resident had a roommate. Family Member #4 stated, the family was not notified Resident #4 would be getting a roommate prior to the window visit on 03/13/2022. Interview with the Business Office Manager (BOM), on 04/20/2023 at 12:05 p.m., revealed Resident #4 had a roommate from 03/13/2022 to 03/20/2022. She further stated the family was sent a bill on 02/20/2022 for the month of March 2022, as bills were sent out each month to prepay for the following month. She continued to state Resident #4's family did not prepay his/her bill every month but did pay at the end of the month. She stated Resident #4's March 2022 bill had been adjusted to include the semi-private rate of $232 a day (total $1936) because Resident #4 had a roommate 03/13/2022 to 03/20/22. She further stated Resident #4 discharged from the facility on 03/21/2022 and was not billed for that date. She continued to state the resident's family paid $2904 on 04/14/2022 and the remaining $1936 was written off the bill on 04/30/2022. Interview with the Administrator, on 04/20/2023 at 12:29 p.m., revealed she had been a Signature stakeholder since September 2021, and it was her expectation if a resident was paying privately, they would go through the BOM and pay the current rate for a room and receive the same care as other residents. She stated the resident and/or resident's family had a right to be notified prior to any room change. She further stated if a resident was in a private room, she would have to get clearance from her supervisors before another resident was moved into that room. She continued to state the nurse or the social services director should notify the resident and/or resident's family before a resident changed rooms or a roommate was moved into the room. Interview with the Regional Nurse Consultant, on 04/20/2023 at 12:50 p.m., revealed Resident #4 did have a roommate beginning 03/13/2022. However, the only documentation the facility could provide of family notification was the 03/14/2022 Progress Note. She further stated the resident and or family should have been notified in writing of a change in room status.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible for one (1) of eleven (11) sampled residents, Resident #2. In addition, the facility had 3 wandering residents located within the facility. Observation, on 04/18/2023 at 9:43 a.m., revealed Housekeeper #1 closed the door to the housekeeping cart and entered Room C9 and closed the door. The cart was left unlocked and unattended by staff with Resident #1 standing in the hallway across from the cart. Resident #1 had a Brief Interview for Mental Status score of eleven (11) out of fifteen (15) indicating the resident was cognitively intact. The findings include: Review of the facility's policy titled Stocking a Cart dated 11/2018, revealed a locked box was required if chemicals were stored on a cart. Continued review revealed this was especially important in resident areas. Observation, on 04/18/2023 at 9:43 a.m., revealed Housekeeper #1 closed the door to the housekeeping cart and entered Room C9 and closed the door. The cart was left unlocked with chemicals stored inside and Resident #1 standing in the hallway across from the cart. Interview, on 04/18/2023 at 9:44 a.m. with Housekeeper #1 revealed she had worked in the facility for a few months. She stated the cart should be locked to prevent residents from getting in the cart and drinking something that could hurt them. She further stated, I should have locked the cart before I went into the room, we just had an in-service yesterday with our supervisor about making sure the cart was locked. Review of the Safety Data Sheet for Glance NA Glass and Multi-Surface Cleaner Non-Ammoniated, Version Number Five (5), revealed the product could cause serious eye damage/eye irritation. Review of the Safety Data Sheet for Prominence Heavy Duty Floor Cleaner revealed this product could cause skin corrosion/irritation and for serious eye damage/eye irritation. Review of the Safety Data Sheet for Sealed Air Diversey Care Good Sense HC 7 Liquid Air Freshener revealed the product could cause Skin Corrosion/Irritation and Serious Eye Damage/Eye Irritation. Review of the Safety Data Sheet for Ecolab Peroxide Multi Surface Cleaner and Disinfectant revealed the product could cause Oral Acute Toxicity, Inhalation Acute Toxicity, Dermal Acute Toxicity, Skin Corrosion, Serious Eye Damage, and Skin Sensitization. Interview on 04/18/2023 at 1:30 p.m. with the Housekeeping Supervisor revealed the top drawer of the housekeeping cart could be unlocked because no chemicals were stored there but the lower door of the cart should be locked when not attended by staff because there were cleaning chemicals stored in the care that could harm residents. Further interview revealed she had just in-serviced staff the prior day about ensuring the carts were locked when not in attendance. It was her expectation staff follow the facility's policy and lock the housekeeping cart to ensure residents did not have access to the chemicals stored in the cart. Interview, on 04/20/2023 at 12:29 PM, with the Administrator revealed the facility had three (3) wandering residents with a BIMS score at Eight (8) or below, meaning these residents had severe cognitive impairment. It was her expectation that the Housekeeping Carts remain locked to protect residents from harm. She stated housekeeping is a contracted service, and she expected the housekeeping carts would be locked to keep residents and visitors out of the cart to keep them from getting hurt. She continued to state she excepted all staff to follow the policies to protect residents, families, visitors, and staff from harm.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation, on 04/18/2023 at 7:55 a.m. revealed Registered Nurse (RN) #1 exited the medication room across from the nurse's station leaving the door unlocked and unattended by nursing staff. Additional observation of the medication room revealed the medication cart had been left unlocked. Continued observation revealed Resident #1 and Resident #2 sitting in wheelchairs in the day room near the nurse's station. Record review revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was severely cognitively impaired. The findings include: Review of the facility's policy titled Medication Storage, Storage of Medication, dated 01/2021, revealed medications and biologicals were expected to be stored properly to maintain their integrity and to support safe effective drug administration. The medication supply should be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review revealed medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. Observation, on 04/18/2023 at 7:55 a.m. revealed RN #1 exited the medication room across from the nurse's station leaving the door unlocked and unattended. Additional observation of the medication room revealed the med cart had been left unlocked. Continued observation revealed Resident #1 and Resident #2 sitting in wheelchairs in the day room near the nurse's station. Record review revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was severely cognitively impaired. Interview with Unit Manager (UM) #1, on 04/18/2023 at 8:00 a.m., revealed the medication room and medication cart should have been locked to protect residents from getting into medication/chemicals that could be harmful or causing death. Further interview revealed the computer on top of the medication cart should have been locked to protect protected health information, and to prevent others from seeing confidential resident information. Interview with the Director of Nursing (DON), on 04/19/2023 at 10:30 a.m., revealed she expected all staff to follow the facility policies and the medication room, medication carts, and computers should be locked per policy. Continued interview revealed the facility had three (3) residents that wandered whose BIMS score had been assessed to be eight (8) or below, which indicated the residents had severe cognitive impairment. Interview, on 04/20/2023 at 12:29 PM, with the Administrator revealed the facility had three (3) wandering residents in the facility with a BIMS score at Eight (8) or below, meaning these residents had severe cognitive impairment. It was her expectation that the medication storage room, medication carts and computers were locked per the Director of Nursing instructions and per facility policies. She further stated all medications should be within date, stored at proper temperatures. She continued to state this was important to keep residents, visitors, and unauthorized staff from being able to get into these areas and take medications or chemicals they are not supposed to and could overdose or possibly die. She continued to state she excepted all staff to follow the policies to protect residents, families, visitors, and staff from harm.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to have sufficient staffing to provide for the care needs of the residents in the facility. Resident #10 and Resident #15 had incontinence episodes while waiting on staff to help them to the bathroom. Resident #30 and Resident #20 did not receive assistance with shaving due to insufficient staff and were observed to have several days' growth of beard. The findings include: Review of the facility policy titled, Scheduling and Staffing, revised date 11/07/2018, revealed, The facility will staff the building using the following considerations, when applicable as it pertains to each individual facility resident needs and population: A.) Acuity Based Staffing modeling as a guideline, not a minimum, which considers our resident populations Minimum Data Set (MDS) input; each facility's volume of assessments and admissions. B.) State and Federal regulations; any mandated staffing minimums. C.) Reviews of the acuity level and needs of the current resident population by the facility Administrator/Chief Executive Officer (CEO) and Director of Nursing (DON). Review of the facility Daily Staffing Form, a form posted daily by the facility showing the resident census for the day and the actual hours worked by the staff, for 09/01/2020 through 09/24/2020, revealed one day with a resident census of 36, one day with a resident census of 38, one day with a resident census of 39, one day with a resident census of 40, six days with a resident census of 41, ten days with a resident census of 42, and four days with a resident census of 43; for an average daily census of 41 residents from 09/01/2020 through 09/24/2020. Further review of the daily staffing forms, revealed an average of daily worked hours of 121 for the same timeframe. Interview with the Administrator revealed the facility was expected to have 3.25 hours of work for each resident. Therefore, the facility would be expected to provide an average of 133.25 worked hours, which was an average of 12.25 less work hours than what was expected. There were 13 days between 09/01/2020 and 09/24/2020 with three (3) State Registered Nurse Aides (SRNAs) to perform care for residents on the 7:00 AM - 7:00 P.M. shift. Review of the Facility Assessment, dated 2020, revealed the areas of Daily Care, Bed Mobility, Bathing, and Hygiene/Grooming were marked In Progress. Interview with the Administrator on 09/25/2020 at 12:51 PM revealed the In Progress meant not enough staff to perform those care areas. 1. Observation on 09/22/2020 at 10:23 AM, of Resident #20 and Resident #30, revealed both residents were sitting in the lobby in wheelchairs. Both residents had a heavy growth of beard on their faces. Observation on 09/23/2020 at 8:58 AM of Resident #20 and Resident #30 revealed both residents in their beds still with several days' growth of facial hair. Record review revealed the facility admitted Resident #20 to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of Resident #20's MDS revealed the facility had assessed the resident to be totally dependent on staff for personal hygiene. Review of Resident #20's Care Plan dated 06/03/2020 revealed the resident's ADL Function related to ability to maintain personal hygiene has deteriorated related to Dementia with an approach for showers twice a week per preference. Review of Resident #20's shower sheets for the month of September revealed the resident received a shower two (2) times a week but did not indicate when the resident was shaved. Record review revealed the facility admitted Resident #30 on 10/23/2018 with [DIAGNOSES REDACTED]. Continued review of Resident #30's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed the facility had assessed Resident #30 to require extensive assistance (resident involved in activity staff provided weight bearing support) with personal hygiene. Review of Resident #30's care plan dated 06/03/2020 revealed the resident's ADL Function related to ability to maintain personal hygiene has deteriorated with an approach for showers twice a week per preference. Review of Resident #30's shower sheets for the month of September revealed the resident received a shower two (2) times a week but the shower sheet did not indicate when the resident was shaved. Interview on 09/22/2020 at 4:03 PM, with Resident #30, revealed the resident rubbed his/her face and stated, I don't like it when asked if they liked to have hair on their face. An interview was attempted with Resident #20, on 09/22/2020 at 4:03 PM; however, the resident did not answer when questioned. Interviews with Resident #6 (BIMS score 15), Resident #10 (BIMS score 10), Resident #15 (BIMS score 14), Resident #17 (BIMS score 15), and Resident #86 (new admission and BIMS score not assessed yet), on 09/23/2020 at 2:00 PM, during the Resident Council meeting revealed the facility did not have enough staff to answer call lights in a timely manner. Residents stated that the average wait time for staff to answer a call light was 30 - 35 minutes; however, they sometimes waited up to an hour. Interview on 09/22/2020 at 3:00 PM, with State Registered Nurse Aide (SRNA) #1, revealed there were usually three SRNAs on the day shift and each SRNA usually had two to three resident showers to give. She stated they try to shave residents on shower days but sometimes there was just not enough time. She further stated she had fourteen (14) residents to care for today (09/22/2020) with two (2) resident baths to complete. Further interview revealed she would be able to get turns and baths done but it was hard to give all the assistance needed. Interview on 09/23/2020 at 9:11 AM, with SRNA #3 revealed, We absolutely do not have enough staff. Most of the time there were three (3) SRNAs on the day shift and three (3) on the night shift. We have lost a lot of good staff due to not having enough help. Interview on 09/24/2020 at 5:05 PM, with SRNA #2, revealed she had shaved Resident #20 and Resident #30 because they needed it and we had extra staff yesterday (09/23/2020). She further revealed she only shaved them and did not shower the residents because they were not due a shower. She stated the residents should be shaved on their shower days but sometimes it was just not possible due to not enough time. Interview with Nurse #3, on 09/25/2020 at 9:15 AM, revealed that most days there were two nurses and three SRNAs. She further stated that three SRNAs was not enough staffing. Interview on 09/23/2020 at 12:30 PM, with the Director of Nursing (DON), revealed they like to have four SRNAs on the day shift. Further interview revealed currently the facility did not have restorative nursing in the building because they don't have the staff for it at this time. The DON stated she had residents to tell her they have had to wait a while for staff to answer call lights. The DON stated she knew what the facility assessment was but she had not had any input into it. She stated she made rounds several times a day and had not identified any concerns with resident care. Interview with the Administrator, on 09/25/2020 at 12:51 PM, revealed the facility assessment was a model where input was entered into the system and it shoots out the results. He stated the model he had used was based on a census of 37 and it showed in progress for areas of Daily Care, Bed Mobility, Bathing, and Hygiene/Grooming. When asked to explain why the area said in progress he said that meant those areas were not sufficiently staffed. The Administrator stated they would like to see four SRNAs on the day shift. 2. Review of the medical record for Resident #10 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS for Resident #10, dated 07/03/2020, Section C0500, Cognitive Patterns, revealed the resident had a BIMS score of fifteen (15) indicating the resident is cognitively intact. Further review of the MDS Section G0110, Functional Status, Section I, Toilet Use, revealed the resident required extensive assistance of two (2) plus persons for toileting. Review of the MDS Sections H0300 and H0400, Bladder and Bowel, revealed the resident was occasionally incontinent of urine and bowel. Review of Resident #10's Comprehensive Care Plan dated 02/04/2020 revealed the resident has a potential for complications associated with urinary incontinence related to [MEDICAL CONDITION] with an intervention for staff to check the resident for incontinence episodes and provide perineal care after each incontinence episode. Observation of Resident #10, on 09/22/2020 at 4:04 PM, revealed the resident sitting up in his/her wheelchair in her room. Interview with Resident #10, on 09/24/2020 at 9:39 AM, revealed he/she frequently had to wait for over twenty (20) minutes for staff to answer his/her call light to provide incontinence care. Resident #10 further revealed he/she would ring his/her call light informing staff he/she needed assistance to be cleaned up and had to wait for extensive periods of time over twenty (20) minutes. Interview with State Registered Nurse Aide (SRNA) #2, on 09/24/2020 at 4:12 PM, revealed rounds should be done every two (2) hours to check residents for incontinence to provide perineal care, or if the resident had an episode of incontinence as soon as possible to provide care. SRNA #2 further revealed Resident #10 was incontinent at times. SRNA #2 also revealed rounds should be done every two hours to check residents for incontinence to provide perineal care, or if the resident had an episode of incontinence as soon as possible to provide care. SRNA #2 revealed staff were not always able to provide care timely to the residents due to not having an adequate number of staff to provide the care. Interview with LPN #1, on 09/24/2020 at 4:03 PM, revealed Resident #10 did have incontinence episodes. LPN #1 further revealed staff try to make rounds every two hours to check the residents for incontinence or provide the perineal care as soon as possible if the resident has had an episode of incontinence. The LPN also revealed perineal care was provided late at times due to not having an adequate number of staff to provide the care. Interview with the Director of Nursing (DON), on 09/24/2020 at 4:29 PM, revealed staff should make rounds every two (2) hours to check residents for incontinence or if a resident had an incontinence episode, the resident should be provided perineal care immediately. The DON revealed she was not aware of any residents having to wait over five (5) to ten (10) minutes for care when they ring their call light. The DON further revealed she monitored call lights being answered and monitored for incontinence care by making rounds daily. The DON revealed she was not aware of any resident not receiving incontinence or perineal care as needed.

