Every finding on record at Siler City Center

Based on observation and staff interviews, the facility failed to store a scoop in a manner that prevented it from becoming contaminated by direct contact with flour, maintaining a clean steam table hood, and ensuring plastic plate bases were dried before being stacked for 2 of 2 kitchen observations. This deficient practice had the potential to affect food served to residents. The findings included:1. The initial tour of the kitchen was on 2/23/26 at 10:17 AM with the Dietary Manager. A large bin of flour was observed by the prep table with the scoop stored in the container of flour.The Dietary Manager was interviewed on 2/23/26 at 10:17 AM. The Dietary Manager asked a kitchen aide to remove the scoop from the flour. The Dietary Manager explained the hook to hang the scoop was inside the container and when the lid to the container slid to the closed position, it often knocked the scoop back into the flour.2. At 10:19 AM on 2/23/26, a continuation of the tour revealed the underside of the steam table hood contained orange, brown residue and felt slick to touch. The Dietary Manager was interviewed on 2/23/26 at 10:20 AM. The Dietary Manager confirmed the buildup, stating the steam table was cleaned between each meal but did not think the underneath of the hood had been cleaned for a while. 3. During a follow-up kitchen tour on 2/25/26 at 11:45 AM 20 out of 30 plastic plate bases were stacked wet on the tray line ready for use.The Dietary Manager was interviewed on 2/25/26 at 11:50 AM. The Dietary Manager stated she had checked other dishware for dryness but had not checked the plastic plate bases. The Dietary Manager then removed the plastic plate bases, rewashed them, and ensured they were air dried, placing them back on the tray line.The Administrator was interviewed on 2/27/26 at 10:22 AM. The Administrator stated he did not know why the hood to the steam table was not clean or why the scoop was left in the flour, and he would want the kitchen staff to keep the kitchen clean and not leave the scoops in the bins. The Administrator also stated he would want all dishware clean and dry before placing it on the tray line.

Based on record review, observation, resident, staff, and Medical Director interviews the facility failed to assess a resident's ability to keep steroid nasal spray at bed side for self-administration for 1 of 1 resident reviewed for self-administration of medications (Resident #138).The findings included:Resident #138 was admitted to the facility on [DATE].Physician order dated 4/15/25 revealed an order for fluticasone propionate nasal suspension (steroid nasal spray for allergies) 50 micrograms 2 sprays in both nostrils twice a day for allergies.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #138 was cognitively intact.Resident #138's care plan dated 2/17/26 did not include any goals or interventions for self-administering medications.Review of Resident #138's medical record did not show an assessment for self-administration of medication.Resident #138 was interviewed on 2/23/26 at 11:16am. During the interview an observation was made of Resident #138's prescribed bottle of nasal spray sitting on the resident's overbed table. Resident #138 stated the nurse had left it in her room, but she was unable to state which nurse. Resident #138 stated she should not have the nasal spray in her room but that it made it easier for her to use when needed.An observation was made on 2/23/26 at 3:52pm of Resident #138's room. The observation revealed the bottle of nasal spray remained on her overbed table.Another observation was made on 2/24/26 at 10:38am of Resident #138's room. The bottle of nasal spray was observed on her overbed table.Nurse #1 was interviewed on 2/24/26 at 3:01pm and confirmed she was assigned to Resident #138 on 2/24/26. Nurse #1 discussed not being sure what the process was for a resident who self-administered medication because there were no residents on the 400 hall who could self-administer medication. She stated if she saw any medication left in a resident room, she would remove it immediately and clarified she had not seen any medication in any resident rooms today (2/24/26). Nurse #1 also clarified that she provided Resident #138's medication while the resident was in her room [ROOM NUMBER]/24/26. During the interview an observation of Resident #138's room was conducted and Nurse #1 found the bottle of nasal spray on the resident's overbed table behind a box of tissue. The Nurse discussed when she provided Resident #138 her medication in the morning (2/24/26), she did not notice the bottle of nasal spray. Nurse #1 was observed removing the nasal spray from Resident #138's room.An interview occurred with the Medical Director on 2/26/26 at 2:40pm. The Medical Director discussed Resident #138 being cognitively intact and stated he would not be concerned about the nasal spray being left at the resident's bedside. However, he explained the medication should not be left in a resident's room without an order/assessment and stated the nasal spray would not cause harm if taken more frequently than ordered. During an interview with the Director of Nursing (DON) on 2/24/26 at 3:11pm, the DON explained if a resident wanted to self-administer their medication, the facility would need to do an assessment to ensure the resident was safe to self-administer their medication. She stated once a resident was able to self-administer their medication, a lock box was placed in their room, and the resident would have a plan of care to self-administer their medication. The DON stated she did not believe there were any residents down hall 400 who self-administered their own medication. She explained Resident #138 had the potential to self-administer her own medication due to the resident's cognition. The DON stated if a nurse saw medication at a residents' bedside, she would want the medication removed, a conversation to be held with the resident about self-administering, an assessment to be completed, and an order obtained.The Administrator was interviewed on 2/24/26 at 3:38pm. The Administrator stated he was not sure if there were any residents in the facility who self-administered their own medication. He explained if a resident wanted to self-administer their medication, the nurse would need to complete an evaluation. The Administrator discussed if a nurse saw medication at a residents' bedside, he would want the medication removed and then an evaluation completed to see if the resident was safe to self-administer.

Based on record review and staff interviews, the facility failed to protect the residents' right to be from physical abuse when Resident #86 hit Resident #14 with a grabber (handheld device used to assist in obtaining items out of reach) on 12/2/25 which resulted in an abrasion to Resident #14's forehead and Resident #86 hit Resident #54 with an open hand across the face while Resident #86 was receiving one-on-one (1:1) supervision on 12/24/25. This for 1 of 4 residents reviewed for abuse (Resident #86). The findings included:Resident #86 was admitted to the facility on [DATE] with diagnosis that included dementia, insomnia, psychotic disturbance, mood disturbance, mild cognitive impairment and anxiety.Review of Resident #86 Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired with no upper or lower extremity impairments, only required set up for mobility and had no physical or verbal behaviors directed towards others. Review of Resident #86 Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired, had no upper or lower extremity impairments, only required set up for mobility and had no behaviors directed towards others during the look back period. Review of Resident #86 care plan dated 11/28/25 and revised 12/3/25 and 12/26/25 indicated he exhibited or had the potential to exhibit behaviors related to cognitive loss and dementia. The care plan reflected resident to resident incidents (hitting other residents) on 10/19/25, 12/2/25 and 12/24/25. The goal stated Resident #68 would not harm another resident. The interventions included evaluating nature and circumstances (i.e., triggers) of physical behavior with resident, evaluating need for psychological/behavioral health consultation, observing the resident for non-verbal signs of physical aggression (rigid body position, clinched fist, etc.), remove resident from the environment if needed and diverting resident by giving alternative objects or activities. 1:1 supervision was written on the care plan 12/3/25.Resident #93 was admitted to the facility on [DATE] with a diagnosis that included mild dementia, major depressive disorder and agitation.Review of Resident #93's quarterly MDS assessment dated [DATE] revealed he was moderately cognitively impaired, had no upper or lower extremity impairments and had no physical behavior directed towards others. Review of the care plan dated 6/20/25 revealed Resident #93 exhibited physical behaviors of grabbing, pushing and being physically aggressive towards others related to dementia with behaviors. The goal stated Resident #93 would not harm others. The interventions included encourage resident to seek staff support for distressed mood, observe for non-verbal signs of physical aggression to include rigid body positioning, clenched fist etc., and remove resident from environment if needed.Care plan dated 6/20/25 and last revised 9/23/25 revealed Resident #93 exhibited verbal behaviors of threatening, cursing, agitation, delusions at times, screaming and accusing others related to dementia with behaviors. The goal stated Resident #93 would not exhibit verbal outbursts directed towards others. The interventions included, evaluate the nature and circumstances (i.e., triggers) of verbal behavior, provide consistent trusted caregiver and structured daily routine when possible; and divert resident by giving alternative objects or activities.The Initial Allegation Report dated 10/19/25 revealed resident-to-resident abuse. The facility became aware of the allegation on 10/19/25 at 4:30PM. The allegation details stated Resident #86 had made contact with Resident #93 in his face. Both residents were separated immediately and placed on 1:1 monitoring for residents' safety. According to the report there were no mental or physical injuries noted, and the incident was reported to law enforcement. The Initial Allegation Report was completed by the Director of Nursing (DON). Review of the facility Investigation Report dated 10/21/25 revealed resident-to-resident abuse occurred on the 500 hall. The report was signed by the DON. The attached investigative summary stated on 10/19/25 nursing assistant (NA #11) was sitting at the nursing station on the 500 hall at approximately 4:30PM, when she witnessed Resident #93 approach the desk smiling. She at the same time noticed Resident #86 in the hallway by his bedroom door. NA #11 asked Resident #93, what did he do? Resident #93 responded that Resident #86 hit him and knocked him down. At this time Resident #86 was coming up the hall in his wheelchair, pointing and fussing that we better keep Resident #93 out of his room. Nurse #10 stated Resident #86 was visibly upset and fussing in his native language (Spanish) while pointing his finger at the nurse. The nurse reported Resident #86 stated he is gonna get what he deserves. The NA stated at this time Resident #86 hit Resident #93 on his left cheek with an open palm slap. The staff reported they were unable to separate the residents quickly enough to avoid the occurrence. Nurse #10 took Resident #86 to the dining room while the nursing supervisor took Resident #93 with her. Resident #86 stated when he was in his bathroom and coming into his room, he found Resident #93 on his side of the room looking through his belongings (not roommates). Resident #86 reported he asked Resident #93 what he was doing. Resident #93 walked up to Resident #86 and hit Resident #86 on the side of the head making him fall. The DON interviewed both residents and heard similar stories of the initial unwitnessed incident in Resident #86's room and the witnessed altercation at the nursing station. The report further stated upon completion of the facility investigation through resident interviews, skin assessments and psych provider evaluations, the facility substantiated the resident-to-resident altercation. Residents #86 and Resident #93 would remain separate and with 1:1 staff supervision until cleared by psychology and the medical director. As of 10/19/25 both residents remained on one-on-one with no behaviors noted since the altercation.Interview with NA #11 on 2/27/26 at 8:54AM revealed from what she could recall, she was sitting at the nursing station when Resident #93 was observed walking down the hall towards the nursing station laughing but could not recall the date during 2nd shift. She stated she saw Resident #86 sitting in his doorway, seated in his wheelchair. She did not see Resident #93 coming out of Resident #86's room but he was coming from the direction of Resident #86 room. She recalled asking Resident #93 what he had done because she could tell something had happened. NA #11 indicated she thought Resident #93 verbalized Resident #86 had hit him. She indicated she saw Resident #86 approaching the nursing station fussing in broken English. NA #11 revealed when Resident #86 got to the nursing station in his wheelchair, he stood up and hit Resident #93 in the face.Interview with Nurse #10 on 2/7/26 at 9:20AM revealed she was the nurse assigned to 500 hall when the altercation occurred with Resident #86 and Resident #93. She recalled Resident #93 already being at the nursing station when Resident #86 came down the hall to the nursing station in his wheelchair. Resident #86 appeared very upset. When Resident #86 got to the nursing station he stood up and shook his finger at Nurse #10 and was saying something she could not make out. She stated when she stood up to talk to Resident #86, Resident #86 smacked Resident #93. Nurse #10 couldn't remember what side of the face Resident #93 was hit. The residents were separated and Resident #86 was moved from the 500 hall with 1:1 supervision.a. Resident #14 was admitted to the facility on [DATE] with a diagnosis that included hypertension, schizoaffective disorder, major depressive disorder and bipolar disease. Resident #14's quarterly MDS assessment dated [DATE] revealed he was cognitively intact, had no behaviors directed towards others and required substantial to maximum assistance with activities of daily living (ADL).Review of care plan dated 7/8/25 and revised 12/13/25 revealed Resident #14 exhibited or was at risk for distressed/fluctuating mood symptoms of being agitated/restless/anxious related to schizoaffective disorder, personality disorder, post-traumatic stress disorder (PTSD) and history of hallucinations. The goal stated Resident #14 would express anxieties/fears to staff, including psych providers, regarding his changs in mood (anxiety/depression, etc.). The interventions included redirect and reassure Resident #14, observe for signs and symptoms of worsening anxiety/fear/anger or agitation. The interventions further included to observe for worsening signs and symptoms of existing psychiatric disorder (e.g., mania, hypomania, frequent mood changes, etc.). Interview with NA #10 on 2/27/26 at 9:10AM revealed she recalled an argument that occurred with Resident #86 and Resident #14 who shared a room. Although she could not recall the date NA #10 could recall she was working 1st shift (7:00 am to 3:00 pm). The argument was over the volume of the televisions, and the residents were going back and forth for control. She indicated she recalled the argument taking place while she was passing dinner trays. She indicated Resident #14 had requested Resident #86 turn down his television and Resident #86 yelled back that it was his television. NA #10 indicated she had tried to intervene, but she was passing dinner trays. She stated she told Resident #14 and Resident #86 they both needed to turn down their televisions. She recalled Resident #86 peering over to Resident #14's side of the room (behind curtain) stating it was his television. NA #10 revealed she notified the nurse (could not recall name) that Resident #86 and Resident #14 could not agree on the volume of the televisions and to see if she could assist. NA #10 stated she did not know what the nurse told Resident #86 and Resident #14, but when the nurse came out of the room she verbalized everything was fine. NA #10 indicated her shift was over before the incident occurred.Interview with Nurse #12 on 2/27/26 at 12:30PM revealed she recalled being assigned to the 300 hall on the date of the incident involving Resident #14 and Resident #86. She indicated she worked first shift (7:00 AM to 3:00 PM) and the incident occurred on 2nd shift (3:00 PM to 11:00 PM). She recalled being approached by an NA (could not recall name) notifying her that Resident #14 and Resident #86 were arguing about the television. She indicated by the time she arrived at Resident #14 and Resident #86's shared room, the resident were no longer arguing about the television. The Initial Allegation Report dated 12/2/25 stated an allegation of resident-to-resident abuse between Resident #86 and Resident #14. The stated Resident #86 and Resident #14 were separated and placed on 1:1 supervision for monitoring and safety. The details of physical or mental injury/harm revealed Resident #14 had an abrasion to his forehead which was cleaned by nursing staff and Resident #86 had an injury to his finger. The Investigation Report dated 12/9/25 revealed the facility became aware of the incident on 12/2/25 at 9:00AM in room [ROOM NUMBER]. The report indicated the incident resulted in physical harm. Resident #14 had an abrasion to his forehead that was cleansed by nursing staff. Resident #86 had a scratch on his finger that was cleansed by nursing staff.Review of a late-entry nursing note dated 12/3/25 stated Resident #86 was expected to transfer rooms. He required a private room due to an altercation on 12/2/25. Resident #86 was moved immediately following the altercation.Interview with Nurse #5 on 2/27/26 at10:53AM revealed she recalled an incident in which Resident #86 hit Resident #14 on 12/2/25. She stated she recalled being by the medication cart when Resident #86 came out of his room and was waving his arms as if he wanted help. When she got to the shared room of Resident #86 and Resident #14, she observed the room to be in disarray and Resident #14 had blood on his forehead. Resident #14 verbalized Resident #86 hit him with his reaching device (device used to aid in reaching items) on his head. She indicated Resident #14 continued to verbalize there was an issue with the volume of the television. Nurse #5 believed Resident #86's universal television remote was controlling Resident #14's television. Following her observation, she brought Resident #86 out of the room, and he was immediately placed on 1:1 supervision. Nurse #5 requested assistance from another nurse (name unknown) for assistance and to assess Resident #14's injuries. Nurse #5 indicated prior to her shift, she was notified during shift change Resident #14 and Resident #86 had an issue with the television volume, but she was told the issue was resolved. The altercation with Resident #86 and Resident #14 was not observed by staff. Interview with the Director of Nursing on 2/27/26 at 10:41PM revealed following the 12/2/25 incident with Resident #86 and Resident #14 interventions were put into place and included 1:1 was initiated for Resident #86 continuously, education was provided to staff regarding abuse with the inclusion of roommate compatibility, a private room was provided for Resident #86 and psych evaluation.Interview with the Administrator on 2/27/26 at 11:49AM revealed his date of employment was 11/3/25. He stated Resident #86 and Resident #14 were involved in an argument over preference of the television volume on 12/2/25 in their shared room. He stated it was identified the resident's television remotes were synched with one another, so they were inadvertently controlling each other's television volumes. Following the incident Resident #86 was placed on 1:1 supervision and he was placed in a private room. A plan of correction was put into place where the facility identified a timeline of the events. Monitoring was put into place, education regarding abuse and roommate compatibility was included. b. Resident #54 was admitted to the facility on [DATE] with a diagnosis that included vascular dementia with mood disturbance, insomnia due to other mental disorder and anxiety disorder.Quarterly MDS assessment dated [DATE] indicated Resident #54 was severely cognitively impaired, was independent with mobility and had no physical behaviors directed towards others during the lookback period. Review of Resident #54 care plan dated 4/2/25 revealed he exhibited or had the potential to exhibit physical behaviors related to his cognitive loss/dementia. Resident #54 would go into other rooms and not leave when asked. Resident #54 showed little knowledge of personal space. He paced, wandered and yelled at others expressing frustration, agitation and restlessness. The goal stated Resident #54 would be kept safe in his living environment. The interventions included, remove him from the environment if needed, gently guide Resident #54 from the environment while speaking in a calm, reassuring voice and divert Resident #54 by giving alternatives objects or activities.Review of the facilities Initial Allegation Report dated 12/24/25 stated the facility became aware of an alleged incident of resident-to-resident abuse between Resident #54 and Resident #86 on 12/24/25 at 7:10PM. The residents were separated and each placed on 1:1 supervision for monitoring and safety. Law enforcement was contacted regarding the incident. The Investigation Report dated 12/31/25 revealed an attached investigation summary that included protect both residents, (Resident #54 and Resident #86) were immediately separated by the facility staff and placed on 1:1 supervision. Resident #54 was moved to a different hall on 12/25/25. On 12/24/25 NA #6 was providing 1:1 supervision to Resident #86 while they were by the nursing station. According to NA #8, Resident #54, who was ambulatory, was standing at the nursing station conversing with other staff. Resident #54 began to speak to Resident #86. In a matter of seconds, Resident #54 leaned in closer to Resident #86, still speaking but not making sense. At that time per NA #8, Resident #86 reached out and struck Resident #54 openhanded across the face. Both residents were interviewed by the DON, and the residents were immediately separated and taken back to their rooms and placed on 1:1 supervision. Based on the accounts of events from the residents and the witness statements taken from staff it had been determined during the investigation that the resident-to-resident abuse was substantiated by the facility. An interview was conducted with Nurse #11 on 2/26/26 at 6:13PM. Nurse #11 indicated she was agency staff and vaguely remembered the incident that occurred with Resident #86 and Resident #54. She recalled Resident #86 utilized a wheelchair for ambulation and Resident #54 was able to walk independently. Nurse #11 did not recall Resident #86 having a 1:1 but did have a NA (name unknown) beside him while Resident #86 was at the nursing station. She recalled Resident #54 approach Resident #86, and Resident #86 was saying, leave me alone. Resident #54 reached out to Resident #86, and Resident #86 stood up from this wheelchair and hit Resident #54. From the nursing station she noticed Resident #54 leaning down toward Resident #86 before he