Based on observation, interview and facility policy review it was determined the facility failed to ensure food was stored under sanitary conditions (covered, labeled and dated) for 12 residents who receive thickened liquids. In addition, observation, on 09/22/2020 at 9:50 AM, revealed unlabeled and undated food and food products being stored in the refrigerator for use. The findings include: Review of the facility policy titled, Food Storage, revised 03/09/2020, revealed food products should be covered, labeled and dated. Observation of the walk in refrigerator during initial tour of the kitchen, on 09/22/20 at 9:50 AM, revealed forty-eight (48) small clear plastic cups covered with clear plastic wrap, on large trays with a yellow/golden thick liquid in each cup unlabeled and undated. Per interview with the Dietary Manager at the time of the observation, the yellow/golden thick liquid was nectar honey flavored thickener, used to thicken liquids for residents that require thickened liquids for drinking. The observation also revealed forty-eight (48) small clear plastic cups covered with clear plastic wrap on large trays with a red thick liquid in each cup unlabeled and undated. The Dietary Manager revealed this was cranberry flavored thickener, used to thicken liquids for residents requiring thickened liquids for drinking. Further observation of the walk in refrigerator during initial tour in the kitchen, on 09/22/20 at 9:50 AM, revealed five (5) bowls covered with clear plastic wrap containing what appeared to be vegetable soup that were unlabeled and undated along with two (2) bowls covered with plastic wrap, containing brown beans that were unlabeled and undated. The observation also revealed four (4) bowls covered with plastic wrap unlabeled and undated containing a slice of onion and tomato in each bowl. Interview with the Dietary Cook, on 09/24/2020 at 8:27 AM, revealed all food stored in the kitchen should always be labeled and dated. The Dietary Cook revealed she had just prepared the thickener in the cups. The Dietary Cook stated she was going to use the thickener soon and did not take the time to label and date the cups. The Dietary Cook further revealed she did not know why the bowls containing the vegetable soup, brown beans and onion and tomato were not dated. The Dietary Cook revealed she had been trained to cover, label and date all food products in the kitchen. Interview with the Dietary Manager, on 09/24/2020 at 9:05 AM, revealed all food products in the kitchen should always be covered, labeled and dated. The Dietary Manager further revealed she had recently became dietary manager and was in the process of organizing the kitchen. The Dietary Manager also revealed all staff had been trained in covering, labeling and dating all food products. The Dietary Manager revealed she monitored covering, labeling and dating of food products by spot checking daily.

Based on observation, interview, and record review, it was determined the facility failed to develop a comprehensive care plan for one (1) resident (Resident #15) and failed to implement the care plan for one (1) of fifteen (15) sampled residents (Resident #10). Resident #15 had an admission assessment with a reference date of 07/14/2020 that assessed the resident to be occasionally incontinent of urine. The facility failed to develop a care plan to address the resident's toileting needs. Resident #10's care plan stated for the resident to be checked for incontinence episodes every two (2) hours; however, the facility failed to implement Resident #10's care plan and the resident had to wait extended amounts of time for incontinence care. The findings include: Review of the facility policy titled Comprehensive Care Plans, with a last reviewed and revised date of 07/19/2018, revealed a person-centered comprehensive care plan is developed for each resident to meet the resident's medical, nursing, mental, and psychological needs. 1. Review of the record for Resident #15 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed an admission Minimum Data Set (MDS) assessment with a reference date of 07/14/2020 that assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating the resident was interviewable. The assessment also stated the resident was occasionally incontinent of bladder (defined as less than seven episodes of incontinence in the previous seven days). Further review of the MDS revealed the resident required the extensive assistance of two (2) staff persons for transfers and toileting needs. Review of the comprehensive care plan under the category of elimination, and a problem start date of 09/23/2020, revealed the resident had a potential for complications associated with urinary incontinence and the approaches or interventions included to check the resident for incontinence episodes approximately every two (2) hours and provide peri (perineal) care after each incontinence episode. The care plan did not include any interventions or information related to toileting needs. Observation of Resident #15, on 09/22/2020 at 9:28 AM, revealed the resident was in a wheelchair in the hallway and was independently moving himself/herself throughout the facility. Interview with Resident #15, on 09/23/2020 at 9:26 AM, revealed the resident stated that he/she was mostly continent of bladder, but the staff did not respond to the call lights in a timely manner which caused the resident to have incontinence episodes. The resident stated although he/she is continent, he/she required assistance to get to the restroom. The resident further stated that the incontinence episodes occur at least every other day. Interview with State Registered Nursing Assistant (SRNA) #6 on 09/24/2020 at 10:21 AM revealed that she often cared for Resident #15. SRNA #6 stated that the resident was incontinent at times. She stated that the resident calls out for assistance for toileting, but staff usually have to change Resident #15 because the resident has been incontinent. SRNA #6 further stated that they do not offer to toilet Resident #15, that the resident calls for assistance when needed. Interview with the Minimum Data Set (MDS) Nurse on 09/24/2020 at 4:44 PM revealed she had completed the resident's MDS upon admission and then developed the care plan along with the Interdisciplinary Team (IDT). The MDS nurse stated she was unaware that Resident #15's care plan did not include toileting needs and since he/she was only occasionally incontinent, the care plan should address toileting needs. 2. Review of the medical record for Resident #10 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS for Resident #10 dated 07/03/2020, Section C0500, Cognitive Patterns, revealed the resident had a BIMS score of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS Section G0110, Functional Status, Section I, Toilet Use, revealed the resident required extensive assistance of two (2) plus persons for toileting. Review of the MDS Sections H0300 and H0400, Bladder and Bowel, revealed the resident was occasionally incontinent of urine and bowel. Review of Resident #10's Comprehensive Care Plan, dated 02/04/2020, revealed the resident had a potential for complications associated with urinary incontinence related to [MEDICAL CONDITION] with an intervention for staff to check the resident for incontinence episodes and provide perineal care after each incontinence episode. Observation of Resident #10, on 09/22/2020 at 4:04 PM, revealed the resident sitting up in his/her wheelchair in his/her room. Interview with Resident #10, on 09/24/2020 at 9:39 AM, revealed he/she frequently had to wait for over twenty (20) minutes for staff to answer his/her call light to provide incontinence care. Interview with State Registered Nurse Aide (SRNA) #2, on 09/24/2020 at 4:12 PM, revealed Resident #10 was incontinent at times. SRNA #2 further revealed staff must check the care plan prior to beginning each shift to care for the resident. SRNA #2 also revealed rounds should be done every two hours to check residents for incontinence to provide perineal care or, if the resident had an episode of incontinence, as soon as possible to provide care. However, SRNA #2 stated staff were not always able to provide care timely to the residents, due to not having an adequate number of staff to provide the care. Interview with Licensed Practical Nurse (LPN) #1, on 09/24/2020 at 4:03 PM, revealed Resident #10 had incontinence episodes. The LPN further revealed all staff were instructed to review the care plan prior to providing care for residents. LPN #1 revealed staff try to make rounds every two hours to check the residents for incontinence or provide the perineal care as soon as possible if the resident had an episode of incontinence. However, the LPN stated perineal care was provided late at times due to not having an adequate number of staff to provide the care. Interview with the Director of Nursing (DON), on 09/24/2020 at 4:29 PM, revealed staff were to review the resident's care plan before providing resident care and care should be provided according to the care plan. The DON further revealed staff should make rounds every two (2) hours to check residents for incontinence or if a resident has an incontinence episode the resident should be provided perineal care immediately. The DON revealed she was not aware of any residents having to wait over five (5) to ten (10) minutes for care when they ring their call light. The DON further revealed she monitored call lights being answered and monitored for incontinence care by making rounds daily. The DON revealed she was not aware of any resident not receiving incontinence or perineal care as needed.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to implement the care plan for one (1) of three (3) residents (Resident #1). The facility developed a care plan that required two staff persons to assist Resident #1 with transfers, and that stated only therapy staff should assist the resident with ambulation. However, on 02/26/19, State Registered Nurse Aide (SRNA) #4 failed to follow the resident's care plan and attempted to assist the resident to the bathroom on her own. Resident #1 fell and sustained a fracture to the right elbow. The findings include: Review of the facility's Comprehensive Care Plans, revised 07/19/18, revealed the care plan is designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. The policy also revealed care plan interventions were implemented to meet the objectives of achieving the resident goals. Further review revealed the policy revealed if a resident refused an intervention, the Interdisciplinary Team would educate the resident as appropriate and would attempt to find alternative interventions. Review of Resident #1's medical record revealed the facility admitted the resident on 02/16/19 with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. The MDS also revealed the resident required extensive assistance of two (2) or more persons for bed mobility, transferring, ambulation, dressing, and toilet use. However, review of Resident #1's baseline care plan for Resident #1 dated 02/17/19, revealed the resident could not bear weight to the right lower extremity and required a lumbar sacral (back) brace during ambulation with therapy only. Further review revealed the resident required two (2) staff persons to assist with transfers. Review of Resident #1's nurse aide care plan dated (MONTH) 2019 revealed Resident #1 was non-ambulatory and required the assistance of two (2) staff persons for transfers and toileting (using bedpan). However, a review of the Nurse Aide Care Plan Affirmation dated 02/26/18 revealed no staff had signed Resident #1's care plan affirming that the care plan was reviewed. Review of Progress Notes/Event Note, dated 02/26/19 at 7:30 AM, revealed Resident #1 suffered a fall with major injury. According to the note, Resident #1 stated he/she could not use the bedpan and had to go to the bathroom. The note revealed SRNA #4 was assisting the resident to the bathroom when the resident reached for the wall, and then lost balance and fell to the floor. Review of the Hospital Discharge Summary, dated 03/08/19, revealed the resident was diagnosed with [REDACTED]. Interview with SRNA #4 on 03/12/19 at 2:50 PM revealed she answered Resident #1's call light on the morning of 02/26/19. She stated the resident wanted to go to the bathroom so she proceeded to assist the resident out of bed and assist the resident with walking (ambulating) to the bathroom. SRNA #4 stated the resident reached for the bathroom doorframe and the resident's hand slipped and the resident fell . The SRNA stated she was not aware that Resident #1 required two (2) staff persons' assistance with transfers and did not know the resident was only supposed to walk with therapy staff's assistance. Further interview with SRNA #4 revealed she was aware she was required to review resident care plans every shift, but had not reviewed Resident #1's care plan that day. She stated she just did not get around to reviewing the care plan. Interviews were conducted with the MDS Coordinator on 03/12/19 at 2:30 PM and the Assistant Director of Nursing (ADON) on 03/12/19 at 3:05 PM. The MDS Coordinator stated she interviewed SRNA #4 on the morning of 02/26/19 regarding the incident. She stated the SRNA assisted Resident #1 by herself and was not aware of the resident's care plan requirements. The MDS Coordinator and the ADON stated SRNAs were required to review and sign nurse aide care plans daily prior to starting their shift. Further interview revealed no one monitored Nurse Aide Care Plan Affirmation sheets prior to the incident to ensure staff were reviewing care plans. **The following action was implemented by the facility to correct the deficient practice. The facility alleged compliance on 03/08/19: 1. On 02/26/19, a fall investigation for Resident #1 was initiated after the resident sustained [REDACTED]. The facility completed the investigation on 02/28/19. 2. On 02/26/19, Resident #1's care plan was updated to reflect the resident's current care needs and will be reviewed and updated when the elder returns to the facility. 3. On 02/26/19, the facility notified Resident #1's Physician and Power of Attorney of the fall sustained by Resident #1 on 02/26/19. 4. The facility suspended State Registered Nurse Aide (SRNA) #4 pending the outcome of the investigation for not following the resident's care plan. SRNA #4 was educated on reviewing and following resident care plans. 5. From 02/27/19 through 03/01/19, the Risk Manager reviewed the care plans of all residents residing in the facility that had sustained a fall in the last 90 days to ensure appropriate fall interventions had been implemented and that the care plans reflected current interventions. The Minimum Data Set (MDS) Coordinator addressed all identified concerns. 6. From 02/26/19 through 03/01/19, the Charge Nurse reviewed all resident care plans to ensure they reflected the appropriate care required by the residents and current physician orders. The MDS Coordinator addressed all identified concerns. 7. On 02/28/19, the Risk Manager reviewed all residents residing in the facility that had sustained a fall in the past 90 days to ensure that each resident's fall risk assessment was current and reflected appropriate interventions. On 03/01/19 the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and MDS Nurse addressed all concerns identified by the Risk Manager. 8. On 02/27/19, the Administrator, DON, ADON, Nursing Supervisor, MDS Coordinator, SDC, Dietary Manager, Business Office Manager, SSD/Chaplain, Rehab Services Manager (RSM), and Medical Records Staff were educated by the Signature Corporate Consultant (SCC) on the facility's neglect and falls policies and procedures. In addition, the staff were educated related to following each resident's care plan as directed. 9. On 02/27/19, the facility Administrator, DON, ADON, Nursing Supervisor, MDS Coordinator, SDC, Dietary Manager, Business Office Manager, SSD/Chaplain, RSM, and Medical Records Staff initiated education with all staff on the facility's neglect and fall policies and procedures. The training will be ongoing until all staff have received the education. All as needed staff or staff currently on leave were sent a certified letter informing the staff member they must complete the required education prior to providing care in the facility. The education included following care plan interventions to meet each resident's need, and reviewing care plans prior to the start of each shift and throughout the shift as necessary. 10. On 02/26/19, the DON, SDC, ADON, and Administrator initiated education with staff on the facility's abuse and neglect policies and procedures. The education will be ongoing until all staff have received the education. 11. Beginning on 02/27/19, the interdisciplinary team will review documentation including but not limited to the electronic medical record, the twenty-four (24) hour report, and updating any resident's care plan who has experienced a fall, during morning clinical meetings. The Administrator or Designee is responsible for oversight of the morning clinical meeting to validate compliance and participation by the interdisciplinary team, which includes the ADON, SDC, SSD, and the MDS Coordinator. 12. Beginning on 02/27/19, falls will be reviewed in the morning meeting for root cause analysis and to ensure care plans are updated by nursing staff. On weekends, the nurse on duty will report all falls with injuries to the DON or Administrative Nurse on Duty. The DON/Administrative Nurse on Duty will review the fall. The nurse on duty during the fall will update the care plan and address the fall on the twenty-four (24) hour report. A shift to shift report will occur between nurses and nursing assistants. 13. Beginning on 02/27/19, the Administrator, DON, ADON, SDC, SSD, and MDS Coordinator will conduct a weekly At Risk Meeting to ensure the effectiveness of all added interventions. Any issues identified at the meeting will be addressed immediately and discussed during Quality Assurance meetings. 14. Beginning on 02/28/19, the SCC or Designee will audit twenty percent of all falls monthly for three (3) months to ensure fall interventions are listed on the comprehensive care plans, that a root cause analysis investigation has been completed, and to ensure care plans are being followed. Any identified issues will be corrected immediately and reviewed by the Quality Assurance Committee. 15. Beginning on 03/04/19, the interdisciplinary team initiated random audits to ensure staff were providing care in accordance with resident care plans related to daily care provided to residents. The audits will be conducted with twelve (12) staff members per week for two (2) weeks; then eight (8) staff members per week for two (2) weeks; then four (4) staff members per week for two (2) weeks; and then two (2) staff members per week for two (2) weeks. Any identified concerns will be addressed immediately and follow-up education will be provided to the staff. 