was hit. Nurse #11 stated she could not tell if Resident #86 was hit with an open hand or his fist. Nurse #11 revealed she was not the assigned nurse for the residents but witnessed the incident because it occurred in front of the nursing station.Interview with NA #12 on 2/26/26 at 6:35PM revealed she recalled providing Resident #86 1:1 supervision on 12/24/25. She recalled Resident #54 coming off the 200 hallway towards the nursing station. NA #12 stated Resident #54 was about 5 steps from Resident #86 who was seated in his wheelchair within arm's reach of her. She stated she didn't think anything would happen when Resident #54 approached close to Resident #86 as she assumed Resident #54 was just coming over to speak. NA #12 indicated she could not remember what Resident #54 was saying but he leaned close to Resident #86 and Resident #86 hit him in the face with an open hand. Resident #54 was not directly in Resident #86 face, but he was very close. She stated Resident #86 hit Resident #54 so quickly she did not have time to prevent the altercation. NA #12 indicated she becomes aware she's assigned 1:1 when she arrives to shift and reviews the assignment sheet. She stated she had not received any instructions regarding Resident #86's triggers or what to avoid.An interview and observation was conducted with NA #9 in Resident #86's room on 2/27/26 at 8:10AM. NA #9 revealed she was assigned the task of 1:1 supervision for Resident #86. She further stated she was as needed (PRN) staff but worked with Resident #86 often. She further revealed she was usually assigned to conduct 1:1 with the resident weekly, completing 16-hour shift with Resident #86. NA #9 revealed the facility had not told her why she was providing Resident #86 with 1:1 supervision. She had overheard a nurse (name not known) verbalizing there was an incident but not the details of the incident. NA #9 further revealed she was only instructed to tell a nurse if Resident #86 was upset and to get them if she needed assistance. Resident #86 was described as very social and he occasionally becomes upset but was easily calmed. NA #9 stated she was not aware of triggers that led to previous resident-to-resident altercations. An interview was conducted with the DON on 2/27/26 at 10:41PM. The DON stated interventions were put into place following 12/24/25 the incident with Resident #86 and Resident #54. The interventions included continued 1:1 supervision with Resident #86, re-education on abuse, resident rooms were reassigned and psych evaluation were completed. The DON stated she was unaware if NAs assigned to provide Resident #86 with 1:1 supervision staff were educated about potential triggers. Interview with the Assistant Director of Nursing (ADON) on 2/27/26 at 10:53AM revealed staff were told when providing 1:1 supervision, they were to stay with the assigned resident at all times. Staff further ensure residents on 1:1 were not being aggressive with other residents. When staff were assigned 1:1 supervision, staff were told triggers. The ADON indicated Resident #86 triggers were if anyone was messing with his personal items or got into his personal space. The ADON could not recall any formal in-service being conducted regarding Resident #86's triggers to resident-to-resident aggression. Interview with the Administrator on 2/27/26 at 11:49AM revealed on 12/24/25 Resident #86 hit Resident #54 in the face while Resident #86 was receiving 1:1 supervision and the incident took place at the nursing station. He described Resident #54 as very friendly and hard of hearing. He revealed he believed Resident #54 leaned in to hear what Resident #86 was saying when Resident #86 was startled and hit Resident #54. He stated both Residents were residing on the same hall and as an intervention, Resident #54 was assigned to another hall. He further revealed staff received education on de-escalation and dementia training. He stated he would expect NAs to be told about what may trigger a resident to display aggressive behaviors prior to providing 1:1 supervision. He further stated he would have to get with the nurse educator to identify if triggers were discussed. He indicated 1:1 supervision failed on 12/24/25 because the movements of Resident #86 were swift and happened in a matter of seconds. The NA assigned to provide 1:1 was present and within arm's reach of the Resident #86 when the incident occurred. To his understanding Resident #54, Resident #86 and staff were talking at the nursing station and Resident #54 leaned in close to Resident #86.

Based on record review, the facility failed to complete an accurate Minimum Data Set (MDS) assessment in the area of skin conditions for 1 of 11 residents who MDS assessments were reviewed (Resident #5).The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses of left patella fracture, atrial fibrillation (A-fib), congestive heart failure (CHF), hypothyroidism, and Alzheimer's disease. An admission progress note written on 10/08/25 at 2:46 PM by Nurse #8 stated Resident #5 had arrived at the facility via ambulance on a stretcher. She noted that Resident #5 had a dark spot to her coccyx, an open area to her spine, and redness to her left knee. A review of Resident #5's care plan dated 10/09/25 revealed she was found to be at risk for skin breakdown. The goal dated 10/9/25 stated Resident #5 would not show any signs of skin breakdown for 90 days. The interventions also dated 10/9/25 included to pat (do not rub) skin when drying, observe skin for signs and symptoms of skin breakdown including redness, cracking, blistering, decreased sensation, and skin that does not blanch easily, provide preventative skin care (lotions, barrier creams as ordered), apply barrier cream with each cleansing, observe skin conditions daily with activities of daily living (ADL) care and to report abnormalities and the resident's skin was to be checked weekly by a licensed nurse. There were no care plans or interventions included for Resident #5 for or directly speaking to the open area noted to her spine or the dark spot on her coccyx observed on admission. Resident #5's admission Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired and required extensive assistance with activities of daily living, bed mobility, and transfers. The MDS noted that she was at risk for developing pressure ulcers/injuries but stated she did not have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing or device. That MDS stated Resident #5 had no pressure ulcers or skin issues. Under 'Other ulcers, wounds, and skin problems' the MDS indicated none were present. The MDS did not indicate that Resident #5 was to have a pressure relieving device in her chair or have her participate in a reposition/turning program or be part of a nutrition and hydration program for skin.

Based on observations, record review and resident, staff and Physician interviews, the facility failed to secure medications stored at the bedside for 1 of 1 resident reviewed for medication storage (Resident #7).The findings included:Resident #7 was admitted to the facility on [DATE]. A review of Resident #7's physician's orders dated 6/25/2025 revealed an order that stated, Resident may not administer his own meds. A review of Physician's order dated 6/25/25 for Resident #7 revealed that staff were to monitor swallowing during medication pass and to document if resident coughed, complained of pain, or demonstrated difficulty when swallowing meds.An observation and interview were conducted on 2/24/26 at 2:50PM with Resident #7 in his room. It was observed that he had a medication cup containing 7 pills sitting on his bedside table. Observation of the hallway outside of resident's room revealed the nurse for this hallway (Nurse #2) was no longer passing medications on the hallway. Resident #7 said he would take his medications in the cup, when they let me out of this place. An interview was then conducted on 2/24/26 at 2:55PM, in Resident #7's room with Nurse #2 (nurse assigned to the 100 hallway). She stated the medication cup contained different medications and named them. Nurse #2 indicated they were Resident #7's lunch meds (medications) which she gave him at approximately 1:30PM. Nurse #2 stated, 'He usually takes them.' Nurse #2 then asked Resident #7 if he would take the medication and resident refused stating, I will take them when I get up outta here and he did not take the medication. Nurse took the med cup with her out of the resident's room and walked back to the staff breakroom. In a continued interview and observation on 2/24/26 at 2:58pm, outside of Resident's room, Nurse #2 explained she would typically administer Resident #7's medications to him, by just handing them to him to take and he would take them. She went on to say that in this case, he told her he would take them so she trusted that he would do that. Nurse #2 stated this was a lapse in her judgement and she should not have left them in there because he didn't take them. She said she was aware that he was not supposed to have his medications left at bedside as well as the order to monitor swallowing during medication pass and document if Resident #7 coughed, complained of pain, or demonstrated difficulty when swallowing medications. An interview was conducted on 2/26/2026 at 2:45PM with the Physician. He stated that he couldn't really speak to Resident #7 having his own meds at his bedside. The Physician did not recall initially that Resident #7 had an order that stated he was not permitted to administer his own medications, but stated, Then he probably shouldn't. He indicated he did not feel like the pills in the cup would hurt Resident #7 to have them on his bedside table, but that he did know he was resistive to care at times. He said he did expect all physicians' orders to be followed by staff, but he can't always control what the staff did. An interview with the Director of Nursing (DON), conducted on 2/27/2026 at 1:14PM revealed that there was only one resident in the facility during the time of survey who had an order to administer their own medications. All other residents had orders that they may not self-administer medications. The DON stated that Nurse #2 should have stayed and watched Resident #7 take his medications and should not have left them at the bedside. Interview with the Administrator on 2/27/2026 at 1:23PM revealed that he was not aware that medications were left at the bedside of Resident #7. The Administrator stated he was not familiar with the resident, and he did not feel he could speak about the situation.

Based on observation and staff interviews, the facility failed to keep the area around the trash compactor free from accumulated trash and debris for 1 of 1 trash compactor observed. This failure had the potential to attract pests and rodents.The findings included:An observation of the dumpster area occurred on 2/23/26 at 10:23 am with the Dietary Manager (DM). The observation revealed the facility had one trash compactor located in a fenced area behind the kitchen entrance. Directly in front of the trash compactor was a cement platform with a grassy area to the left side and back of the trash compactor. On the left side of the trash compactor in the grassy area there were four plastic bottles, six disposable cups, four disposable gloves, and seven straws.The DM was interviewed on 2/23/26 at 10:24 am. The DM explained the cement platform was cleaned weekly by a member of the kitchen staff but the trash and debris on the left side and back of the trash compactor did not get picked up. The DM stated she was not sure why the area was not attended to and commented that all departments in the facility used the same trash compactor.During an interview with the Administrator on 2/27/26 at 10:22am, the Administrator stated he did not know why the trash compactor area had not been cleaned and explained he would want the area cleaned of any debris.

Based on record review, observation, and interviews with the Responsible Parties (RPs), PACE (Program of All-Inclusive Care for the Elderly) Nurse Practitioner, psychiatric Nurse Practitioner and staff, the facility failed to protect a cognitively impaired male resident's right to be free from sexual abuse (Resident #2) perpetrated by a cognitively impaired male resident (Resident #1). On 9/1/25 Nurse Aide (NA) #1 overheard Resident #2 laughing from the hallway and proceeded to the room he shared with Resident #1 as this was an unusual behavior for Resident #2. When NA #1 stepped into the doorway of the room, she observed Resident #2 lying on his back in bed with his penis exposed on the left side of his brief as Resident #1 stood beside the bed grasping Resident #2's penis with his hand as he moved his hand in an up and down motion. The residents did not have the cognitive capacity to consent to sexual relations or express an adverse psychosocial outcome. A reasonable person would have been traumatized by being sexually abused by a resident in their home environment resulting in feelings such as anger, fear, anxiety, and/or humiliation. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #2). Immediate Jeopardy began on 9/1/25 when Resident #2, who did not have the cognitive capacity to consent, was sexually abused by Resident #1. Immediate Jeopardy was removed on 9/5/25 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure education is completed and monitoring systems put into place are effective.The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, major depression and dementia with other behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment and displayed other behavioral symptoms not directed towards others on one to three days during the seven-day look back period. Resident #1 was independent with eating, bed mobility and transfers but required assistance from staff for all other Activities of Daily Living (ADL) and was able to ambulate independently. Resident #1 received an anticonvulsant medication. Resident #1's active care plan, last revised on 8/7/25, included focus areas for a behavior of hoarding items, wandering into other residents' rooms, physical and verbal behaviors and refusal of care. Resident #1's care plan did not identify any sexually inappropriate behaviors. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia and adjustment disorder with mixed anxiety and depressed mood. A review of Resident #2's active care plan, last revised 6/2/25, included focus areas for behaviors of pacing, wandering into other residents' rooms, rummaging, throwing/smearing bodily waste, disrobing in public and physical and verbal behaviors. Resident #2's care plan did not identify any sexually inappropriate behaviors. An annual MDS assessment dated [DATE] indicated Resident #2 had severe cognitive impairment and displayed physical and verbal behavioral symptoms as well as other behavioral symptoms not directed towards others, rejection of care and wandering on one to three days during the seven-day look back period. He was independent with eating, bed mobility, and transfers but required assistance from staff for all other ADL and was able to ambulate independently. Resident #2 was coded as being always incontinent of bowel and bladder and received an antidepressant medication. A review of Resident #2's nursing progress notes revealed that on 8/26/25 he was holding the front of his pants, saying I am burning. The PACE provider was notified and ordered a urinalysis. A review of Resident #2's physician orders included an order dated 8/28/25 for Fosfomycin (an antibiotic) 3 grams by mouth one time only for urinary tract infection (UTI). The incident report completed by the Unit Manager on 9/1/25 at 8:50 AM, revealed that when the NA #1 walked by the room she saw Resident #1 on Resident #2's side of the room by his bed. The NA entered the room and witnessed Resident #2 masturbating and Resident #1 was helping him and touching him inappropriately. The NA called out to stop, which Resident #1 did and returned to his side of the room. Neither one of the residents was able to give a description of what occurred. There were no injuries identified during skin assessments. The two residents were immediately separated and placed on one-to-one monitoring. The physicians, RPs for both residents, Administrator, Director of Nursing (DON) and local law enforcement were notified of the incident. The Initial Allegation Report dated 9/1/25, completed by the Unit Manager, read there was an allegation of resident-to-resident sexual abuse between Resident #1 and Resident #2, who resided in the memory care unit. Staff immediately intervened and separated the residents for safety, and both were placed on one-to-one observation. The local law enforcement was notified. There was no injury or harm to either resident. An undated staff statement from NA #1 read, .on 9/1/25 as I was coming back onto the hall, I heard Resident #2 laughing not a normal laugh, so I went to look in his room and I saw Resident #1 standing beside Resident #2's bed masturbating Resident #2 and I told him to stop. He stopped and jumped right back into his bed.I also noticed Resident #2 that morning playing with his self before all this occurred. NA #1 was interviewed on 9/4/25 at 2:45 PM. She stated that she was walking in the hallway of the memory care unit on 9/1/25 around 8:45 AM, and overheard Resident #2 laughing, which was unusual behavior for him. The door to Resident #1 and Resident #2's room was open. When she stepped into the doorway, she observed Resident #2 lying on his back in his bed, his arms to his sides with a shirt and fastened brief and his penis exposed to the left side of the brief. She observed Resident #1 standing beside the bed (facing the doorway), fully clothed, with one hand grasping Resident #2's penis and moving his hand in an up and down motion. She stated that Resident #2 was laughing and not attempting to move Resident #1's hand away. There was no verbal interaction between the two. NA #1 stated she immediately yelled stop, and Resident #1 returned to his bed. NA #1 stated that she placed pants on Resident #2 and escorted him into a chair in the hallway. Nurse #1 approached the room, and she told her what happened. NA #1 stated that she remained in the doorway to keep an eye on both Resident #1 and Resident #2 until management arrived. Both residents were placed on one-to-one monitoring and Resident #2's room was changed. NA #1 added that around 7:30 AM she had observed Resident #2 with his hand in his brief while in bed but was easily redirected to remove his hand. NA #1 stated that neither resident had displayed inappropriate sexual behavior in the past. An unsigned staff statement dated 9/1/25 read, in part, while passing medications, I was called to room at approximately [8:50 AM] by NA. When I arrived, the residents were separated. NA reported sexual interactions between the two. I did not witness the above interaction. A phone interview occurred with Nurse #1 on 9/4/25 at 1:08 PM. She explained the morning of 9/1/25 she was in the hallway completing the medication pass when she heard NA #1 saying stop very loudly. She stated she locked the medication cart and walked towards the room. Nurse #1 stated that by that time, NA #1 was bringing Resident #2 into the hallway to a chair. She stated that NA #1 told her that when she walked into Resident #1 and Resident #2's room, she observed Resident #1 grasping Resident #2's penis in his hand with a motion involved. NA #1 stated when she yelled out stop Resident #1 walked back to his bed. The two residents were separated, and she immediately reported it to the Unit Manager, both residents were placed on one-to-one monitoring and Resident #2's room was changed. Nurse #1 stated that she had written a staff statement regarding the incident on 9/1/25. Nurse #1 stated that neither resident had exhibited inappropriate sexual behaviors in the past. Nurse #1 stated that Resident #2 was currently being treated for a UTI and had been seen pulling at the groin area a few times that morning. The Unit Manager was interviewed on 9/4/25 at 2:30 PM and stated that on the morning of 9/1/25 she was informed by Nurse #1 that Resident #1 and Resident #2 had an incident of inappropriate sexual behavior. She stated Nurse #1 overheard NA #1 say stop very loudly. She stopped what she was doing and went to the room. NA #1 explained to the Unit Manager that she had observed Resident #2 lying on the bed and Resident #1 standing beside the bed grasping Resident #2's penis in his hand with an up and down motion. When NA #1 stated stop loudly, Resident #1 returned to his bed. The Unit Manager stated that she observed Resident #1 lying in his bed and Resident #2 sitting in a chair in the hallway. The two residents were immediately separated with one-to-one monitoring initiated and Resident #2's room changed. She stated that the Administrator and DON were made aware, as well as the providers, RPs and the police department. Skin assessments were completed on Resident #1 and Resident #2 with no negative findings. The Unit Manager stated she attempted to interview both residents regarding the incident, but they were unable to recall what had occurred. The Unit Manager stated that when initially completing the incident report she was under the impression that Resident #2 was masturbating, and Resident #1 was assisting him, since Resident #2 had been seen pulling at his groin several times in the past. Review of a psychiatric progress note dated 9/3/25 read that Resident #1 was seen as an acute visit due to recent sexually inappropriate behavior in the memory care unit at the facility. A NA reported an incident where she found Resident #1 holding his roommate's penis and appearing to perform a sexual act. Upon being instructed to stop, Resident #1 immediately complied and returned to his bed. Since this incident Resident #1 has been assigned a sitter and his roommate has been relocated to a different room. Resident #1's Depakote dosage was increased from twice a day to three times a day on 9/2/25, which may help to slow impulsive behaviors. During the visit, Resident #1 appeared happy with his confusion at baseline. A phone interview occurred with the PACE Nurse Practitioner (NP) on 9/4/25 at 12:21 PM. She indicated she was Resident #2's primary care provider and had been notified of the incident that occurred on 9/1/25. She explained that Resident #2 was being actively treated for a UTI and she had been changing some of his psychotropic medications. The NP further stated that Resident #2 had not displayed any inappropriate sexual behaviors in the past and did not have the cognitive capacity to consent to sexual relations. She completed a face-to-face assessment of Resident #2 on 9/2/25 and had no negative findings to report. A phone interview was completed with Resident #1's psychiatric provider on 9/4/25 at 3:47 PM. He stated he was made aware of the incident on 9/1/25 and was told Resident #2 had his penis out, the NA