16. On 03/01/19, a Quality Assurance Performance Improvement (QAPI) meeting was conducted with the Facility Medical Director and SCC to review the facility's plan of action and ensure compliance with all regulatory requirements. The MDS Coordinator and Medical Records also attended the meeting. Every four weeks a QAPI meeting will occur to review all audits and any testing completed by staff, to ensure compliance with the facility's ongoing plan. The meeting will include attendance by the Administrator or Designee, DON, Medical Director, and other IDT members designated to attend. Any identified concerns will be addressed by increasing monitoring and/or education. The SCC or Designee will be in attendance during the meetings to validate compliance with the plan. ** The surveyor verified the facility's action based on the following and determined the facility was in compliance as of 03/08/19, as alleged: 1. Record review and interview with the Signature Care Consultant (SCC) on 03/21/19 at 2:35 PM and review of a facility investigation completed on 02/28/19, revealed the resident fell while being transferred with one staff person assisting to the bathroom on 02/26/19. An investigation of the fall revealed the resident was assessed to require to two (2) staff persons assisting with transfers. The resident remained in the hospital as of 03/21/19. 2. Review of Resident #1's care plan revealed it had been updated to reflect the fall and care needs. 3. Review of Resident #1's Nursing Notes dated 02/26/19, revealed the facility notified the resident's Physician and Power of Attorney of the fall sustained by the resident. 4. Record review and interview with SRNA #4 on 03/21/19 at 3:42 PM revealed the SRNA who was assisting Resident #1 when the resident sustained [REDACTED]. SRNA #4 stated that after being suspended for three (3) days, she received 1:1 training related to following resident care plans, falls, abuse, and neglect. SRNA #4 stated she also took a posttest following the training. The SRNA stated she was trained to review the resident care plans prior to each shift and to sign off that she has reviewed the care plans. 5. Record review and interview with the Risk Manager on 03/22/19 at 9:03 AM and the Minimum Data Set (MDS) Nurse on 03/21/19 at 3:28 PM revealed the care plans for all residents who had fallen in the past 90 days were reviewed by the Risk Manager between 02/27/19 and 03/01/19. The MDS Nurse stated she and other facility staff addressed any needed revision identified during this review. 6. Record review and interview with the Charge Nurse (RN #1) on 03/22/19 at 10:50 AM and the MDS Nurse on 03/21/19 at 3:28 PM revealed all residents' orders and care plans were reviewed between 02/27/19 and 03/01/19 to ensure the care reflected the resident's current level of care and orders. 7. Record review and interview with the Risk Manager on 03/22/19 at 9:03 AM and the Minimum Data Set (MDS) Nurse on 03/21/19 at 3:28 PM revealed that fall investigations and the care plans for all residents who had fallen in the past 90 days were reviewed by the Risk Manager between 02/27/19 and 03/01/19. The MDS nurse stated she and other facility staff addressed any needed revision identified during this review. 8. Review of training records and interview on 03/21/19 with the Signature Care Consultant (SCC) at 2:35 PM, and the Social Services Director (SSD) at 4:02 PM, and on 03/22/19 at 9:04 AM with the Assistant Director of Nursing (ADON) revealed the SCC educated administrative staff at the facility on 02/27/19 on the policies and procedures which included neglect, falls, implementing the care plan and SRNA care plan, and providing the level of assistance per the care plan. Interview on 03/22/19 with the Interim Administrator at 8:40 AM and Interim DON at 9:53 AM revealed both had started work at the facility on 03/04/19 and received the above training. All stated a posttest had also been completed. 9. Review of training records and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, SRNA #1 at 3:15 PM, SRNA #2 at 3:02 PM, SRNA #3 at 2:57 PM, SRNA #4 at 3:42 PM, SRNA #6 at 2:50 PM, and SRNA #7 at 3:10 PM revealed all had received training on the care plan policy which included reviewing care plans prior to the start of each shift and throughout the shift as needed. The SRNAs were educated to sign after reviewing the SRNA care plan prior to the start of their shift. Further, the interviews revealed all took a posttest after receiving the in-service education. Interview with the SCC on 03/21/19 at 2:35 PM revealed all staff who missed questions on the posttest were reeducated and took the test again. 10. Review of training records and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, SRNA #1 at 3:15 PM, SRNA #2 at 3:02 PM, SRNA #3 at 2:57 PM, SRNA #4 at 3:42 PM, SRNA #6 at 2:50 PM, and SRNA #7 at 3:10 PM revealed all were educated on the abuse/neglect policy and on falls. Further, the interviews revealed all took a posttest after receiving the in-service education. Interview with the SCC on 03/21/19 at 2:35 PM revealed all staff who missed questions on the posttest were reeducated and took the test again. 11. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, the MDS Coordinator at 3:28 PM, and the SCC at 2:35 PM, and on 03/22/19 with the DON at 9:53 AM and the ADON at 9:37 AM, revealed the electronic medical record and twenty-four (24) hour report and care plan has been reviewed in the morning meetings for any resident who had sustained a fall. 12. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, the MDS Coordinator at 3:28 PM, and the SCC at 2:35 PM, and on 03/22/19 with the DON at 9:53 AM and the ADON at 9:37 AM, revealed all attend the clinical morning meetings held Monday through Friday. Per interviews, during the meeting the interdisciplinary team is reviewing all falls to ensure identification of root cause, and to ensure immediate intervention and appropriate interventions were implemented, and that the care plan updates and SRNA care plan were updated. Review of event reports revealed there had been two (2) resident falls since 03/08/19 involving Resident #4 and Resident #5. Review of the audit notes, fall investigations, and interview with the SCC on 03/21/19 at 2:35 PM revealed these resident fall investigations/care plans were reviewed in the AM meetings. 13. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, the MDS Coordinator at 3:28 PM, and the SCC at 2:35 PM, and on 03/22/19 with the DON at 9:53 AM and the ADON at 9:37 AM, revealed at-risk meetings have been conducted weekly to ensure the effectiveness of implemented interventions. Any issues identified have been addressed by the facility's Quality Assurance Committee. 14. Review of audits and interview on 03/21/19 with the SCC at 2:35 PM and the DON at 9:53 AM revealed an audit of twenty percent of all falls monthly for (MONTH) had been completed to ensure fall interventions are on the comprehensive care plan and SRNA care plan, root cause investigation has been completed, and to ensure care plans for the level of assistance are being followed. 15. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, and the MDS Coordinator at 3:28 PM, and on 03/22/19 with the ADON at 9:04 AM and the Charge Nurse (RN #1) at 10:50 AM, revealed all had completed audits of staff providing care to residents. The audits included observing SRNAs assisting residents with bathing, transfers, dining, positioning, grooming, etc. Per interview, any issues or problems were immediately addressed. 16. Review of Quality Assurance Performance Improvement (QAPI) meetings and interviews on 03/21/19 with the SCC at 2:35 PM, the SSD at 4:02 PM, the SDC at 4:07 PM, and the MDS Coordinator at 3:28 PM, and on 03/22/19 with the ADON at 9:04 AM, the DON at 9:53 AM, and the Administrator at 8:40 AM, revealed QAPI meetings had been held every week starting on 03/01/19 and the Medical Director had attended each meeting. The results of the above audits are discussed during the meeting and ongoing progress with the plan of correction.

Based on observation, interview, record review, and review of the facility policy there was sufficient evidence to determine the facility failed to ensure Resident #1 received adequate supervision and assistance devices to prevent accidents. The facility developed a care plan that required two staff persons to assist the resident with transfers and for only therapy staff to assist the resident with ambulation. However, on 02/26/19, Resident #1 suffered a fall when State Registered Nurse Aide (SRNA) #4 failed to follow to the resident's care plan and attempted to assist the resident to the bathroom on her own. Resident #1 sustained a fracture to the right elbow as a result of the fall. The findings include: Review of the facility's Fall policy, not dated, revealed all residents would have a comprehensive fall risk assessment upon admission/readmission, quarterly, annually, and with any significant change in condition. The policy also stated appropriate care plan interventions would be implemented as indicated by the assessment. Review of Resident #1's medical record revealed the facility admitted the resident on 02/16/19 with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment, dated 02/16/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. The MDS also revealed the resident required extensive assistance of two (2) or more persons for bed mobility, transferring, ambulation, dressing, and toilet use. review of the resident's medical record revealed [REDACTED]. Review of the baseline care plan for Resident #1 dated 02/17/19, revealed the facility identified that the resident had a self-care deficit and required two (2) staff persons to assist with bed mobility, transfers, and toileting. The care plan also revealed the resident could not bear weight to the right lower extremity and required a lumbar sacral (back) brace during ambulation with therapy only. Review of physician orders for Resident #1 revealed an order dated 02/19/19 that also stated the resident was non-weight bearing to the right lower extremity and the resident could only ambulate with therapy staff while wearing a back brace. Review of the nurse aide care plan dated (MONTH) 2019 revealed Resident #1 required staff assistance of two (2) persons for transfers, toileting (using bedpan), bathing, and personal hygiene. According to the nurse aide's care plan, Resident #1 was non-ambulatory. Review of Progress Notes/Event Note, dated 02/26/19 at 7:30 AM, revealed Resident #1 suffered a fall with major injury. According to the note, Resident #1 stated he/she could not use the bedpan and had to go to the bathroom. The note revealed State Registered Nurse Aide (SRNA) #4 was assisting the resident to the bathroom when the resident reached for the wall, and then lost balance and fell to the floor. Further review revealed Resident #1 sustained a skin tear and bruising to the right elbow, and Resident #1 stated he/she thought his/her arm was broken. Further review revealed Resident #1 refused transfer to the hospital for evaluation and the physician ordered a mobile x-ray of right the elbow. The right elbow was immobilized, elevated, and an ice pack was applied as per physician orders. Further review of Progress Notes dated 02/26/19 at 12:44 PM, revealed Resident #1 began to experience dyspnea (shortness of breath) and a decrease in oxygenation saturation to 78 percent (78%) (normal is 95-100%). The note stated the resident's physician was notified and the resident agreed to a transfer to the hospital for evaluation. Review of the Hospital Discharge Summary, dated 03/08/19, revealed the resident was diagnosed with [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #4 on 03/12/19 at 2:50 PM revealed she answered Resident #1's call light on the morning of 02/26/19. She stated the resident wanted to go to the bathroom so she proceeded to assist the resident out of bed and to assist the resident with walking (ambulating) to the bathroom. SRNA #4 stated the resident reached for the bathroom doorframe and the resident's hand slipped and the resident fell . The SRNA stated she was not aware that Resident #1 required two (2) staff persons' assistance with transfers and did not know the resident was only supposed to walk with therapy staff's assistance. Further interview with SRNA #4 revealed she was aware she was required to review resident care plans every shift, but had not reviewed Resident #1's care plan that day. She stated she just did not get around to reviewing the care plan. Interview with Licensed Practical Nurse (LPN) #1 on 03/12/19 at 12:40 PM, revealed she was working on 02/26/19 at the time Resident #1 sustained a fall. She stated she was called to the resident's room and when she entered, she found the resident had fallen and SRNA #4 was present. She further stated the resident stated, I think I broke my arm. According to the LPN, SRNA #4 reported that she had attempted to assist the resident to the bathroom when the resident fell . LPN #1 stated she reported the incident to the Director of Nursing (DON), and also notified the DON that the resident required two (2) staff persons for transfers and was supposed to be nonambulatory. The LPN stated Resident #1 was nonambulatory due to spinal fractures sustained from a fall at home. Interview with the MDS Coordinator on 03/12/19 at 2:30 PM, revealed she interviewed SRNA #4 on the morning of 02/26/19 regarding the incident. The SRNA stated she had assisted Resident #1 by herself and was not aware the resident required the assist of two (2) staff persons. Review of the facility's investigation dated 02/26/19 revealed the facility investigated the circumstances of Resident #1's fall and determined staff did not follow the resident's care plan that stated staff should not ambulate the resident and that the resident required two staff persons for transfers. **The following action was implemented by the facility to correct the deficient practice. The facility alleged compliance on 03/08/19: 1. On 02/26/19, a fall investigation for Resident #1 was initiated after the resident sustained [REDACTED]. The facility completed the investigation on 02/28/19. 2. On 02/26/19, Resident #1's care plan was updated to reflect the resident's current care needs and will be reviewed and updated when the elder returns to the facility. 3. On 02/26/19, the facility notified Resident #1's Physician and Power of Attorney of the fall sustained by Resident #1 on 02/26/19. 4. The facility suspended State Registered Nurse Aide (SRNA) #4 pending the outcome of the investigation for not following the resident's care plan. SRNA #4 was educated on reviewing and following resident care plans. 5. From 02/27/19 through 03/01/19, the Risk Manager reviewed the care plans of all residents residing in the facility that had sustained a fall in the last 90 days to ensure appropriate fall interventions had been implemented and that the care plans reflected current interventions. The Minimum Data Set (MDS) Coordinator addressed all identified concerns. 6. From 02/26/19 through 03/01/19, the Charge Nurse reviewed all resident care plans to ensure they reflected the appropriate care required by the residents and current physician orders. The MDS Coordinator addressed all identified concerns. 7. On 02/28/19, the Risk Manager reviewed all residents residing in the facility that had sustained a fall in the past 90 days to ensure that each resident's fall risk assessment was current and reflected appropriate interventions. On 03/01/19 the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and MDS Nurse addressed all concerns identified by the Risk Manager. 8. On 02/27/19, the Administrator, DON, ADON, Nursing Supervisor, MDS Coordinator, SDC, Dietary Manager, Business Office Manager, SSD/Chaplain, Rehab Services Manager (RSM), and Medical Records Staff were educated by the Signature Corporate Consultant (SCC) on the facility's neglect and falls policies and procedures. In addition, the staff were educated related to following each resident's care plan as directed. 9. On 02/27/19, the facility Administrator, DON, ADON, Nursing Supervisor, MDS Coordinator, SDC, Dietary Manager, Business Office Manager, SSD/Chaplain, RSM, and Medical Records Staff initiated education with all staff on the facility's neglect and fall policies and procedures. The training will be ongoing until all staff have received the education. All as needed staff or staff currently on leave were sent a certified letter informing the staff member they must complete the required education prior to providing care in the facility. The education included following care plan interventions to meet each resident's need, and reviewing care plans prior to the start of each shift and throughout the shift as necessary. 10. On 02/26/19, the DON, SDC, ADON, and Administrator initiated education with staff on the facility's abuse and neglect policies and procedures. The education will be ongoing until all staff have received the education. 11. Beginning on 02/27/19, the interdisciplinary team will review documentation including but not limited to the electronic medical record, the twenty-four (24) hour report, and updating any resident's care plan who has experienced a fall, during morning clinical meetings. The Administrator or Designee is responsible for oversight of the morning clinical meeting to validate compliance and participation by the interdisciplinary team, which includes the ADON, SDC, SSD, and the MDS Coordinator. 12. Beginning on 02/27/19, falls will be reviewed in the morning meeting for root cause analysis and to ensure care plans are updated by nursing staff. On weekends, the nurse on duty will report all falls with injuries to the DON or Administrative Nurse on Duty. The DON/Administrative Nurse on Duty will review the fall. The nurse on duty during the fall will update the care plan and address the fall on the twenty-four (24) hour report. A shift to shift report will occur between nurses and nursing assistants. 13. Beginning on 02/27/19, the Administrator, DON, ADON, SDC, SSD, and MDS Coordinator will conduct a weekly At Risk Meeting to ensure the effectiveness of all added interventions. Any issues identified at the meeting will be addressed immediately and discussed during Quality Assurance meetings. 14. Beginning on 02/28/19, the SCC or Designee will audit twenty percent of all falls monthly for three (3) months to ensure fall interventions are listed on the comprehensive care plans, that a root cause analysis investigation has been completed, and to ensure care plans are being followed. Any identified issues will be corrected immediately and reviewed by the Quality Assurance Committee. 15. Beginning on 03/04/19, the interdisciplinary team initiated random audits to ensure staff were providing care in accordance with resident care plans related to daily care provided to residents. The audits will be conducted with twelve (12) staff members per week for two (2) weeks; then eight (8) staff members per week for two (2) weeks; then four (4) staff members per week for two (2) weeks; and then two (2) staff members per week for two (2) weeks. Any identified concerns will be addressed immediately and follow-up education will be provided to the staff. 