heard laughter, went to investigate and observed Resident #1 holding Resident #2's penis. When she yelled out stop, he (Resident #1) went back to his bed. The psychiatric provider stated this was new behavior for Resident #1. He added that Resident #1 was seen via telehealth on 9/2/25 where his Depakote (mood stabilizer/anticonvulsant) was increased. A face-to-face visit was completed with Resident #1 on 9/3/25 with a recommendation to initiate Sertraline (an antidepressant medication) as it would suppress any libido. The psychiatric provider added that Resident #1 did not have the cognitive capacity to consent to sexual relations. On 9/4/25 at 12:12 PM, Resident #2 was observed walking unassisted out of the dining room on the memory care unit and entering the room across the hall. He was observed turning around at the door and being redirected by staff back into the dining room. On 9/4/25 at 12:13 PM, Resident #1 was observed sitting in a chair in the memory care unit dining room with a staff member beside him. On 9/4/25 at 12:51 PM, a phone interview was held with Resident #1's RP. He indicated he had been made aware of the incident that occurred on 9/1/25 and stated that Resident #1 would never have acted sexually inappropriate prior to his dementia diagnosis. Resident #2's RP was his wife and she was interviewed via the phone on 9/4/25 at 12:58 PM. She indicated she had been made aware of the incident that occurred on 9/1/25. She explained that Resident #2 had recently been diagnosed with a UTI and was undergoing antibiotic treatment. She stated prior to his dementia diagnosis he would not have let something like that happen when speaking about the incident from 9/1/25. An interview occurred with the DON on 9/4/25 at 3:09 PM and stated that she was not at the facility when Resident #1 inappropriately touched Resident #2's penis on 9/1/25. She stated the Unit Manager called her to report the incident and she gave her the steps to follow until she arrived at the facility. The DON stated that both residents were immediately separated following the incident and placed on one-to-one monitoring. The providers, RPs and police department were notified. Skin assessments were completed on both residents with no negative findings. The DON added that neither resident had experienced any inappropriate sexual behavior in the past and that they did not have the cognitive capacity to consent. She added that Resident #2 was currently being treated for a UTI as well. The DON stated that she was initially under the impression that Resident #1 had laid his hand on top of a clothed Resident #2's penis. She explained she had not asked the NA specific questions about whether Resident #2's penis was exposed, or if Resident #1 was using any motion with his hand. She added the investigation was ongoing, and she wasn't sure if this would be substantiated as both residents were cognitively impaired. The interim Administrator was interviewed on 9/4/25 at 3:30 PM and stated that he was informed that Resident #2 had been observed grasping Resident #1's penis on the morning of 9/1/25 by the Unit Manager. He presumed that Resident #2 was engaged in a masturbating act in his room and Resident #1 was observed assisting him, as this was what he had been told by the Unit Manager. The interim Administrator stated the DON was currently completing the investigation and added that providers, RPs, police department as well as Department of Social Services were notified on 9/1/25 of the incident. The Administrator was notified of the Immediate Jeopardy on 9/4/25 at 4:00 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 9/1/25 at approximately 8:50am, NA #1 entered the room for Residents #1 (Brief Interview for Mental Status score of 3 indicating the resident had severe cognitive impairment) and Resident #2 (Brief Interview for Mental Status score of 0 indicating the resident had severe cognitive impairment) due to hearing Resident #2 laughing loudly inside of his room. NA #1 witnessed Resident #2 lying in the A bed (the bed located closest to the door) on his back, both hands by his side while Resident #1 was standing beside Resident #2's bed with his hand on Resident #2's penis making an up and down motion while Resident #2 was lying in bed. Resident #2 was wearing a tee shirt and a brief while lying in bed. NA #1 stated that resident #2's brief was fastened; however, his penis was outside of the brief on the left side. NA #1 yelled stop when she observed the incident and Resident #1 returned to his bed. Nurse #1 heard NA #1 yell stop and went to assist her in the resident's room and immediately separated both Residents #1 and #2 to ensure safety. Both residents were immediately placed on 1:1 supervision by facility staff. Staff that witnessed the event were interviewed by the Nurse Supervisor on 9/1/25 and statements were obtained related to the incident. On 9/1/25, the Nurse Supervisor interviewed both Residents #1 and #2 in regard to the occurrence. Neither resident was able to recall the incident. A room change was immediately conducted with Resident #2 by facility staff on 9/1/25 and Resident #2 remained on 1:1 supervision. On 9/1/25, the Responsible Parties for Resident's #1 and #2 were notified by the licensed nurse. The Medical Director and Nurse Practitioner were notified of the occurrence by the licensed nurse, and the local Police Department was notified by the Nurse Supervisor. On 9/1/25 the Licensed Nurse conducted skin assessments on Resident #1 and Resident #2. No new findings identified on either resident based on the skin assessments conducted. An initial report was sent to the North Carolina Department of Health and Human Services by the Nurse Unit Manager on 9/1/25 at 10:31am for the allegation of resident abuse. Adult Protective Services was notified of the allegation of resident abuse on 9/1/25 by the Nurse Unit Manager on 9/1/25 at 11:04am. Psychiatric services was notified by the Assistant Director of Nursing on 9/2/25 at 8:30am for Resident #1 due to the allegation. A telehealth visit was conducted on 9/2/25 and a follow up in person visit was conducted on 9/3/25. Follow up notes from the psychiatric visit on 9/2/25 recommended continued 1:1 supervision for Resident #1 as well as medication changes were recommended for the following: Increased Depakote (a mood stabilizer) 250 milligrams (mg) by mouth, three times a day (TID) and Hydroxyzine (an antihistamine that can be utilized to treat anxiety) 25mg by mouth, two times a day (BID), as needed for 14 days. On 9/2/25, the Nurse Practitioner for the Program of All Inclusive Care for the elderly (PACE, a program that provides comprehensive medical and social services) conducted an onsite assessment for Resident #2. Resident #2's Zoloft (antidepressant) was increased from 50MG to 75MG to decrease resident libido (sexual desires). On 8/27/25, a urine sample was collected on Resident #2 due to a burning sensation while urinating. Culture result dated 9/2/25, antibiotics started. On 9/1/25, a chart review was completed of Resident #1 and Resident #2 by the Director of Nursing. Neither resident has a history of sexual behaviors. The chart review included reviewing the care plan with no indication of sexual behavior. There was no behavior or indication prior to the event that would have indicated this occurrence. On 9/1/25 skin assessments were completed on all non-alert/oriented residents by licensed nursing staff. There were no negative findings as a result of the skin assessments. From 9/2/25 to 9/3/25, the Social Worker Director and the Assistant Social Worker interviewed all alert and oriented residents in regard to resident abuse. There were no negative findings as a result of this audit. From 9/1/25 to 9/4/25, residents with roommates were interviewed by the Assistant Director of Nursing, Licensed Nurses and Admissions Director to ensure roommate compatibility. There were no concerns at this time as a result of the resident interviews. On 9/4/25, the Director of Nursing and the Regional Nurse Consultant completed a medical record audit of all residents by reviewing the most current comprehensive resident assessment to identify residents with behaviors. For residents identified as having behaviors, the previous 30 days of the behavior monitoring tool and care plan were reviewed to ensure behaviors were not related to any type of sexual behaviors displayed towards other residents. No issues were identified. The Director of Nursing and Nurse Managers review residents identified as having behaviors in the clinical morning meeting Monday through Friday and the weekend supervisor reviews on Saturday and Sunday to ensure appropriate interventions are in place for the safety of other residents. Interventions included but are not limited to: medication regimen review, one to one supervision, Psychiatric consultation/ visit, Physician notification and assessment, roommate compatibility, etc. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: From 9/1/25 to 9/4/25 education was provided to all facility staff, to include agency staff, by the Director of Nursing and Nurse Practice Educator on the abuse policy with an emphasis on sexual behaviors: management of symptoms, and ensuring resident safety by reporting, identifying, preventing and managing behavioral symptoms. Any staff identified as not receiving abuse education by 9/4/25 will not be allowed to work before receiving education on the facility's abuse policy. All newly hired staff, to include new agency staff, will be educated on the facility's abuse prohibition policy in the new hire orientation program. The Director of Nursing and Nurse Practice Educator are tracking the abuse education to ensure no staff works after 9/4/25 prior to receiving education. Alleged date of Immediate Jeopardy removal: 9/5/25 The credible allegation was verified on 9/8/25 as evidenced by interviews completed with staff from different departments and who worked different shifts and verified, they had received education about the types of abuse (physical, sexual, emotional, neglect and financial), how to report abuse, who to report to, and the prevention of abuse. Interviews with staff verified the training was provided following the incident on 9/1/25 prior to staff being allowed to work with residents. A review was completed of educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were reviewed; staff names were randomly selected and verified to have received training. Interviews were completed with alert and oriented residents and verified they knew they had the right to be free from abuse and to report incidents to staff immediately. Review of residents' skin checks was completed and showed no negative findings. Documentation showed the DON and Regional Nurse Consultant reviewed the comprehensive resident assessment, care plans, and any behavior logs for the previous 30 days to identify any type of sexual behavior directed towards other residents. No issues were identified. The facility's alleged immediate jeopardy removal date of 9/5/25 was validated.

Based on record review, observations, and resident and staff interviews the facility failed to maintain the resident's dignity by not emptying urinals prior to lunch and as needed. This was evident for 1 of 4 residents (Resident #41) reviewed for dignity. Findings include: Resident #41 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41's cognition was moderately impaired. He required moderate assistance with toileting and dressing and minimal assistance with transfers. He was occasionally incontinent of bowel and bladder. Resident #41 had range of motion impairment to both sides of his upper extremities. An observation and interview were conducted with Resident #41 in his room on 11/04/24 at 10:39 AM. Resident #41 was observed laying on his bed watching TV. Two urinals were noted on the nightstand with urine in them. One with approximately 400 milliliters (ml) of yellow urine and one with approximately 250 ml of yellow urine. He stated the staff emptied them when they got a chance but sometimes the urinals sat there with urine in them for a while. An observation and interview were conducted on 11/04/24 at 11:34 AM revealed the urinals with the same amount of urine were still on the nightstand. Resident #41 stated the urinals had not yet been emptied. An observation and interview were conducted on 11/04/24 at 1:05 PM. An observation was made of Nursing Assistant #1 bringing Resident #41's lunch tray into his room and then exiting the room. She did not empty the urinals on the nightstand which still had urine in two of them. Nursing Assistant #1 indicated she did not see the urinals therefore she did not empty them. An interview was conducted on 11/04/24 at 1:06 PM with Resident #41. He stated he would like for the urinals to be emptied more often. At least before he eats his meals because he felt it was unsanitary. An interview was conducted with Nursing Assistant #2 on 11/04/24 at 1:15 PM. She verified she was the direct care Nursing Assistant for Resident #41. She stated she emptied Resident #41's urinals an hour ago. When Nursing Assistant #2 was asked to observe the urinals on the nightstand which were in the same place and had the same amount of urine in them as they did in the earlier observations, Nursing Assistant #2 walked away and refused to respond to the surveyor. An observation on 11/06/24 at 10:25 AM in Resident #41's room revealed a urinal sitting on the nightstand that had approximately 300ml of yellow urine in it. An observation and interview were conducted on 11/06/24 at 12:45 PM. Resident #41 was observed sitting in his wheelchair eating lunch in his room. There was a urinal sitting on the nightstand with approximately 300ml or yellow urine in it. An observation and interview were conducted on 11/06/24 at 12:51 PM with Resident #41 in his room. He stated his urinal had not been emptied since that morning. He also stated it's nasty for the urinals to be sitting there so long and that they should at least be emptied before meals so it's not sitting there when he ate his meals. He further commented, it won't do any good to say anything because as soon as you and I turn our backs it'll happen again. An interview was conducted with Nursing Assistant #3 on 11/06/24 at 12:59 PM. She verified she was the direct care Nursing Assistant for Resident #41. When asked about when the last time she emptied the urinals she quickly turned away and entered Resident #41's room. She did not respond to the question. Nurse #2 was present at that time. An interview was conducted with Nurse #2 on 11/06/24 at 1:02 PM. He stated earlier in the shift he instructed Nursing Assistant #3 to make sure she kept Resident #41's urinals empty throughout her shift. He explained that Resident #41 requested the urinals to be emptied more often especially prior to his meals because he did not want to smell the urine while he ate. He indicated he had not looked at the urinals when he was in the room. An interview was conducted with the Director of Nursing (DON) on 11/06/24 at 1:12 PM. She stated she had reminded staff to make sure rounds were done to make sure Resident's urinals were empty. She explained she expected staff to empty urinals prior to meals being served and as needed. She indicated residents should not have to look at or smell urine in their rooms.

Based on record review, observations, and interviews with resident and staff, the facility failed to assess and obtain a physician's order for the self-administration of medications found at bedside for 1 of 1 resident (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes type 2, and hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #58 was cognitively intact and displayed no behaviors or rejection of care. A review of Resident #58's medical record did not reveal an order to self-administer medications. On 11/4/24 at 10:30 AM, an observation was made of medications in a medication cup sitting on Resident #58's over the bed table. Resident #58 stated that the medication had been sitting there since his breakfast was delivered and that staff did not normally leave his medication sitting on the over the bed table. Resident #58's breakfast plate sitting on the over the bed table and Resident #58 stated he had completed his breakfast meal. He did not indicate he was going to take the medications. An interview was conducted with Nurse #3 on 11/4/24 at 10:40 AM. She verified she was the nurse that left Resident #58's morning medication on the over the bed table for him to take. She stated, He had them in his hand when I was in there. She returned to the room, Resident #58 stated he didn't want to take them at that time, Nurse #3 retrieved the medications and marked them as refused by Resident #58 on the Medication Administration Record (MAR). Nurse #3 further stated the medications should be secured and Resident #58 did not have an order to self-administer medications. The medications left in the medication cup on the over the bed table included the following: Amlodipine 10 milligrams (mg) 1 tablet, Cefdinir 300mg 1 tablet, Coreg 25mg 1 tablet, Divalproex 500mg 2 tablets, Entresto 49-51mg 1 tablet, Finasteride 5mg 1 tablet, Furosemide 20mg 1 tablet, Gabapentin 300mg 2 capsules, Levothyroxine 50 micrograms (mcg) 1 tablet, Metformin 500mg 1 tablet, Multivitamin 1 tablet, Senna Docusate 8.6-50mg 1 tablet and Sertraline 50mg 1 tablet. The Director of Nursing was interviewed on 11/4/24 at 12:37 PM and stated that medications should not be left at bedside unsecured unless the resident had an order for self-administration. She added that Resident #58 did not have an order for self-administration.

Based on resident and staff interviews, the facility failed to deliver resident mail unopened for 3 of 7 residents reviewed for mail delivery (Resident #29, Resident #91, and Resident #100). The findings included: a. Resident #29 was admitted to the facility on [DATE]. Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. An interview on 11/05/24 at 10:24 AM with Resident #29 revealed that he had received opened mail that was addressed to him. He stated that it had happened on more than one occasion but was unable to give specific dates. Resident #29 stated the mail that was opened was related to his financial status. b. Resident #91 was admitted to the facility on [DATE]. Resident #91's annual MDS assessment dated [DATE] revealed Resident #91 was cognitively intact. An interview on 11/05/24 at 10:26 AM with Resident #91 revealed that she had received opened mail that was addressed to her. She stated that it had happened on more than one occasion but was unable to give specific dates. Resident #91 stated the mail that was opened was related to her financial status. c. Resident #100 was admitted to the facility on [DATE]. Resident #100's quarterly MDS assessment dated [DATE] revealed Resident #100 was cognitively intact. An interview on 11/05/24 at 10:28 AM with Resident #100 revealed that she had received opened mail that was addressed to her. She stated that it had happened on more than one occasion but was unable to give specific dates. She also stated for staff to open her mail without her consent was against her rights. Resident #100 stated the mail that was opened was related to her financial status. During an interview on 11/05/24 at 3:02 PM with the Activity Director she revealed she delivered mail to the residents Monday through Friday. She explained that there had been times when she delivered mail that had been taped closed due to previously being opened. During an interview on 11/05/24 at 3:22 PM with the Business Office Manager (BOM), she verified that she handled mail that related to resident's financial aspects. She indicated mail that came to the business office was put in a box that was attached to her office door. She explained that she grabbed the stack of mail and opened all envelopes prior to looking at who the mail was addressed to. She stated if a resident's cognition was impaired, she opened their mail. If they were cognitively intact, she was not supposed to open their mail. When she opened mail in error, she taped it back closed, and had it delivered to the resident. She agreed she should not open any mail without verifying who it was addressed to. During an interview on 11/06/24 at 1:15 PM with the Administrator he stated he was unaware the mail addressed to cognitively intact residents had been opened prior to them receiving it and the mail should not be opened. He explained that the only time mail should be opened was if the mail was addressed to the facility or if the resident was cognitively impaired. He then indicated that employees should always follow the mail handling process.

Based on record review, observations and staff interviews, the facility failed to administer water flushes via a feeding tube at the physician ordered flow rate for 1 of 2 residents reviewed with tube feedings (Resident #22). The findings included: Resident #22 was originally admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and presence of a feeding tube. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 rarely made herself understood and had severely impaired decision-making skills. She was coded as receiving 51% or more of her total calories through a tube feeding and an average fluid intake of 501 cubic centimeters (cc) per day or more by tube feeding. A review of Resident #22's active physician orders included an order dated 10/17/24 to flush the feeding tube with 110 milliliters (ml) of water every 3 hours during continuous feedings. Resident #22's active care plan, last reviewed 10/25/24, revealed a focus area for an enteral feeding tube to meet nutritional needs. The interventions included to provide water as ordered. An observation of Resident #22 on 11/5/24 at 8:35 AM, revealed her feeding tube was connected to a continuous bottle of formula with a standby bag of water. The water flush was observed to be running at 110 cc and the setting on the pump for frequency of the water flush was set at every 4 hours. Resident #22's lips were not dry or cracked in appearance. An observation was made with Nurse #1 on 11/5/24 at 2:05 PM, of Resident #22's water flush setting on the tube feed pump. He acknowledged the settings for the water flush were set at a rate was at 110 ml and the frequency of the water flush was set at every 4 hours. After reviewing the physician orders, he verified the water flush order was for 110 ml every 3 hours. He was unable to state why the rate was different than the physician's order but would correct it on the feeding tube pump. The Director of Nursing was interviewed on 11/5/24 at 3:10 PM and stated she expected water flushes to be at the prescribed rate.