16. On 03/01/19, a Quality Assurance Performance Improvement (QAPI) meeting was conducted with the Facility Medical Director and SCC to review the facility's plan of action and ensure compliance with all regulatory requirements. The MDS Coordinator and Medical Records also attended the meeting. Every four weeks a QAPI meeting will occur to review all audits and any testing completed by staff, to ensure compliance with the facility's ongoing plan. The meeting will include attendance by the Administrator or Designee, DON, Medical Director, and other IDT members designated to attend. Any identified concerns will be addressed by increasing monitoring and/or education. The SCC or Designee will be in attendance during the meetings to validate compliance with the plan. ** The surveyor verified the facility's action based on the following and determined the facility was in compliance as of 03/08/19, as alleged: 1. Record review and interview with the Signature Care Consultant (SCC) on 03/21/19 at 2:35 PM and review of a facility investigation completed on 02/28/19, revealed the resident fell while being transferred with one staff person assisting to the bathroom on 02/26/19. An investigation of the fall revealed the resident was assessed to require to two (2) staff persons assisting with transfers. The resident remained in the hospital as of 03/21/19. 2. Review of Resident #1's care plan revealed it had been updated to reflect the fall and care needs. 3. Review of Resident #1's Nursing Notes dated 02/26/19, revealed the facility notified the resident's Physician and Power of Attorney of the fall sustained by the resident. 4. Record review and interview with SRNA #4 on 03/21/19 at 3:42 PM revealed the SRNA who was assisting Resident #1 when the resident sustained [REDACTED]. SRNA #4 stated that after being suspended for three (3) days, she received 1:1 training related to following resident care plans, falls, abuse, and neglect. SRNA #4 stated she also took a posttest following the training. The SRNA stated she was trained to review the resident care plans prior to each shift and to sign off that she has reviewed the care plans. 5. Record review and interview with the Risk Manager on 03/22/19 at 9:03 AM and the Minimum Data Set (MDS) Nurse on 03/21/19 at 3:28 PM revealed the care plans for all residents who had fallen in the past 90 days were reviewed by the Risk Manager between 02/27/19 and 03/01/19. The MDS Nurse stated she and other facility staff addressed any needed revision identified during this review. 6. Record review and interview with the Charge Nurse (RN #1) on 03/22/19 at 10:50 AM and the MDS Nurse on 03/21/19 at 3:28 PM revealed all residents' orders and care plans were reviewed between 02/27/19 and 03/01/19 to ensure the care reflected the resident's current level of care and orders. 7. Record review and interview with the Risk Manager on 03/22/19 at 9:03 AM and the Minimum Data Set (MDS) Nurse on 03/21/19 at 3:28 PM revealed that fall investigations and the care plans for all residents who had fallen in the past 90 days were reviewed by the Risk Manager between 02/27/19 and 03/01/19. The MDS nurse stated she and other facility staff addressed any needed revision identified during this review. 8. Review of training records and interview on 03/21/19 with the Signature Care Consultant (SCC) at 2:35 PM, and the Social Services Director (SSD) at 4:02 PM, and on 03/22/19 at 9:04 AM with the Assistant Director of Nursing (ADON) revealed the SCC educated administrative staff at the facility on 02/27/19 on the policies and procedures which included neglect, falls, implementing the care plan and SRNA care plan, and providing the level of assistance per the care plan. Interview on 03/22/19 with the Interim Administrator at 8:40 AM and Interim DON at 9:53 AM revealed both had started work at the facility on 03/04/19 and received the above training. All stated a posttest had also been completed. 9. Review of training records and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, SRNA #1 at 3:15 PM, SRNA #2 at 3:02 PM, SRNA #3 at 2:57 PM, SRNA #4 at 3:42 PM, SRNA #6 at 2:50 PM, and SRNA #7 at 3:10 PM revealed all had received training on the care plan policy which included reviewing care plans prior to the start of each shift and throughout the shift as needed. The SRNAs were educated to sign after reviewing the SRNA care plan prior to the start of their shift. Further, the interviews revealed all took a posttest after receiving the in-service education. Interview with the SCC on 03/21/19 at 2:35 PM revealed all staff who missed questions on the posttest were reeducated and took the test again. 10. Review of training records and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, SRNA #1 at 3:15 PM, SRNA #2 at 3:02 PM, SRNA #3 at 2:57 PM, SRNA #4 at 3:42 PM, SRNA #6 at 2:50 PM, and SRNA #7 at 3:10 PM revealed all were educated on the abuse/neglect policy and on falls. Further, the interviews revealed all took a posttest after receiving the in-service education. Interview with the SCC on 03/21/19 at 2:35 PM revealed all staff who missed questions on the posttest were reeducated and took the test again. 11. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, the MDS Coordinator at 3:28 PM, and the SCC at 2:35 PM, and on 03/22/19 with the DON at 9:53 AM and the ADON at 9:37 AM, revealed the electronic medical record and twenty-four (24) hour report and care plan has been reviewed in the morning meetings for any resident who had sustained a fall. 12. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, the MDS Coordinator at 3:28 PM, and the SCC at 2:35 PM, and on 03/22/19 with the DON at 9:53 AM and the ADON at 9:37 AM, revealed all attend the clinical morning meetings held Monday through Friday. Per interviews, during the meeting the interdisciplinary team is reviewing all falls to ensure identification of root cause, and to ensure immediate intervention and appropriate interventions were implemented, and that the care plan updates and SRNA care plan were updated. Review of event reports revealed there had been two (2) resident falls since 03/08/19 involving Resident #4 and Resident #5. Review of the audit notes, fall investigations, and interview with the SCC on 03/21/19 at 2:35 PM revealed these resident fall investigations/care plans were reviewed in the AM meetings. 13. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, the MDS Coordinator at 3:28 PM, and the SCC at 2:35 PM, and on 03/22/19 with the DON at 9:53 AM and the ADON at 9:37 AM, revealed at-risk meetings have been conducted weekly to ensure the effectiveness of implemented interventions. Any issues identified have been addressed by the facility's Quality Assurance Committee. 14. Review of audits and interview on 03/21/19 with the SCC at 2:35 PM and the DON at 9:53 AM revealed an audit of twenty percent of all falls monthly for (MONTH) had been completed to ensure fall interventions are on the comprehensive care plan and SRNA care plan, root cause investigation has been completed, and to ensure care plans for the level of assistance are being followed. 15. Review of audits and interview on 03/21/19 with the SSD at 4:02 PM, the SDC at 4:07 PM, and the MDS Coordinator at 3:28 PM, and on 03/22/19 with the ADON at 9:04 AM and the Charge Nurse (RN #1) at 10:50 AM, revealed all had completed audits of staff providing care to residents. The audits included observing SRNAs assisting residents with bathing, transfers, dining, positioning, grooming, etc. Per interview, any issues or problems were immediately addressed. 16. Review of Quality Assurance Performance Improvement (QAPI) meetings and interviews on 03/21/19 with the SCC at 2:35 PM, the SSD at 4:02 PM, the SDC at 4:07 PM, and the MDS Coordinator at 3:28 PM, and on 03/22/19 with the ADON at 9:04 AM, the DON at 9:53 AM, and the Administrator at 8:40 AM, revealed QAPI meetings had been held every week starting on 03/01/19 and the Medical Director had attended each meeting. The results of the above audits are discussed during the meeting and ongoing progress with the plan of correction.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure allegations of abuse were thoroughly investigated, failed to ensure residents were protected from further abuse, and failed to report allegations to state agencies as required, for one (1) of two (2) sampled residents (Resident #2). Facility staff reported to the former Director of Nursing (DON) and the former Assistant DON on [DATE] that Resident #1 was observed to take Resident #2's hand and place it on his/her private part and rub himself/herself. The facility failed to conduct an investigation related to the alleged incident, failed to protect residents from further abuse, and failed to report the alleged incident to state agencies. The facility's failure to ensure allegations of abuse were thoroughly investigated, failure to ensure residents were protected from further abuse, failure to ensure abuse allegations were reported to state agencies, as well as failure to review/revise residents' plans of care when inappropriate sexual behavior was observed, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility submitted an acceptable Allegation of Compliance (AOC) on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. Based on the State Survey Agency's (SSA) validation of the AOC it was determined the Immediate Jeopardy was removed on [DATE] prior to the SSA initiating the investigation on [DATE]; therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled Abuse, Neglect and Misappropriation of Property, last reviewed [DATE], revealed that all alleged violations involving abuse would be reported to the administrator and the State Survey Agency in accordance with federal and state law. The policy stated that a reasonable investigation of alleged violations would be conducted. Further review of the policy revealed when a resident exhibited any form of abuse toward another resident the residents were to be removed/separated to ensure their safety. The policy stated the Charge Nurse or DON would ensure the residents had no access to one another until the circumstances of the incident could be determined. 1. Review of the medical record for Resident #1 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident was interviewable. Interview on [DATE] at 1:20 PM with Resident #1 revealed the resident was unable to recall the incident, which was witnessed by facility staff, involving Resident #2 on [DATE]. 2. Record review revealed the facility admitted Resident #2 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS score of 6, which indicated the resident was not interviewable. Interview on [DATE] at 1:40 PM with Resident #2 revealed the resident stated he/she had broken up with his/her significant other and that he/she didn't live here. Resident #2 stated he/she felt safe in the facility. Interview with the Regional Vice President (RVP) on [DATE] at 4:45 PM revealed Resident #1 and Resident #2 became friends around mid-[DATE]. The residents had been observed holding hands, at times, in the front lobby of the facility. The Power of Attorneys (POAs) of Resident #2 were notified that the residents were having physical contact. Resident #2's POAs gave verbal consent related to hand holding/physical contact between Resident #1 and Resident #2. Further interview revealed Resident #1 and Resident #2's previous spouses were deceased ; however, both residents referred to the other as their deceased spouses, and called each other the name of their deceased spouses. The RVP also stated that as the residents' relationship continued the residents were observed kissing (exact dates unknown), and Resident #2's POAs were again notified and no concerns were voiced related to the residents' physical contact. Interview on [DATE] at 3:45 PM with the Assistant Business Office Manager revealed she had witnessed Resident #1 take Resident #2's hand and place it on his/her private part and rub himself/herself on [DATE]. She stated she felt the incident was potential abuse and immediately reported the incident to the former DON and the former ADON. Further interview revealed the former DON stated that the family is aware of it. She stated she did not report the incident to the former Administrator, because she reported it to the former DON and former ADON, like I had been trained to do. The Assistant Business Office Manager stated she never witnessed the former DON or former ADON take any action related to the incident. Interview on [DATE] at 5:10 PM with the former ADON revealed she and the former DON were notified on [DATE] that Resident #1 had placed Resident #2's hand on his/her private part and was observed to rub himself/herself. She stated she did not report the incident immediately to the former Administrator because the Assistant Business Office Manager had stated she was reporting the incident to the former Administrator. However, the former ADON stated she and the former DON followed up with the former Administrator the following day, on [DATE]. She stated the former Administrator just walked out of the room and never acknowledged that we had told him anything. Interview on [DATE] at 10:00 AM with the former DON revealed she and the former ADON were notified on [DATE] that Resident #1 was observed to place Resident #2's hand on his/her private part and rub himself/herself. She stated she did not report it immediately to the former Administrator because the staff that informed her of the incident stated she was reporting the allegation to the former Administrator. However, the former DON stated she and the former ADON discussed the allegation with the former Administrator, who was also the Abuse Coordinator, on [DATE]. The former DON stated the former Administrator never assigned me anything to do and no investigation was done or directed, because he always did that stuff; he was the Abuse Coordinator. The former DON stated it was not her responsibility to report or coordinate investigations in the facility, because the former Administrator usually took care of all of that. Interview was attempted with the former Administrator on [DATE], [DATE], and [DATE] and he was unable to be reached. Interview on [DATE] at 4:30 PM with the Regional Vice President (RVP) revealed the former Administrator and/or former DON should have followed the facility's policy when allegations of abuse were identified. She stated when the allegation was reported to administrative staff they should have protected the residents involved as well as other facility residents, reported the alleged incident to state agencies, and investigated the incident as required. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy. 1) On [DATE], the Regional Vice President (RVP) was made aware of the incident, which was reported to the Administrator and the DON on [DATE]; they were both suspended pending investigation. It was determined that the two (2) residents (Resident #1 and Resident #2) had been more physical with each other and nothing had been done to validate the relationship was appropriate. Staff had repeatedly reported their concerns of physical touching between these two (2) residents to Administration. However, Administration failed to follow the Center's abuse policy and procedures. The facility also failed to update the resident's care plans (Resident #1 and Resident #2). The Administrator and the DON were terminated from the facility. 2) Resident #1 had been on 15-minute checks since [DATE] and had made no attempts to go into Resident #2's room, or any other resident's room in the facility. Resident #1 was evaluated by a psychiatrist on [DATE], and again on [DATE], with medication recommendations, and to monitor the resident every 15 minutes, which were followed through as ordered. Resident #1 has not exhibited any further behaviors. Staff continued to monitor the resident every 15 minutes. A care plan meeting was conducted with Resident #1's Power of Attorney (POA), as well as his/her son on [DATE], and all concerns were discussed and all questions answered at that time. Resident #1 was provided spiritual support by the facility Chaplain on [DATE], and weekly visits will continue for one (1) month. 3) The Medical Director completed a physical examination on Resident #2 (the alleged victim) on [DATE], and no signs or symptoms of sexual abuse were identified. Resident #2 was evaluated by a psychiatrist on [DATE] and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on [DATE] with recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The facility's Chaplain provided spiritual support for the resident on [DATE] and will meet weekly with Resident #2 for the next thirty (30) days. A care plan/family meeting was conducted on [DATE] to discuss any concerns and to answer any questions that Resident #2's POAs may ask. All questions were answered and no concerns were voiced. 4) All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on [DATE] by the Social Services Worker (SSW), Staff Development Coordinator (SDC), ADON, and the Activity Director related to any concerns related to abuse in the facility. One (1) resident voiced concerns; the concern was reported and investigated as required, with no concerns identified. 5) Skin assessments for 100 percent of residents were conducted on [DATE], for signs and symptoms of abuse with no concerns identified. The assessments were conducted by facility staff nurses, as well as nurse management staff. All assessments were reviewed by the Consulting Nurse on [DATE]. 6) All prior grievances were reviewed by the Administrator/Regional Controller on [DATE] for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) The Administrator/Regional Controller had reviewed all Resident Council Notes from the past six (6) months on [DATE]. The Regional Controller identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) was reported from the November meeting. 8) All reportable incidents for the past twelve (12) months were reviewed on [DATE] to ensure complete and thorough investigations were completed and to ensure compliance with the facility's abuse policy. 9) All residents' charts, which included Progress Notes, were reviewed for the last 60-day timeframe on [DATE] and [DATE]. Resident records were reviewed by the Consulting Nurse, DON, SDC from another facility, and one (1) Nurse Administrator, to ensure no abuse allegations had been documented with no actions taken and to ensure the resident's physician and family had been notified of any changes in condition. 10) All residents were verified to ensure no current residents were on the sex offender registry on [DATE] by Human Resources. No concerns were identified. 11) Facility audits revealed all accidents and incidents were reviewed on [DATE], for the last 30 days, for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by Nurse Management, the Interim DON, SDC, and Consulting Nurse. 12) Interviews and review of facility documentation revealed the RVP (Regional Vice President) held a Resident Council Meeting on [DATE] to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. 13) The RVP, Consulting Nurse, and SDC Nurse initiated abuse education on [DATE] with all staff with a post-test of 100 percent to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. The content of training was as follows: abuse policy and procedures, nine (9) types of abuse including use of any video or pictures of residents used in a demeaning way, and all reporting options (Regional team, Signature Caring Line, Ombudsman, Adult Protective Services and the Office of the Inspector General) if a staff member believed possible abuse was ongoing. Certified letters were sent to any employees that had not been re- educated on abuse on [DATE]. The letter informed the employees that they would not be permitted to work until the abuse education was completed. 14) Files for all employees hired in the past six (6) months (25 employees) were reviewed for appropriate credentials and possible abuse allegations. 15) On [DATE] and [DATE], staff was also provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact Situation, Background, Assessment and Recommendation (SBAR) forms and stop and watch form, care plans policy and procedure, to include appropriately updating the resident's care plan to reflect the resident's current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures, with a post-test score of 100 required, effective [DATE]. 16) Daily monitoring of audits will be conducted by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. The audits include the following: five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse; ten (10) random resident chart audits for change in resident condition that have not been followed through with as required to monitor for any unreported allegations of abuse; and, ten (10) random staff abuse tests that require a passing score of 100%. 17) The Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator, will continue to provide daily monitoring by conducting ten (10) random resident interviews (with BIMS score of 8 and above) for any abuse allegations or concerns. The audits will be conducted until IJ is removed, and then for two (2) weeks with weekly QAPI (Quality Assurance Performance Improvement Committee) Audits will be monitored through the QA committee, which will determine the frequency to continue the audits. 18) Clinical meetings five (5) times a week with the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator will be held to review the 24-Hour Report, all accident and incidents, physician orders, and daily charting. The interdisciplinary team will be monitoring for signs and symptoms of abuse or any unreported abuse allegations. 19) The RVP will provide administrative oversight of the Center effective [DATE]. The RVP is the Interim Administrator and will be in place until an administrator has been hired. The Administrator will be provided with abuse training and reporting as part of orientation. 20) The Quality Assurance Performance Improvement (QAPI) committee (Interim Administrator and DON, SSW, SDC, Dietary Manager, Activity Director, Consulting Nurse and Medical Director by phone) meetings were conducted on [DATE] and [DATE], to review this plan and all audits for needed revisions, compliance, and/or further education. The QAPI committee will then determine the need for reduction of audits monthly, based on audit outcomes and compliance. 21) Determining Decision-Making Capacity, Sexual Consent Capacity will be used as a guide or reference for the care plan team, physician, psychologists and families to help generate the correct conversations and decisions effective [DATE]. ***The State Survey Agency verified the removal of the jeopardy through the following actions on [DATE]. 1) Interview with the Regional Vice President of Operations (RVP) on [DATE] revealed the Administrator and DON were terminated from employment on [DATE]. 2) Review of Resident #1's record revealed documentation of 15-minute checks and an evaluation by a psychiatrist on [DATE] and [DATE]. Further review of the record revealed documentation that the care plan meeting was conducted and the resident's care plan was revised. Review of the facility's documentation revealed the resident received visits from the Chaplain on [DATE] and [DATE]. 3) Review of Resident #2's medical record revealed the Medical Director completed a physical examination of Resident #2 (the alleged victim) on [DATE], and no signs or symptoms of sexual abuse were identified. The record further revealed that Resident #2 was evaluated by a psychiatrist on [DATE] and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on [DATE] with a recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The record further revealed the Chaplain had provided spiritual support for the resident on [DATE] and again on [DATE]. The record revealed a care plan/family meeting was conducted on [DATE]. 4) Review of the facility's audits on [DATE] revealed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on [DATE] by the SSW, SDC, ADON, and the Activity Director related to any concerns related to abuse in the facility. Review of an investigation dated [DATE] revealed one (1) resident voiced a concern; the concern was reported and investigated as required, with no problems identified. Interview with the SSW on [DATE] at 3:20 PM, the SDC on [DATE] at 4:00 PM, and the ADON on [DATE] at 5:10 PM, revealed all residents with a BIMS score of eight (8) to fifteen (15) were interviewed on [DATE]. 5) Review of the facility's audits on [DATE] revealed skin assessments for 100% of residents were conducted on [DATE], for signs and symptoms of abuse, with no concerns identified. Interview with the SDC on [DATE] at 4:00 PM, ADON on [DATE] at 3:40 PM, and Registered Nurse (RN) #1 on [DATE] at 3:20 PM confirmed skin assessments had been conducted on 100% of facility residents on [DATE]. 6) Review of the facility audits revealed all prior grievances were reviewed by the Administrator/Regional Controller on [DATE] for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) Further review of audits conducted by the facility revealed the Administrator/Regional Controller had reviewed all resident council notes from the past six (6) months on [DATE]. Interview with the Regional Controller on [DATE] at 5:00 PM revealed he had identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) reported from November's meeting. All concerns were addressed and corrected by the Regional Controller. 8) Review of the facility's audits on [DATE], conducted by the Regional Controller, revealed the Regional Consulting Nurse had reviewed all reportable incidents for the last 12 months on [DATE]. The Consulting Nurse had reviewed the allegations to ensure the facility's policy had been followed and that complete and thorough investigations had been conducted. Further review of the audits revealed the Consulting Nurse reviewed all reportable incidents, at least monthly when she visits the Center. Interview with the RVP on [DATE] at 4:30 PM revealed since [DATE] she had been involved as the Interim Administrator, and had remained on-site since [DATE]. The RVP stated she had been involved in all reportable incidents to ensure they had been reported and that a thorough and complete investigation had been conducted. 9) Interviews with the Regional Consulting Nurse and the RVP on [DATE] at 4:15 PM and 4:30 PM, as well as review of the facility's audits revealed all residents' charts which included progress notes had been reviewed for the last 60-day timeframe on [DATE] and [DATE] to ensure no abuse allegations had been documented with no actions taken, and no concerns were identified, and that the resident's physician and family had been notified of any changes in condition, and no concerns were identified. 10) Review of facility's documentation revealed 100% of the residents were verified to ensure no current residents were on the sex offender registry on [DATE] by Human Resources, and no concerns were identified. Interview with the RVP on [DATE] at 4:30 PM revealed she had validated that Human Resources had ensured that none of the residents were listed on the sex offender registry. 11) Review of facility's audits revealed all accidents and incidents from the last 30 days were reviewed on [DATE] for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by nurse management, the interim DON, SDC, and consulting nurse. Interviews with the SDC on [DATE] at 4:00 PM, the ADON on [DATE] at 5:10 PM, and the Regional Consulting Nurse verified they assisted with the audits. 12) Interview with the RVP on [DATE] at 4:30 PM and review of facility documentation revealed the she had held a Resident Council Meeting on [DATE] to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. Interviews with Residents A and B on [DATE] at 12:55 PM and 1:00 PM confirmed they had been educated, during a Resident Council Meeting, related to abuse and relationships in the facility. 13) Review of facility documentation related to staff training revealed the RVP, Consulting Nurse, and SDC nurse had initiated abuse education on [DATE] with all staff with validation of training with post-test requiring a score of 100% to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. Review of post tests revealed staff competency was acquired. Review of personnel records revealed certified letters were sent to staff informing them they would not be permitted to work until retrained. 14) Review of facility documentation of audits conducted revealed the Administrator/Regional Controller reviewed files of all new employees on [DATE], that had been hired in the past 6 months (25 employee files), for appropriate credentials and possible abuse allegations; and no concerns were identified. 15) Review of facility documentation revealed that on [DATE] and [DATE] staff was provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact SBAR and Stop and Watch form, care plans policy and procedure, to include appropriately updating the residents' care plans to reflect the residents' current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures with post-test score of 100 required, effective [DATE]. Interview with the Consulting Nurse on [DATE] at 4:15 PM revealed the training was conducted with on [DATE] and [DATE]. 16) Review of facility documentation revealed daily monitoring audits had been conducted from [DATE] through [DATE] by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator that included five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse, ten (10) random resident chart audits for change in resident condition that had not been followed through with as required, and ten (10) random staff abuse tests. Interviews with the interim DON on [DATE] at 3:40 PM and the Consulting Nurse on [DATE] at 4:15 PM revealed the audits were conducted. 17) Review of the facility's documentation and interview with the RVP on [DATE] at 4:30 PM revealed she, as well as the Consulting Nurse, Interim DON, SDC, and SSW conducted ten (10) random resident interviews (with BIMS scores of 8 and above) for any abuse allegations or concerns. 18) Review of facility documentation revealed on [DATE] staff initiated ongoing monitoring through clinical meetings five (5) times a week, which consisted of the following staff members in attendance: Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. Interviews with the Consulting Nurse on [DATE] at 4:15 PM and the RVP on [DATE] at 4:30 PM, revealed staff reviewed the 24-hour report, all accident and incidents, physician orders, and daily charting for sign and symptoms of abuse or any unreported abuse allegations. 19) Interview with the RVP on [DATE] at 4:30 PM confirmed she had provided administrative oversight of the facility since [DATE]. 20) Review of facility documentation and interviews with the Consulting Nurse on [DATE] at 4:15 PM and the RVP on [DATE] at 4:30 PM revealed the QAPI committee met on [DATE] and [DATE] to review the plan and all audits for needed revisions, compliance, and or further education. 21) Review of facility documentation and interviews with the Consulting Nurse on [DATE] at 4:15 PM and the RVP on [DATE] at 4:30 PM confirmed the Determining Decision-Making Capacity, Sexual Consent Capacity would be used as a guide or reference for the care plan team, physician, psychologists, and families to help generate the correct conversations and decisions effective [DATE].

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure policies and procedures were implemented when allegations of abuse were reported for one (1) of two (2) sampled residents (Resident #2). Facility staff reported to the former Director of Nursing (DON) and the former Assistant DON on 10/26/16 that Resident #1 was observed to take Resident #2's hand and place it on his/her private part and rub him/herself. The facility failed to follow their policy and procedures as they did not conduct an investigation related to the alleged incident, failed to protect residents from further abuse, and failed to report the alleged incident to state agencies as outlined in the facility policy. The facility's failure to ensure its policies and procedures were followed and its failure to ensure allegations of abuse were thoroughly investigated, failure to ensure residents were protected from further abuse, failure to ensure abuse allegations were reported to state agencies, as well as failure to review/revise residents' plans of care when inappropriate caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/10/16, and was determined to exist on 10/26/16. The facility submitted an acceptable Allegation of Compliance (AOC) on 11/16/16 alleging the Immediate Jeopardy was removed on 11/05/16. Based on the State Survey Agency's (SSA) validation of the AOC it was determined the Immediate Jeopardy was removed on 11/05/16 prior to the SSA initiating the investigation on 11/09/16; therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled Abuse, Neglect and Misappropriation of Property, last reviewed 08/30/16, directed the facility to ensure all alleged violations involving abuse were reported to the administrator, and the state survey agency in accordance with federal and state law. Staff was required to conduct a reasonable investigation of all alleged violations that occurred in the facility. The policy stated when a resident exhibited any form of abuse toward another resident the residents were to be removed/separated to ensure their safety. The Charge Nurse or DON was directed to ensure the residents had no access to one another until the circumstances of the incident were determined. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 05/20/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/27/16, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident was interviewable. Interview on 11/09/16 at 1:20 PM with Resident #1 revealed the resident was unable to recall the incident involving Resident #2 on 10/26/16, which was witnessed by facility staff. 2. Resident #2's medical record revealed the facility admitted the resident on 05/28/15, with [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 09/13/16, revealed the facility assessed the resident to have a BIMS score of 6, which indicated the resident was not interviewable. Interview on 11/09/16 at 1:40 PM with Resident #2 revealed the resident stated he/she had broken up with his/her significant other and that he/she didn't live here. Resident #2 stated he/she felt safe in the facility. Interview on 11/09/16 at 3:45 PM with the Assistant Business Office Manager revealed she had observed Resident #1 take Resident #2's hand and place it on his/her private part and rub himself/herself on 10/26/16. She stated she felt she had witnessed potential abuse and immediately reported the incident to the former DON and the former ADON. She stated the former DON told her that the family was aware of it. The Assistant Business Office Manager stated she never witnessed the former DON or former ADON take any action related to the reported incident. Interview on 11/10/16 at 5:10 PM with the former ADON confirmed that she and the former DON were notified on 10/26/16 that Resident #1 had placed Resident #2's hand on his/her private part and was observed to rub him/herself. The former ADON stated she did not report the incident immediately to the former Administrator, because the Assistant Business Office Manager had stated she was reporting the incident to the former Administrator. However, the former ADON stated she and the former DON followed up with the former Administrator the following day, 10/27/16, and the former Administrator just walked out of the room and never acknowledged that we had told him anything. Interview on 11/14/16 at 10:00 AM with the former DON revealed she and the former ADON were notified on 10/26/16 that Resident #1 was observed to place Resident #2's hand on his/her private part and rub himself/herself. She stated she did not report it immediately to the former Administrator because the staff that informed her of the incident stated she was reporting the allegation to the former Administrator. However, the former DON stated she and the former ADON discussed the allegation with the former Administrator, who was also the abuse coordinator, on 10/27/16. The former DON stated the former Administrator never assigned me anything to do and no investigation was done or directed, because he always did that stuff; he was the Abuse Coordinator. She stated it was not her responsibility to report or coordinate investigations in the facility because the former Administrator usually took care of all of that. Interview was attempted with the former Administrator on 11/10/16, 11/14/16, and 11/16/16 and he was unable to be reached. Interview on 11/16/16 at 4:30 PM with the Regional Vice President (RVP) revealed the former Administrator and/or former DON should have followed the facility's policy when allegations of abuse were reported in the facility. According to the facility's policy, staff was required to conduct a reasonable investigation of all alleged violations that occurred. The policy stated when a resident exhibited any form of abuse toward another resident the residents were to be removed/separated to ensure their safety. The RVP stated when the allegation was reported to administrative staff they should have protected the residents involved as well as other facility residents, reported the alleged incident to state agencies, and investigated the incident as outlined in the facility policy. **The facility provided an acceptable Allegation of Compliance (AOC) on 11/16/16. The facility implemented the following actions to remove the Immediate Jeopardy. 1) On 11/02/16, the Regional Vice President (RVP) was made aware of the incident, which was reported to the Administrator and the DON on 10/26/16; they were both suspended pending investigation. It was determined that the two (2) residents (Resident #1 and Resident #2) had been more physical with each other and nothing had been done to validate the relationship was appropriate. Staff had repeatedly reported their concerns of physical touching between these two (2) residents to Administration. However, Administration failed to follow the Center's abuse policy and procedures. The facility also failed to update the resident's care plans (Resident #1 and Resident #2). The Administrator and the DON were terminated from the facility. 2) Resident #1 had been on 15-minute checks since 10/27/16 and had made no attempts to go into Resident #2's room, or any other resident's room in the facility. Resident #1 was evaluated by a psychiatrist on 11/03/16, and again on 11/10/16, with medication recommendations, and to monitor the resident every 15 minutes, which were followed through as ordered. Resident #1 has not exhibited any further behaviors. Staff continued to monitor the resident every 15 minutes. A care plan meeting was conducted with Resident #1's Power of Attorney (POA), as well as his/her son on 11/04/16, and all concerns were discussed and all questions answered at that time. Resident #1 was provided spiritual support by the facility Chaplain on 11/04/16, and weekly visits will continue for one (1) month. 