Based on record review, and Medical Director and staff interviews, the facility failed to hold blood pressure medication as ordered by the physician for 1 of 6 residents reviewed for unnecessary medications (Resident #95). The findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses that included low blood pressure (hypotension). A review of Resident #95's active physician orders included an order dated 10/7/24 for Midodrine (a blood pressure medication) 10 milligrams (mg) one tablet by mouth three times a day for low blood pressure- take if systolic blood pressure is less than 120. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #95 was cognitively intact. The October 2024 and November 2024 Medication Administration Records (MARs) were reviewed and revealed Resident #95 had received Midodrine despite the systolic blood pressure (SBP) being greater than 120. - 10/9/24 at 1:00 PM the SBP was 122 and at 5:00 PM the SBP was 124. - 10/21/24 at 9:00 AM the SBP was 122, at 1:00 PM the SBP was 122 and at 5:00 PM the SBP was 122. - 10/24/24 at 9:00 AM the SBP was 122. - 11/1/24 at 9:00 AM the SBP was 121, at 1:00 PM the SBP was 121 and at 5:00 PM the SBP was 121. - 1/2/24 at 9:00 AM the SBP was 122 and the 5:00 PM SBP was 122. - 11/3/24 at 9:00 AM the SBP was 122, the 1:00 PM SBP was 122 and the 5:00 PM SBP was 122. - 11/5/24 at 9:00 AM the SBP was 134, the 1:00 PM SBP was 134 and the 5:00 PM SBP was 130. An interview was conducted with Nurse #5 on 11/6/24 at 12:56 PM. She was the nurse assigned to Resident #95 on 10/24/24, 11/1/24 and 11/3/24. The October 2024 and November 2024 MARs were reviewed with Nurse #5 who stated the medication should have been held per the parameter and felt it was an oversight. A phone interview was held with Nurse #3 on 11/6/24 at 3:30 PM, who was assigned to Resident #95 on 10/21/24. The October 2024 MAR was reviewed with Nurse #3 who stated the medication should have been held per the order and felt it was an oversight. Attempts to contact Nurse #1 were made without success. He was assigned to Resident #95 on 11/5/24. Attempts to contact Nurse #4 were made without success. She was assigned to Resident #95 on 10/9/24 and 11/2/24. The Director of Nursing was interviewed on 11/7/24 at 8:52 AM who reviewed the October 2024 and November 2024 MARs. She stated she would expect the medication to be given as ordered. A phone interview occurred with the Medical Director on 11/7/24 at 10:03 AM and stated if Resident #95 had received a few dosages of Midodrine outside the parameter it would not have caused any serious harm. The Medical Director added he would expect the nurses to follow the orders for the Midodrine as written.

Based on record review and staff interviews, the facility failed to provide the resident or Responsible Party (RP) written notification of the reason for a hospital transfer for 4 of 4 residents reviewed for hospitalization (Residents #22, #58, #111 and #132). The findings included: 1. Resident #22 was admitted to the facility on [DATE]. Resident #22's medical record revealed she was transferred to the hospital on 4/15/24 and readmitted to the facility on [DATE] and transferred again to the hospital on 5/18/24 and readmitted to the facility on [DATE]. There was no documentation that written notices of transfers were provided to the RP for the reasons for the transfers. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 had severely impaired cognition. An interview occurred with Nurse #2 on 11/6/24 at 1:00 PM and explained when a resident was transferred to the hospital a copy of the face sheet, physician orders, medication list, DNR information and bed hold policy were sent with them. He was unaware of a written notice of transfer that was provided to the resident or RP. On 11/5/24 at 3:10 PM, the Director of Nursing (DON) was interviewed and stated a copy of the face sheet, any Do Not Resuscitate (DNR) information, physician's orders, medication list and the Bed Hold policy were sent when a resident was transferred to the hospital. The RP would be notified by phone regarding the change and reason for the transfer. The DON stated a written notification of transfer was not sent to Resident #22's RP. The Administrator was interviewed on 11/6/24 at 1:09 PM and stated he was unaware a written notification of transfer was not being sent to the RP and would expect the regulation to be followed. 2. Resident #58 was admitted to the facility on [DATE]. Resident #58's medical record revealed he was transferred to the hospital on 11/16/23 and readmitted to the facility on [DATE] and transferred again to the hospital on 3/24/24 and readmitted to the facility on [DATE]. There was no documentation that written notices of transfers were provided to the resident or RP for the reasons of the transfers. A quarterly MDS assessment dated [DATE] indicated Resident #58 was cognitively intact. An interview occurred with Nurse #2 on 11/6/24 at 1:00 PM and explained when a resident was transferred to the hospital a copy of the face sheet, physician orders, medication list, DNR information and bed hold policy were sent with them. He was unaware of a written notice of transfer that was provided to the resident or RP. On 11/5/24 at 3:10 PM, the DON was interviewed and stated a copy of the face sheet, any DNR information, physician's orders, medication list and the Bed Hold policy were sent when a resident was transferred to the hospital. The RP would be notified by phone regarding the change and reason for the transfer. The DON stated a written notification of transfer was not sent to Resident #58's RP. The Administrator was interviewed on 11/6/24 at 1:09 PM and stated he was unaware a written notification of transfer was not being sent to the RP and would expect the regulation to be followed. 3. Resident #111 was admitted to the facility on [DATE]. Resident #111's medical record revealed he was transferred to the hospital on 12/5/23 and readmitted to the facility on [DATE], transferred to the hospital on 2/22/24 and readmitted to the facility on [DATE], and transferred again to the hospital on 5/7/24 and readmitted to the facility on [DATE]. There was no documentation that written notices of transfers were provided to the resident or RP for the reasons of the transfers. A quarterly MDS assessment dated [DATE] indicated Resident #111 had moderately impaired cognition. An interview occurred with Nurse #2 on 11/6/24 at 1:00 PM and explained when a resident was transferred to the hospital a copy of the face sheet, physician orders, medication list, DNR information and bed hold policy were sent with them. He was unaware of a written notice of transfer that was provided to the resident or RP. On 11/5/24 at 3:10 PM, the DON was interviewed and stated a copy of the face sheet, any DNR information, physician's orders, medication list and the Bed Hold policy were sent when a resident was transferred to the hospital. The RP would be notified by phone regarding the change and reason for the transfer. The DON stated a written notification of transfer was not sent to Resident #111's RP. The Administrator was interviewed on 11/6/24 at 1:09 PM and stated he was unaware a written notification of transfer was not being sent to the RP and would expect the regulation to be followed. 46095 4. Resident #132 was admitted to the facility on [DATE]. Resident #132's medical record revealed he was transferred to the hospital on 10/28/24. There was no documentation that written notices of transfers were provided to the RP for the reasons for the transfers. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #132's Resident #132 was cognitively intact. An interview was conducted with Nurse #6 on 11/07/24 at 4:23 PM. She indicated Resident #132 called 911 himself for transport to the hospital due to him not feeling well. He did not notify staff he was calling 911. She stated emergency medical services (EMS) arrived, took face sheet, list of medications, and DNR form and transported Resident #132 to the hospital per his request. She notified his power of attorney (POA), Hospice, and the Director of Nursing (DON) of the transfer. On 11/5/24 at 3:10 PM, the Director of Nursing (DON) was interviewed and stated a copy of the face sheet, any Do Not Resuscitate (DNR) information, physician's orders, medication list and the Bed Hold policy were sent when a resident was transferred to the hospital. The responsible party (RP) would be notified by phone regarding the change and reason for the transfer. The DON stated a written notification of transfer was not sent to Resident #132's RP. The Administrator was interviewed on 11/6/24 at 1:09 PM and stated he was unaware a written notification of transfer was not being sent to the RP and would expect the regulation to be followed.