3) The Medical Director completed a physical examination on Resident #2 (the alleged victim) on 11/03/16, and no signs or symptoms of sexual abuse were identified. Resident #2 was evaluated by a psychiatrist on 11/03/16 and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on 11/10/16 with recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The facility's Chaplain provided spiritual support for the resident on 11/04/16 and will meet weekly with Resident #2 for the next thirty (30) days. A care plan/family meeting was conducted on 11/02/16 to discuss any concerns and to answer any questions that Resident #2's POAs may ask. All questions were answered and no concerns were voiced. 4) All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on 11/02/16 by the Social Services Worker (SSW), Staff Development Coordinator (SDC), ADON, and the Activity Director related to any concerns related to abuse in the facility. One (1) resident voiced concerns; the concern was reported and investigated as required, with no concerns identified. 5) Skin assessments for 100 percent of residents were conducted on 11/02/16, for signs and symptoms of abuse with no concerns identified. The assessments were conducted by facility staff nurses, as well as nurse management staff. All assessments were reviewed by the Consulting Nurse on 11/02/16. 6) All prior grievances were reviewed by the Administrator/Regional Controller on 11/03/16 for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) The Administrator/Regional Controller had reviewed all Resident Council Notes from the past six (6) months on 11/03/16. The Regional Controller identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) was reported from the November meeting. 8) All reportable incidents for the past twelve (12) months were reviewed on 11/03/16 to ensure complete and thorough investigations were completed and to ensure compliance with the facility's abuse policy. 9) All residents' charts, which included Progress Notes, were reviewed for the last 60-day timeframe on 11/03/16 and 11/04/16. Resident records were reviewed by the Consulting Nurse, DON, SDC from another facility, and one (1) Nurse Administrator, to ensure no abuse allegations had been documented with no actions taken and to ensure the resident's physician and family had been notified of any changes in condition. 10) All residents were verified to ensure no current residents were on the sex offender registry on 11/04/16 by Human Resources. No concerns were identified. 11) Facility audits revealed all accidents and incidents were reviewed on 11/04/16, for the last 30 days, for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by Nurse Management, the Interim DON, SDC, and Consulting Nurse. 12) Interviews and review of facility documentation revealed the RVP (Regional Vice President) held a Resident Council Meeting on 11/03/16 to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. 13) The RVP, Consulting Nurse, and SDC Nurse initiated abuse education on 11/02/16 with all staff with a post-test of 100 percent to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. The content of training was as follows: abuse policy and procedures, nine (9) types of abuse including use of any video or pictures of residents used in a demeaning way, and all reporting options (Regional team, Signature Caring Line, Ombudsman, Adult Protective Services and the Office of the Inspector General) if a staff member believed possible abuse was ongoing. Certified letters were sent to any employees that had not been re- educated on abuse on 11/03/16. The letter informed the employees that they would not be permitted to work until the abuse education was completed. 14) Files for all employees hired in the past six (6) months (25 employees) were reviewed for appropriate credentials and possible abuse allegations. 15) On 11/03/16 and 11/04/16, staff was also provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact Situation, Background, Assessment and Recommendation (SBAR) forms and stop and watch form, care plans policy and procedure, to include appropriately updating the resident's care plan to reflect the resident's current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures, with a post-test score of 100 required, effective 11/04/16. 16) Daily monitoring of audits will be conducted by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. The audits include the following: five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse; ten (10) random resident chart audits for change in resident condition that have not been followed through with as required to monitor for any unreported allegations of abuse; and, ten (10) random staff abuse tests that require a passing score of 100%. 17) The Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator, will continue to provide daily monitoring by conducting ten (10) random resident interviews (with BIMS score of 8 and above) for any abuse allegations or concerns. The audits will be conducted until IJ is removed, and then for two (2) weeks with weekly QAPI (Quality Assurance Performance Improvement Committee) Audits will be monitored through the QA committee, which will determine the frequency to continue the audits. 18) Clinical meetings five (5) times a week with the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator will be held to review the 24-Hour Report, all accident and incidents, physician orders, and daily charting. The interdisciplinary team will be monitoring for signs and symptoms of abuse or any unreported abuse allegations. 19) The RVP will provide administrative oversight of the Center effective 11/02/16. The RVP is the Interim Administrator and will be in place until an administrator has been hired. The Administrator will be provided with abuse training and reporting as part of orientation. 20) The Quality Assurance Performance Improvement (QAPI) committee (Interim Administrator and DON, SSW, SDC, Dietary Manager, Activity Director, Consulting Nurse and Medical Director by phone) meetings were conducted on 11/02/16 and 11/09/16, to review this plan and all audits for needed revisions, compliance, and/or further education. The QAPI committee will then determine the need for reduction of audits monthly, based on audit outcomes and compliance. 21) Determining Decision-Making Capacity, Sexual Consent Capacity will be used as a guide or reference for the care plan team, physician, psychologists and families to help generate the correct conversations and decisions effective 11/04/16. ***The State Survey Agency verified the removal of the jeopardy through the following actions on 11/16/16. 1) Interview with the Regional Vice President of Operations (RVP) on 11/09/16 revealed the Administrator and DON were terminated from employment on 11/04/16. 2) Review of Resident #1's record revealed documentation of 15-minute checks and an evaluation by a psychiatrist on 11/03/16 and 11/10/16. Further review of the record revealed documentation that the care plan meeting was conducted and the resident's care plan was revised. Review of the facility's documentation revealed the resident received visits from the Chaplain on 11/04/16 and 11/11/16. 3) Review of Resident #2's medical record revealed the Medical Director completed a physical examination of Resident #2 (the alleged victim) on 11/03/16, and no signs or symptoms of sexual abuse were identified. The record further revealed that Resident #2 was evaluated by a psychiatrist on 11/03/16 and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on 11/10/16 with a recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The record further revealed the Chaplain had provided spiritual support for the resident on 11/04/16 and again on 11/11/16. The record revealed a care plan/family meeting was conducted on 11/02/16. 4) Review of the facility's audits on 11/16/16 revealed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on 11/02/16 by the SSW, SDC, ADON, and the Activity Director related to any concerns related to abuse in the facility. Review of an investigation dated 11/02/16 revealed one (1) resident voiced a concern; the concern was reported and investigated as required, with no problems identified. Interview with the SSW on 11/10/16 at 3:20 PM, the SDC on 11/16/16 at 4:00 PM, and the ADON on 11/10/16 at 5:10 PM, revealed all residents with a BIMS score of eight (8) to fifteen (15) were interviewed on 11/02/16. 5) Review of the facility's audits on 11/16/16 revealed skin assessments for 100% of residents were conducted on 11/02/16, for signs and symptoms of abuse, with no concerns identified. Interview with the SDC on 11/16/16 at 4:00 PM, ADON on 11/16/16 at 3:40 PM, and Registered Nurse (RN) #1 on 11/16/16 at 3:20 PM confirmed skin assessments had been conducted on 100% of facility residents on 11/02/16. 6) Review of the facility audits revealed all prior grievances were reviewed by the Administrator/Regional Controller on 11/03/16 for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) Further review of audits conducted by the facility revealed the Administrator/Regional Controller had reviewed all resident council notes from the past six (6) months on 11/03/16. Interview with the Regional Controller on 11/09/16 at 5:00 PM revealed he had identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) reported from November's meeting. All concerns were addressed and corrected by the Regional Controller. 8) Review of the facility's audits on 11/16/16, conducted by the Regional Controller, revealed the Regional Consulting Nurse had reviewed all reportable incidents for the last 12 months on 11/03/16. The Consulting Nurse had reviewed the allegations to ensure the facility's policy had been followed and that complete and thorough investigations had been conducted. Further review of the audits revealed the Consulting Nurse reviewed all reportable incidents, at least monthly when she visits the Center. Interview with the RVP on 11/16/16 at 4:30 PM revealed since 11/02/16 she had been involved as the Interim Administrator, and had remained on-site since 11/02/16. The RVP stated she had been involved in all reportable incidents to ensure they had been reported and that a thorough and complete investigation had been conducted. 9) Interviews with the Regional Consulting Nurse and the RVP on 11/16/16 at 4:15 PM and 4:30 PM, as well as review of the facility's audits revealed all residents' charts which included progress notes had been reviewed for the last 60-day timeframe on 11/03/16 and 11/04/16 to ensure no abuse allegations had been documented with no actions taken, and no concerns were identified, and that the resident's physician and family had been notified of any changes in condition, and no concerns were identified. 10) Review of facility's documentation revealed 100% of the residents were verified to ensure no current residents were on the sex offender registry on 11/04/16 by Human Resources, and no concerns were identified. Interview with the RVP on 11/16/16 at 4:30 PM revealed she had validated that Human Resources had ensured that none of the residents were listed on the sex offender registry. 11) Review of facility's audits revealed all accidents and incidents from the last 30 days were reviewed on 11/04/16 for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by nurse management, the interim DON, SDC, and consulting nurse. Interviews with the SDC on 11/16/16 at 4:00 PM, the ADON on 11/10/16 at 5:10 PM, and the Regional Consulting Nurse verified they assisted with the audits. 12) Interview with the RVP on 11/16/16 at 4:30 PM and review of facility documentation revealed the she had held a Resident Council Meeting on 11/03/16 to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. Interviews with Residents A and B on 11/16/16 at 12:55 PM and 1:00 PM confirmed they had been educated, during a Resident Council Meeting, related to abuse and relationships in the facility. 13) Review of facility documentation related to staff training revealed the RVP, Consulting Nurse, and SDC nurse had initiated abuse education on 11/02/16 with all staff with validation of training with post-test requiring a score of 100% to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. Review of post tests revealed staff competency was acquired. Review of personnel records revealed certified letters were sent to staff informing them they would not be permitted to work until retrained. 14) Review of facility documentation of audits conducted revealed the Administrator/Regional Controller reviewed files of all new employees on 11/03/16, that had been hired in the past 6 months (25 employee files), for appropriate credentials and possible abuse allegations; and no concerns were identified. 15) Review of facility documentation revealed that on 11/03/16 and 11/04/16 staff was provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact SBAR and Stop and Watch form, care plans policy and procedure, to include appropriately updating the residents' care plans to reflect the residents' current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures with post-test score of 100 required, effective 11/04/16. Interview with the Consulting Nurse on 11/16/16 at 4:15 PM revealed the training was conducted with on 11/03/16 and 11/04/16. 16) Review of facility documentation revealed daily monitoring audits had been conducted from 11/03/16 through 11/16/16 by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator that included five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse, ten (10) random resident chart audits for change in resident condition that had not been followed through with as required, and ten (10) random staff abuse tests. Interviews with the interim DON on 11/16/16 at 3:40 PM and the Consulting Nurse on 11/16/16 at 4:15 PM revealed the audits were conducted. 17) Review of the facility's documentation and interview with the RVP on 11/16/16 at 4:30 PM revealed she, as well as the Consulting Nurse, Interim DON, SDC, and SSW conducted ten (10) random resident interviews (with BIMS scores of 8 and above) for any abuse allegations or concerns. 18) Review of facility documentation revealed on 11/04/16 staff initiated ongoing monitoring through clinical meetings five (5) times a week, which consisted of the following staff members in attendance: Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. Interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM, revealed staff reviewed the 24-hour report, all accident and incidents, physician orders, and daily charting for sign and symptoms of abuse or any unreported abuse allegations. 19) Interview with the RVP on 11/16/16 at 4:30 PM confirmed she had provided administrative oversight of the facility since 11/02/16. 20) Review of facility documentation and interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM revealed the QAPI committee met on 11/02/16 and 11/09/16 to review the plan and all audits for needed revisions, compliance, and or further education. 21) Review of facility documentation and interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM confirmed the Determining Decision-Making Capacity, Sexual Consent Capacity would be used as a guide or reference for the care plan team, physician, psychologists, and families to help generate the correct conversations and decisions effective 11/04/16.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to review and revise residents' plans of care when inappropriate sexual contact between residents was observed in the facility for two (2) of two (2) sampled residents (Residents #1 and #2). Resident #1 was observed to take Resident #2's hand and place it on his/her private part and rub himself/herself on 10/26/16. The incident was reported to the former Director of Nursing (DON) and the former Assistant DON on 10/26/16. However, staff failed to review and revise the residents' plans of care when the sexual contact was observed on 10/26/16. The facility's failure to ensure residents' plans of care were reviewed/revised when inappropriate sexual behavior was observed has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/10/16, and was determined to exist on 10/26/16. The facility submitted an acceptable Allegation of Compliance (AOC) on 11/16/16 alleging the Immediate Jeopardy was removed on 11/05/16. Based on the State Survey Agency's (SSA) validation of the AOC it was determined the Immediate Jeopardy was removed on 11/05/16 prior to the SSA initiating the investigation on 11/09/16; therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled Care Plans-Comprehensive, last reviewed 06/01/15, revealed that residents' care plans were designed to incorporate identified problem areas and risk factors associated with those problem areas identified by facility staff. Residents' care plans were to be revised as information about the resident and the resident's condition changed. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 05/20/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/27/16, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident was interviewable. Review of Resident #1's Comprehensive Care Plan, last reviewed/revised in September 2016, revealed no documented evidence that staff had reviewed or revised the resident's plan of care when he/she was observed to inappropriately exhibit sexual behaviors toward Resident #2 on 10/26/16. Interview on 11/09/16 at 1:20 PM with Resident #1 revealed the resident was unable to recall the incident involving Resident #2 which occurred on 10/26/16. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 05/28/15, with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment, dated 09/13/16, revealed the resident had a BIMS score of 6, which indicated the resident was not interviewable. Interview on 11/09/16 at 1:40 PM with Resident #2 revealed he/she had broken up with his/her significant other and he/she didn't live here. Resident #2 stated he/she felt safe in the facility. Interview on 11/09/16 at 3:45 PM with the Assistant Business Office Manager revealed she observed Resident #1 take Resident #2's hand and place it on his/her private part and rub himself/herself on 10/26/16. She immediately reported the incident to the former DON and the former ADON. She stated the former DON stated that the family was aware of it. Interview on 11/14/16 at 10:00 AM with the former DON confirmed that she and the former ADON were notified on 10/26/16 that Resident #1 was observed to place Resident #2's hand on his/her private part and rub him/herself. She stated she did not report it immediately to the former Administrator because the staff that informed her stated she was reporting the allegation to the former Administrator. The former DON stated she was responsible for ensuring residents' care plans had been reviewed and revised when changes in the residents' condition or behaviors occurred. However, she had not reviewed or revised the residents' care plans related to the inappropriate sexual behaviors that were reported. She stated she should have revised the care plans. Interview was attempted with the former Administrator on 11/10/16, 11/14/16, and 11/16/16 and he was unable to be reached. Interview on 11/16/16 at 4:30 PM with the Regional Vice President (RVP) revealed staff should have followed the facility's policy and updated Resident #1 and Resident #2's care plans when the incident occurred on 10/26/16. **The facility provided an acceptable Allegation of Compliance (AOC) on 11/16/16. The facility implemented the following actions to remove the Immediate Jeopardy. 1) On 11/02/16, the Regional Vice President (RVP) was made aware of the incident, which was reported to the Administrator and the DON on 10/26/16; they were both suspended pending investigation. It was determined that the two (2) residents (Resident #1 and Resident #2) had been more physical with each other and nothing had been done to validate the relationship was appropriate. Staff had repeatedly reported their concerns of physical touching between these two (2) residents to Administration. However, Administration failed to follow the Center's abuse policy and procedures. The facility also failed to update the resident's care plans (Resident #1 and Resident #2). The Administrator and the DON were terminated from the facility. 2) Resident #1 had been on 15-minute checks since 10/27/16 and had made no attempts to go into Resident #2's room, or any other resident's room in the facility. Resident #1 was evaluated by a psychiatrist on 11/03/16, and again on 11/10/16, with medication recommendations, and to monitor the resident every 15 minutes, which were followed through as ordered. Resident #1 has not exhibited any further behaviors. Staff continued to monitor the resident every 15 minutes. A care plan meeting was conducted with Resident #1's Power of Attorney (POA), as well as his/her son on 11/04/16, and all concerns were discussed and all questions answered at that time. Resident #1 was provided spiritual support by the facility Chaplain on 11/04/16, and weekly visits will continue for one (1) month. 3) The Medical Director completed a physical examination on Resident #2 (the alleged victim) on 11/03/16, and no signs or symptoms of sexual abuse were identified. Resident #2 was evaluated by a psychiatrist on 11/03/16 and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on 11/10/16 with recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The facility's Chaplain provided spiritual support for the resident on 11/04/16 and will meet weekly with Resident #2 for the next thirty (30) days. A care plan/family meeting was conducted on 11/02/16 to discuss any concerns and to answer any questions that Resident #2's POAs may ask. All questions were answered and no concerns were voiced. 4) All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on 11/02/16 by the Social Services Worker (SSW), Staff Development Coordinator (SDC), ADON, and the Activity Director related to any concerns related to abuse in the facility. One (1) resident voiced concerns; the concern was reported and investigated as required, with no concerns identified. 5) Skin assessments for 100 percent of residents were conducted on 11/02/16, for signs and symptoms of abuse with no concerns identified. The assessments were conducted by facility staff nurses, as well as nurse management staff. All assessments were reviewed by the Consulting Nurse on 11/02/16. 6) All prior grievances were reviewed by the Administrator/Regional Controller on 11/03/16 for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) The Administrator/Regional Controller had reviewed all Resident Council Notes from the past six (6) months on 11/03/16. The Regional Controller identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) was reported from the November meeting. 8) All reportable incidents for the past twelve (12) months were reviewed on 11/03/16 to ensure complete and thorough investigations were completed and to ensure compliance with the facility's abuse policy. 9) All residents' charts, which included Progress Notes, were reviewed for the last 60-day timeframe on 11/03/16 and 11/04/16. Resident records were reviewed by the Consulting Nurse, DON, SDC from another facility, and one (1) Nurse Administrator, to ensure no abuse allegations had been documented with no actions taken and to ensure the resident's physician and family had been notified of any changes in condition. 10) All residents were verified to ensure no current residents were on the sex offender registry on 11/04/16 by Human Resources. No concerns were identified. 11) Facility audits revealed all accidents and incidents were reviewed on 11/04/16, for the last 30 days, for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by Nurse Management, the Interim DON, SDC, and Consulting Nurse. 12) Interviews and review of facility documentation revealed the RVP (Regional Vice President) held a Resident Council Meeting on 11/03/16 to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. 13) The RVP, Consulting Nurse, and SDC Nurse initiated abuse education on 11/02/16 with all staff with a post-test of 100 percent to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. The content of training was as follows: abuse policy and procedures, nine (9) types of abuse including use of any video or pictures of residents used in a demeaning way, and all reporting options (Regional team, Signature Caring Line, Ombudsman, Adult Protective Services and the Office of the Inspector General) if a staff member believed possible abuse was ongoing. Certified letters were sent to any employees that had not been re- educated on abuse on 11/03/16. The letter informed the employees that they would not be permitted to work until the abuse education was completed. 14) Files for all employees hired in the past six (6) months (25 employees) were reviewed for appropriate credentials and possible abuse allegations. 15) On 11/03/16 and 11/04/16, staff was also provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact Situation, Background, Assessment and Recommendation (SBAR) forms and stop and watch form, care plans policy and procedure, to include appropriately updating the resident's care plan to reflect the resident's current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures, with a post-test score of 100 required, effective 11/04/16. 16) Daily monitoring of audits will be conducted by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. The audits include the following: five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse; ten (10) random resident chart audits for change in resident condition that have not been followed through with as required to monitor for any unreported allegations of abuse; and, ten (10) random staff abuse tests that require a passing score of 100%. 17) The Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator, will continue to provide daily monitoring by conducting ten (10) random resident interviews (with BIMS score of 8 and above) for any abuse allegations or concerns. The audits will be conducted until IJ is removed, and then for two (2) weeks with weekly QAPI (Quality Assurance Performance Improvement Committee) Audits will be monitored through the QA committee, which will determine the frequency to continue the audits. 18) Clinical meetings five (5) times a week with the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator will be held to review the 24-Hour Report, all accident and incidents, physician orders, and daily charting. The interdisciplinary team will be monitoring for signs and symptoms of abuse or any unreported abuse allegations. 19) The RVP will provide administrative oversight of the Center effective 11/02/16. The RVP is the Interim Administrator and will be in place until an administrator has been hired. The Administrator will be provided with abuse training and reporting as part of orientation. 20) The Quality Assurance Performance Improvement (QAPI) committee (Interim Administrator and DON, SSW, SDC, Dietary Manager, Activity Director, Consulting Nurse and Medical Director by phone) meetings were conducted on 11/02/16 and 11/09/16, to review this plan and all audits for needed revisions, compliance, and/or further education. The QAPI committee will then determine the need for reduction of audits monthly, based on audit outcomes and compliance. 21) Determining Decision-Making Capacity, Sexual Consent Capacity will be used as a guide or reference for the care plan team, physician, psychologists and families to help generate the correct conversations and decisions effective 11/04/16. ***The State Survey Agency verified the removal of the jeopardy through the following actions on 11/16/16. 1) Interview with the Regional Vice President of Operations (RVP) on 11/09/16 revealed the Administrator and DON were terminated from employment on 11/04/16. 2) Review of Resident #1's record revealed documentation of 15-minute checks and an evaluation by a psychiatrist on 11/03/16 and 11/10/16. Further review of the record revealed documentation that the care plan meeting was conducted and the resident's care plan was revised. Review of the facility's documentation revealed the resident received visits from the Chaplain on 11/04/16 and 11/11/16. 3) Review of Resident #2's medical record revealed the Medical Director completed a physical examination of Resident #2 (the alleged victim) on 11/03/16, and no signs or symptoms of sexual abuse were identified. The record further revealed that Resident #2 was evaluated by a psychiatrist on 11/03/16 and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on 11/10/16 with a recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The record further revealed the Chaplain had provided spiritual support for the resident on 11/04/16 and again on 11/11/16. The record revealed a care plan/family meeting was conducted on 11/02/16. 4) Review of the facility's audits on 11/16/16 revealed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on 11/02/16 by the SSW, SDC, ADON, and the Activity Director related to any concerns related to abuse in the facility. Review of an investigation dated 11/02/16 revealed one (1) resident voiced a concern; the concern was reported and investigated as required, with no problems identified. Interview with the SSW on 11/10/16 at 3:20 PM, the SDC on 11/16/16 at 4:00 PM, and the ADON on 11/10/16 at 5:10 PM, revealed all residents with a BIMS score of eight (8) to fifteen (15) were interviewed on 11/02/16. 5) Review of the facility's audits on 11/16/16 revealed skin assessments for 100% of residents were conducted on 11/02/16, for signs and symptoms of abuse, with no concerns identified. Interview with the SDC on 11/16/16 at 4:00 PM, ADON on 11/16/16 at 3:40 PM, and Registered Nurse (RN) #1 on 11/16/16 at 3:20 PM confirmed skin assessments had been conducted on 100% of facility residents on 11/02/16. 6) Review of the facility audits revealed all prior grievances were reviewed by the Administrator/Regional Controller on 11/03/16 for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) Further review of audits conducted by the facility revealed the Administrator/Regional Controller had reviewed all resident council notes from the past six (6) months on 11/03/16. Interview with the Regional Controller on 11/09/16 at 5:00 PM revealed he had identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) reported from November's meeting. All concerns were addressed and corrected by the Regional Controller. 8) Review of the facility's audits on 11/16/16, conducted by the Regional Controller, revealed the Regional Consulting Nurse had reviewed all reportable incidents for the last 12 months on 11/03/16. The Consulting Nurse had reviewed the allegations to ensure the facility's policy had been followed and that complete and thorough investigations had been conducted. Further review of the audits revealed the Consulting Nurse reviewed all reportable incidents, at least monthly when she visits the Center. Interview with the RVP on 11/16/16 at 4:30 PM revealed since 11/02/16 she had been involved as the Interim Administrator, and had remained on-site since 11/02/16. The RVP stated she had been involved in all reportable incidents to ensure they had been reported and that a thorough and complete investigation had been conducted. 9) Interviews with the Regional Consulting Nurse and the RVP on 11/16/16 at 4:15 PM and 4:30 PM, as well as review of the facility's audits revealed all residents' charts which included progress notes had been reviewed for the last 60-day timeframe on 11/03/16 and 11/04/16 to ensure no abuse allegations had been documented with no actions taken, and no concerns were identified, and that the resident's physician and family had been notified of any changes in condition, and no concerns were identified. 10) Review of facility's documentation revealed 100% of the residents were verified to ensure no current residents were on the sex offender registry on 11/04/16 by Human Resources, and no concerns were identified. Interview with the RVP on 11/16/16 at 4:30 PM revealed she had validated that Human Resources had ensured that none of the residents were listed on the sex offender registry. 11) Review of facility's audits revealed all accidents and incidents from the last 30 days were reviewed on 11/04/16 for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by nurse management, the interim DON, SDC, and consulting nurse. Interviews with the SDC on 11/16/16 at 4:00 PM, the ADON on 11/10/16 at 5:10 PM, and the Regional Consulting Nurse verified they assisted with the audits. 12) Interview with the RVP on 11/16/16 at 4:30 PM and review of facility documentation revealed the she had held a Resident Council Meeting on 11/03/16 to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. Interviews with Residents A and B on 11/16/16 at 12:55 PM and 1:00 PM confirmed they had been educated, during a Resident Council Meeting, related to abuse and relationships in the facility. 13) Review of facility documentation related to staff training revealed the RVP, Consulting Nurse, and SDC nurse had initiated abuse education on 11/02/16 with all staff with validation of training with post-test requiring a score of 100% to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. Review of post tests revealed staff competency was acquired. Review of personnel records revealed certified letters were sent to staff informing them they would not be permitted to work until retrained. 14) Review of facility documentation of audits conducted revealed the Administrator/Regional Controller reviewed files of all new employees on 11/03/16, that had been hired in the past 6 months (25 employee files), for appropriate credentials and possible abuse allegations; and no concerns were identified. 15) Review of facility documentation revealed that on 11/03/16 and 11/04/16 staff was provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact SBAR and Stop and Watch form, care plans policy and procedure, to include appropriately updating the residents' care plans to reflect the residents' current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures with post-test score of 100 required, effective 11/04/16. Interview with the Consulting Nurse on 11/16/16 at 4:15 PM revealed the training was conducted with on 11/03/16 and 11/04/16. 16) Review of facility documentation revealed daily monitoring audits had been conducted from 11/03/16 through 11/16/16 by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator that included five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse, ten (10) random resident chart audits for change in resident condition that had not been followed through with as required, and ten (10) random staff abuse tests. Interviews with the interim DON on 11/16/16 at 3:40 PM and the Consulting Nurse on 11/16/16 at 4:15 PM revealed the audits were conducted. 17) Review of the facility's documentation and interview with the RVP on 11/16/16 at 4:30 PM revealed she, as well as the Consulting Nurse, Interim DON, SDC, and SSW conducted ten (10) random resident interviews (with BIMS scores of 8 and above) for any abuse allegations or concerns. 18) Review of facility documentation revealed on 11/04/16 staff initiated ongoing monitoring through clinical meetings five (5) times a week, which consisted of the following staff members in attendance: Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. Interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM, revealed staff reviewed the 24-hour report, all accident and incidents, physician orders, and daily charting for sign and symptoms of abuse or any unreported abuse allegations. 19) Interview with the RVP on 11/16/16 at 4:30 PM confirmed she had provided administrative oversight of the facility since 11/02/16. 20) Review of facility documentation and interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM revealed the QAPI committee met on 11/02/16 and 11/09/16 to review the plan and all audits for needed revisions, compliance, and or further education. 21) Review of facility documentation and interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM confirmed the Determining Decision-Making Capacity, Sexual Consent Capacity would be used as a guide or reference for the care plan team, physician, psychologists, and families to help generate the correct conversations and decisions effective 11/04/16.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident when allegations of abuse were identified for one (1) of two (2) sampled residents (Resident #2). Facility staff reported to the former Director of Nursing (DON) and the former Assistant DON on 10/26/16 that Resident #1 was observed to take Resident #2's hand and place it on his/her private part and rub himself/herself. The allegation was discussed with the former Administrator on 10/27/16; however, the former Administrator and the administrative staff failed to conduct an investigation related to the alleged incident, failed to protect residents from further abuse, and failed to report the alleged incident to state agencies. The facility's failure to ensure allegations of abuse were thoroughly investigated, failure to ensure residents were protected from further abuse, failure to ensure abuse allegations were reported to state agencies, as well as failure to review/revise residents' plans of care when inappropriate sexual behavior was observed, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/10/16, and was determined to exist on 10/26/16. The facility submitted an acceptable Allegation of Compliance (AOC) on 11/16/16 alleging the Immediate Jeopardy was removed on 11/05/16. Based on the State Survey Agency's (SSA) validation of the AOC it was determined the Immediate Jeopardy was removed on 11/05/16 prior to the SSA initiating the investigation on 11/09/16; therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Facility Advisory Board (FAB), not dated, revealed the facility had designated the Administrator to be one of the persons responsible for establishing and implementing policies in the facility. The policy further stated the Administrator was responsible for the management of the facility. 1. Review of the medical record for Resident #1 revealed the facility admitted the resident on 05/20/16 with [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/27/16, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident was interviewable. 2. Record review revealed the facility admitted Resident #2 on 05/28/15, with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment, dated 09/13/16, revealed the resident had a BIMS score of 6, which indicated the resident was not interviewable. Per interview on 11/09/16 at 3:45 PM, with the Assistant Business Office Manager she witnessed Resident #1 take Resident #2's hand and place it on his/her private part and rub himself/herself on 10/26/16. She stated she felt this was potential abuse and so she immediately reported the incident to the former DON and the former ADON. The former DON told her the family was aware of it. Further interview revealed she did not witness the former DON or former ADON take any action related to the incident. Interview on 11/10/16 at 5:10 PM with the former ADON revealed she and the former DON were notified on 10/26/16 of the incident with Resident #1 and Resident #2. The former ADON stated she and the former DON followed up with the former Administrator the following day, on 10/27/16. She stated, He just walked out of the room and never acknowledged that we had told him anything. Interview on 11/14/16 at 10:00 AM with the former DON revealed she and the former ADON were notified on 10/26/16 of the incident related to Resident #1 and Resident #2. She stated she and the former ADON discussed the allegation with the former Administrator on 10/27/16. Continued interview revealed the former Administrator did not assign the investigation to her. She further stated that no investigation was done or directed, because he always did that stuff; he was the Abuse Coordinator. The former DON stated it was not her responsibility to report or coordinate investigations in the facility because the former Administrator usually took care of all of that. Interview was attempted with the former Administrator on 11/10/16, 11/14/16, and 11/16/16 and he was unable to be reached. Interview on 11/16/16 at 4:30 PM with the Regional Vice President (RVP) revealed the former Administrator should have followed the facility's policy when he was notified of the allegation on 10/27/16. The RVP stated that Administrators were responsible to ensure residents were protected and allegations of abuse were investigated and reported to state agencies as required. **The facility provided an acceptable Allegation of Compliance (AOC) on 11/16/16. The facility implemented the following actions to remove the Immediate Jeopardy. 1) On 11/02/16, the Regional Vice President (RVP) was made aware of the incident, which was reported to the Administrator and the DON on 10/26/16; they were both suspended pending investigation. It was determined that the two (2) residents (Resident #1 and Resident #2) had been more physical with each other and nothing had been done to validate the relationship was appropriate. Staff had repeatedly reported their concerns of physical touching between these two (2) residents to Administration. However, Administration failed to follow the Center's abuse policy and procedures. The facility also failed to update the resident's care plans (Resident #1 and Resident #2). The Administrator and the DON were terminated from the facility. 2) Resident #1 had been on 15-minute checks since 10/27/16 and had made no attempts to go into Resident #2's room, or any other resident's room in the facility. Resident #1 was evaluated by a psychiatrist on 11/03/16, and again on 11/10/16, with medication recommendations, and to monitor the resident every 15 minutes, which were followed through as ordered. Resident #1 has not exhibited any further behaviors. Staff continued to monitor the resident every 15 minutes. A care plan meeting was conducted with Resident #1's Power of Attorney (POA), as well as his/her son on 11/04/16, and all concerns were discussed and all questions answered at that time. Resident #1 was provided spiritual support by the facility Chaplain on 11/04/16, and weekly visits will continue for one (1) month. 3) The Medical Director completed a physical examination on Resident #2 (the alleged victim) on 11/03/16, and no signs or symptoms of sexual abuse were identified. Resident #2 was evaluated by a psychiatrist on 11/03/16 and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on 11/10/16 with recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The facility's Chaplain provided spiritual support for the resident on 11/04/16 and will meet weekly with Resident #2 for the next thirty (30) days. A care plan/family meeting was conducted on 11/02/16 to discuss any concerns and to answer any questions that Resident #2's POAs may ask. All questions were answered and no concerns were voiced. 4) All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on 11/02/16 by the Social Services Worker (SSW), Staff Development Coordinator (SDC), ADON, and the Activity Director related to any concerns related to abuse in the facility. One (1) resident voiced concerns; the concern was reported and investigated as required, with no concerns identified. 5) Skin assessments for 100 percent of residents were conducted on 11/02/16, for signs and symptoms of abuse with no concerns identified. The assessments were conducted by facility staff nurses, as well as nurse management staff. All assessments were reviewed by the Consulting Nurse on 11/02/16. 6) All prior grievances were reviewed by the Administrator/Regional Controller on 11/03/16 for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) The Administrator/Regional Controller had reviewed all Resident Council Notes from the past six (6) months on 11/03/16. The Regional Controller identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) was reported from the November meeting. 8) All reportable incidents for the past twelve (12) months were reviewed on 11/03/16 to ensure complete and thorough investigations were completed and to ensure compliance with the facility's abuse policy. 9) All residents' charts, which included Progress Notes, were reviewed for the last 60-day timeframe on 11/03/16 and 11/04/16. Resident records were reviewed by the Consulting Nurse, DON, SDC from another facility, and one (1) Nurse Administrator, to ensure no abuse allegations had been documented with no actions taken and to ensure the resident's physician and family had been notified of any changes in condition. 10) All residents were verified to ensure no current residents were on the sex offender registry on 11/04/16 by Human Resources. No concerns were identified. 11) Facility audits revealed all accidents and incidents were reviewed on 11/04/16, for the last 30 days, for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by Nurse Management, the Interim DON, SDC, and Consulting Nurse. 12) Interviews and review of facility documentation revealed the RVP (Regional Vice President) held a Resident Council Meeting on 11/03/16 to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. 13) The RVP, Consulting Nurse, and SDC Nurse initiated abuse education on 11/02/16 with all staff with a post-test of 100 percent to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. The content of training was as follows: abuse policy and procedures, nine (9) types of abuse including use of any video or pictures of residents used in a demeaning way, and all reporting options (Regional team, Signature Caring Line, Ombudsman, Adult Protective Services and the Office of the Inspector General) if a staff member believed possible abuse was ongoing. Certified letters were sent to any employees that had not been re- educated on abuse on 11/03/16. The letter informed the employees that they would not be permitted to work until the abuse education was completed. 14) Files for all employees hired in the past six (6) months (25 employees) were reviewed for appropriate credentials and possible abuse allegations. 15) On 11/03/16 and 11/04/16, staff was also provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact Situation, Background, Assessment and Recommendation (SBAR) forms and stop and watch form, care plans policy and procedure, to include appropriately updating the resident's care plan to reflect the resident's current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures, with a post-test score of 100 required, effective 11/04/16. 16) Daily monitoring of audits will be conducted by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. The audits include the following: five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse; ten (10) random resident chart audits for change in resident condition that have not been followed through with as required to monitor for any unreported allegations of abuse; and, ten (10) random staff abuse tests that require a passing score of 100%. 17) The Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator, will continue to provide daily monitoring by conducting ten (10) random resident interviews (with BIMS score of 8 and above) for any abuse allegations or concerns. The audits will be conducted until IJ is removed, and then for two (2) weeks with weekly QAPI (Quality Assurance Performance Improvement Committee) Audits will be monitored through the QA committee, which will determine the frequency to continue the audits. 18) Clinical meetings five (5) times a week with the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator will be held to review the 24-Hour Report, all accident and incidents, physician orders, and daily charting. The interdisciplinary team will be monitoring for signs and symptoms of abuse or any unreported abuse allegations. 19) The RVP will provide administrative oversight of the Center effective 11/02/16. The RVP is the Interim Administrator and will be in place until an administrator has been hired. The Administrator will be provided with abuse training and reporting as part of orientation. 20) The Quality Assurance Performance Improvement (QAPI) committee (Interim Administrator and DON, SSW, SDC, Dietary Manager, Activity Director, Consulting Nurse and Medical Director by phone) meetings were conducted on 11/02/16 and 11/09/16, to review this plan and all audits for needed revisions, compliance, and/or further education. The QAPI committee will then determine the need for reduction of audits monthly, based on audit outcomes and compliance. 21) Determining Decision-Making Capacity, Sexual Consent Capacity will be used as a guide or reference for the care plan team, physician, psychologists and families to help generate the correct conversations and decisions effective 11/04/16. ***The State Survey Agency verified the removal of the jeopardy through the following actions on 11/16/16. 1) Interview with the Regional Vice President of Operations (RVP) on 11/09/16 revealed the Administrator and DON were terminated from employment on 11/04/16. 2) Review of Resident #1's record revealed documentation of 15-minute checks and an evaluation by a psychiatrist on 11/03/16 and 11/10/16. Further review of the record revealed documentation that the care plan meeting was conducted and the resident's care plan was revised. Review of the facility's documentation revealed the resident received visits from the Chaplain on 11/04/16 and 11/11/16. 3) Review of Resident #2's medical record revealed the Medical Director completed a physical examination of Resident #2 (the alleged victim) on 11/03/16, and no signs or symptoms of sexual abuse were identified. The record further revealed that Resident #2 was evaluated by a psychiatrist on 11/03/16 and medication changes were recommended and followed through as ordered. A follow-up visit with the psychiatrist was conducted on 11/10/16 with a recommendation to change the resident to every fifteen (15) minute monitoring and no other concerns were noted. The record further revealed the Chaplain had provided spiritual support for the resident on 11/04/16 and again on 11/11/16. The record revealed a care plan/family meeting was conducted on 11/02/16. 4) Review of the facility's audits on 11/16/16 revealed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to fifteen (15) were interviewed on 11/02/16 by the SSW, SDC, ADON, and the Activity Director related to any concerns related to abuse in the facility. Review of an investigation dated 11/02/16 revealed one (1) resident voiced a concern; the concern was reported and investigated as required, with no problems identified. Interview with the SSW on 11/10/16 at 3:20 PM, the SDC on 11/16/16 at 4:00 PM, and the ADON on 11/10/16 at 5:10 PM, revealed all residents with a BIMS score of eight (8) to fifteen (15) were interviewed on 11/02/16. 5) Review of the facility's audits on 11/16/16 revealed skin assessments for 100% of residents were conducted on 11/02/16, for signs and symptoms of abuse, with no concerns identified. Interview with the SDC on 11/16/16 at 4:00 PM, ADON on 11/16/16 at 3:40 PM, and Registered Nurse (RN) #1 on 11/16/16 at 3:20 PM confirmed skin assessments had been conducted on 100% of facility residents on 11/02/16. 6) Review of the facility audits revealed all prior grievances were reviewed by the Administrator/Regional Controller on 11/03/16 for appropriate follow-up and to identify any abuse allegations that had not been reported for the last six (6) months, and no concerns were identified. 7) Further review of audits conducted by the facility revealed the Administrator/Regional Controller had reviewed all resident council notes from the past six (6) months on 11/03/16. Interview with the Regional Controller on 11/09/16 at 5:00 PM revealed he had identified nine (9) grievances that he stated needed to be addressed more appropriately and one (1) reported from November's meeting. All concerns were addressed and corrected by the Regional Controller. 8) Review of the facility's audits on 11/16/16, conducted by the Regional Controller, revealed the Regional Consulting Nurse had reviewed all reportable incidents for the last 12 months on 11/03/16. The Consulting Nurse had reviewed the allegations to ensure the facility's policy had been followed and that complete and thorough investigations had been conducted. Further review of the audits revealed the Consulting Nurse reviewed all reportable incidents, at least monthly when she visits the Center. Interview with the RVP on 11/16/16 at 4:30 PM revealed since 11/02/16 she had been involved as the Interim Administrator, and had remained on-site since 11/02/16. The RVP stated she had been involved in all reportable incidents to ensure they had been reported and that a thorough and complete investigation had been conducted. 9) Interviews with the Regional Consulting Nurse and the RVP on 11/16/16 at 4:15 PM and 4:30 PM, as well as review of the facility's audits revealed all residents' charts which included progress notes had been reviewed for the last 60-day timeframe on 11/03/16 and 11/04/16 to ensure no abuse allegations had been documented with no actions taken, and no concerns were identified, and that the resident's physician and family had been notified of any changes in condition, and no concerns were identified. 10) Review of facility's documentation revealed 100% of the residents were verified to ensure no current residents were on the sex offender registry on 11/04/16 by Human Resources, and no concerns were identified. Interview with the RVP on 11/16/16 at 4:30 PM revealed she had validated that Human Resources had ensured that none of the residents were listed on the sex offender registry. 11) Review of facility's audits revealed all accidents and incidents from the last 30 days were reviewed on 11/04/16 for any unidentified change of condition, and any non-reported abuse allegations, and no concerns were identified. These audits were conducted by nurse management, the interim DON, SDC, and consulting nurse. Interviews with the SDC on 11/16/16 at 4:00 PM, the ADON on 11/10/16 at 5:10 PM, and the Regional Consulting Nurse verified they assisted with the audits. 12) Interview with the RVP on 11/16/16 at 4:30 PM and review of facility documentation revealed the she had held a Resident Council Meeting on 11/03/16 to educate residents on all types of abuse, reporting abuse, and to discuss appropriate resident relationships. All residents understood and felt comfortable and more informed after the meeting. Interviews with Residents A and B on 11/16/16 at 12:55 PM and 1:00 PM confirmed they had been educated, during a Resident Council Meeting, related to abuse and relationships in the facility. 13) Review of facility documentation related to staff training revealed the RVP, Consulting Nurse, and SDC nurse had initiated abuse education on 11/02/16 with all staff with validation of training with post-test requiring a score of 100% to determine competency. No employees were permitted to return to work until they had been re-educated and passed the competency test. Review of post tests revealed staff competency was acquired. Review of personnel records revealed certified letters were sent to staff informing them they would not be permitted to work until retrained. 14) Review of facility documentation of audits conducted revealed the Administrator/Regional Controller reviewed files of all new employees on 11/03/16, that had been hired in the past 6 months (25 employee files), for appropriate credentials and possible abuse allegations; and no concerns were identified. 15) Review of facility documentation revealed that on 11/03/16 and 11/04/16 staff was provided with re-education and a post-test with a score of 100% related to family and physician notification, resident rights, Interact SBAR and Stop and Watch form, care plans policy and procedure, to include appropriately updating the residents' care plans to reflect the residents' current care needs along with supervision needs. This staff training was conducted by the Consulting Nurse. All new hires will be educated on the abuse policy and procedures with post-test score of 100 required, effective 11/04/16. Interview with the Consulting Nurse on 11/16/16 at 4:15 PM revealed the training was conducted with on 11/03/16 and 11/04/16. 16) Review of facility documentation revealed daily monitoring audits had been conducted from 11/03/16 through 11/16/16 by the Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator that included five (5) random skin assessments on residents with BIMS scores of seven (7) and below for signs or symptoms of abuse, ten (10) random resident chart audits for change in resident condition that had not been followed through with as required, and ten (10) random staff abuse tests. Interviews with the interim DON on 11/16/16 at 3:40 PM and the Consulting Nurse on 11/16/16 at 4:15 PM revealed the audits were conducted. 17) Review of the facility's documentation and interview with the RVP on 11/16/16 at 4:30 PM revealed she, as well as the Consulting Nurse, Interim DON, SDC, and SSW conducted ten (10) random resident interviews (with BIMS scores of 8 and above) for any abuse allegations or concerns. 18) Review of facility documentation revealed on 11/04/16 staff initiated ongoing monitoring through clinical meetings five (5) times a week, which consisted of the following staff members in attendance: Consulting Nurse, Interim DON, SDC, SSW, and the Interim Administrator. Interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM, revealed staff reviewed the 24-hour report, all accident and incidents, physician orders, and daily charting for sign and symptoms of abuse or any unreported abuse allegations. 19) Interview with the RVP on 11/16/16 at 4:30 PM confirmed she had provided administrative oversight of the facility since 11/02/16. 20) Review of facility documentation and interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM revealed the QAPI committee met on 11/02/16 and 11/09/16 to review the plan and all audits for needed revisions, compliance, and or further education. 21) Review of facility documentation and interviews with the Consulting Nurse on 11/16/16 at 4:15 PM and the RVP on 11/16/16 at 4:30 PM confirmed the Determining Decision-Making Capacity, Sexual Consent Capacity would be used as a guide or reference for the care plan team, physician, psychologists, and families to help generate the correct conversations and decisions effective 11/04/16.