Based on record review, police reports, resident, staff, and psychotherapist interviews, the facility failed to protect moderately cognitively impaired residents (Resident #135 and Resident #49) right to be free from sexual abuse from a cognitively intact resident (Resident #122). During the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M., Resident #122 entered Resident #135's room, while he was sleeping, lifted Resident #135's blanket and reached his hand into Resident #135's brief, and then stimulated Resident #135's penis. Resident #135 reported the sexual abuse to Nurse Aide (NA) #1 on 7/12/23 at approximately 4:00 A.M. Resident #135 explained Resident #122 had not been invited into his room and the physical touch was not consensual. Resident #135 reported the incident hurt me mentally and he made me sick. On the evening of 7/11/23 at approximately 11:00 P.M, Resident #49 was lying in bed watching television when Resident #122 entered Resident #49's room and manipulated Resident #49's penis through a blanket. Resident #49 reported this encounter was not consensual. This was for 2 of 3 residents reviewed for abuse. Immediate Jeopardy began on 7/12/23 when Resident #122 entered Resident #135's room and inappropriately touched Resident #135's genitals without consent. Immediate Jeopardy was removed on 7/20/23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Example #2, for Resident #49, was cited at a lower scope and severity of a level D. The findings included: Resident #135 was admitted to the facility on [DATE] with diagnoses that included hemiparesis (mild or partial weakness or loss of strength) following a stroke and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #135 was moderately cognitively impaired. Resident #135 had physical impairment on one side of his upper body and one side of his lower body. Resident #122 was admitted to the facility on [DATE] with diagnoses that included Parkinsons' disease, cognitive communication deficit, and spinal stenosis lumbar region with neurogenic claudication (narrowing of the space around your lower spine, which can compress the blood vessels). The admission MDS assessment dated [DATE], showed Resident #122 was cognitively intact. No wandering or physical/verbal behaviors were noted. Review of the facility's initial report dated 7/12/23 read on 7/12/123 at 4:00 A.M. Resident #135 reported another male resident (Resident #122) went into his room and touched him inappropriately. There were no injuries noted. A skin assessment for Resident #135, completed by Nurse #1, on 7/12/23 showed Resident #135 was assessed and showed no signs or symptoms of an injury. Resident #135's skin was intact. There was no redness or bruised areas observed. Review of facility records showed a form titled Continuous 1:1 Supervision with Resident #122's name handwritten at the top of the form. The form showed Resident #122 had 1:1 supervision with a start date/ time of 7/12/23 at 4:30 A.M. and an end date/time of 7/14/23 at 3:00 P.M., when Resident #122 was discharged to the community. Review of a police report completed by Police Officer #1, dated 7/12/23 at 5:15 A.M. showed a narrative section that read Resident #135 stated he woke up during the night to readjust his blanket and noticed that (Resident #122) was at the foot of the bed. He noticed that (Resident #122) had his hand under the blanket and in his briefs touching his penis in a rubbing up and down motion. (Resident #122) asked (Resident #135) if he liked it and he stated, 'S ., no.' He stated (Resident #122) left the room because the nurses would be checking rooms soon. (Resident #135) had encountered (Resident #122) the day before yesterday, 7/10/23. They were in (Resident #135's) room watching TV together and (Resident #122) began to rub on (Resident #135's) leg. He told (Resident #122) to stop. We spoke with (Resident #122) again and he said that he did not inappropriately touch (Resident #135). He did admit to going to his room in the night to watch TV and he readjusted (Resident #135's) blanket. The police report showed Resident #135 did not press charges, but Resident #135 wanted Resident #122 to stay out of his room. Review of Resident #135's medical record showed a psychotherapist progress note dated 7/13/23 that read in part Patient reports depression and being a 'victim' of inappropriate sexual behavior from another male resident. Patient processes event stating it 'hurt me mentally. he made me sick'. Review of the facility's 5-day working report dated 7/18/23 showed Resident #135 was awakened by Resident #122 rubbing his private area. Resident #135 reported he knew Resident #122 from therapy sessions. The report read Resident #135 told Resident #122 to leave his room before the nurses came to check on him. Resident #122 left Resident #135's room. During the investigation for the incident dated 7/12/23, Resident #135 reported to staff, prior to this incident over the weekend, Resident #122 had entered Resident #135's room to watch television with him. While Resident #122 was in his room, Resident #135 observed Resident #122 with his hands inside of his own pants. Resident #135 did not say anything to Resident #122 or report this incident to staff prior to 7/12/23. Review of Resident #135's medical record showed a psychotherapist progress note dated 7/20/23 that read in part Patient reports 'a little' depression this past week. Patient continues to process inappropriate sexual behavior towards him and states 'I didn't do anything to provoke that'. An interview was conducted on 7/31/23 at 2:38 P.M. with Resident #135. During the shift from 7/11/23 11:00 P.M. to 7/12/23 7:00 A.M., Resident #135 stated he was awakened from sleep by someone moving his brief and his first thought was the nurse aide was checking to see if he had soiled his brief. Resident #135 explained as he became more alert, he realized someone's hand was moving in an up and down motion on his penis. Resident #135 stated it was at this time he realized it was not the nurse aide because the nurse aid had never touched him in that manner. Resident #135 stated Resident #122 had parked his wheelchair against the wall at the foot of his bed, with the wheelchair facing the bed. Resident #135 was standing with his feet on the floor, leaning over the footrest of bed, and had his upper body under Resident #135's blanket. Resident #122 had Resident #135's penis in his hand and was moving it up and down. Resident #135 stated I felt wet around the places I'm not normally wet and I thought maybe he had blown me off. I didn't want to think about it. He stated Resident #122 asked him if it felt good and he replied No. During the interview, Resident #135 indicated he told Resident #122 he had to leave his room because the nursing staff would be coming into his room any minute to check on him. When he told Resident #122 this, Resident #122 left his room. Resident #135 was unsure how much time passed from when Resident #122 left his room and the nurse aide entered during a one of her routine rounds. Resident #135 stated when the nurse aide entered his room, he told her Resident #122 had touched him inappropriately. Resident #135 indicated NA #1, Nurse #2, and Nurse #1 all entered his room and asked him questions about the incident. During the interview, Resident #135 explained the staff told him the police had been notified. Resident #135 stated he told the police he did not want to press charges because I didn't want to tarnish my name with this incident. Resident #135 stated staff asked him had Resident #122 previously entered his room uninvited and Resident #135 stated yes. The night before Resident #122 entered his room to watch television and rubbed him on his leg. Resident #135 indicated he did not think much about it until Resident #135 moved his blanket down from his bare chest to scratch a bump and Resident #122 commented he had some pretty hair on my chest and he asked if he could touch it. Resident #135 responded no, and Resident #122 immediately left Resident #135's room. During the interview, Resident #135 indicated he felt safe in the facility after the incident when he told staff he did not want Resident #122 in his room again. Resident #122 had staff constantly watching him and he never returned to Resident #135's room. At the time of the investigation, Resident #122 no longer resided in the facility and was unable to be interviewed. A telephone interview was conducted on 7/31/23 at 2:06 P.M. with Nurse Aide (NA) #1 who was the nurse aide for both Resident #135 and Resident #122 on the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M. On the morning of 7/12/23, she checked on Resident #135 at approximately 4:20 A.M. NA #1 indicated she woke Resident #135 up and asked if he needed his brief changed, to which Resident #135 replied yes. NA#1 indicated while she completed incontinence care for Resident #135, he told her Resident #122 had entered his room last night and touched him inappropriately on his penis. During the interview, NA #1 reported Resident #135 told her Oh God, this is embarrassing, this is a shame, I don't want to tell anyone. When she asked Resident #135 why he had not pushed his call light during the incident to alert staff of his need for assistance, Resident #135 stated he was ashamed it was happening. NA #1 immediately left Resident #135's room to report the incident between Resident #135 and Resident #122 to Nurse #2. NA #1 indicated she had not observed Resident #122 in Resident #135's room during her shift on 7/11/23 to 7/12/23. During the interview, NA #1 indicated she had not witnessed any inappropriate sexual behavior from Resident #122 directed at staff or other residents and she had not received reports of Resident #122 going into other resident rooms without being invited. A telephone interview was conducted on 7/31/23 at 10:36 P.M. with Nurse #2 who was the nurse for both Resident #122 and Resident #135 on the shift 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M. Nurse #2 indicated NA #1 started her last rounding on residents about 4:00 A.M and after the start of her last rounds, NA #1 reported to her Resident #122 had entered Resident #135's room while he slept and touched him inappropriately. Nurse #2 stated herself and NA#1, went and told the night shift supervisor, Nurse #1, and they went to Resident #135's room to interview Resident #135. Nurse #2 stated Resident #122 was in his bed when the staff went down the hallway to interview Resident #135 and Resident #122 was in bed when she had last made her rounds in the hallway at approximately 3:00 A.M. During the interview with staff, Nurse # 2 stated Resident #135 told her he woke up and the bottom half of his sheet was lifted. Nurse #2 indicated Resident #135 told her Resident #122 was at the foot of his bed with his upper body leaned over Resident #135's legs, stimulating Resident #135's penis by moving his hand up and down the penis shaft. Nurse #2 indicated Resident #135 said his bedroom door was closed. Nurse #2 stated Resident #135 told Resident #122 to leave his room, or he was going to push his call light and at that time Resident #122 left Resident #135's room. Nurse #2 indicated during the interview, Resident #135 stated on a previous day (Nurse #2 indicated the date was 7/9/23 as determined by a staff party), Resident #122 had rolled into Resident #135's room with his wheelchair. Resident #135 reported he thought Resident #122 wanted to watch television with him until he noticed Resident #122 was sitting with his own hand down his pants, beside the television masturbating. During the interview, Nurse #2 indicated Resident #135 wasn't his usual self for the rest of the shift, you could tell something had happened, you could tell he felt embarrassed telling the story and letting us know what happened. Nurse #2 was unable to explain how Resident #135 was different. During the interview, Nurse #2 indicated she completed a skin assessment on Resident #135 and did not observe any injuries. She reported that she had never witnessed Resident #122 to have inappropriate sexual behaviors towards staff or other residents. Nurse #2 stated Resident #122 was generally in his room, and she had never observed him in another resident's room. An interview was conducted on 8/1/23 at 2:24 P.M. with Nurse #1. Nurse #1 worked on the shift from 7/11/23 7:00 P.M. to 7/12/23 7:00P.M. as the supervisor. During the interview, Nurse #1 indicated he was unfamiliar with Resident #122 and Resident #135. Nurse #1 indicated in the early morning hours of 7/12/23, Nurse #2 and NA #1 informed him a nonconsensual sexual encounter had occurred between Resident #122 and Resident #135. Nurse #1 stated it was reported to him NA #1 had gone to Resident #135's room to provide incontinence care and observed Resident's 135's penis out the top of his brief, which Nurse #1 indicated unusual for this resident. Nurse #1 then went down the hallway to speak with Resident #135 who told him he was embarrassed about the whole situation. During the interview, Nurse #1 explained he examined Resident #135 and did not observe any injuries. He then went to Resident #122's bedroom, assisted Resident #122 into a wheelchair, relocated Resident #122 to an empty room, and assigned a nurse aide to stay with Resident #122 under 1:1 observation. Nurse #1 indicated he interviewed Resident #122 about the incident with Resident #135 and he asked Resident #122 what he had been doing that night. Nurse #1 stated Resident #122 was beating around the bush and denied he was in Resident #135's room that night. Nurse #1 stated he left Resident #122's room and contacted both the Director of Nursing and the police department. During the interview, Nurse #1 explained Resident #135 genuinely looked embarrassed. An interview was attempted on 8/1/23 at 9:05 A.M. with Police Officer #1 and was unsuccessful. An interview was conducted on 8/1/23 at 8:43 A.M. with Occupational Therapist #1. Occupational Therapist #1 indicated he was familiar with both Resident #135 and Resident #122 because they both received therapy each morning in the therapy room. He explained Resident #122 was able to self-propel in his manual wheelchair and was able to stand, although it was very unsafe for Resident #122 to stand unassisted. The Occupational Therapist indicated he had never heard Resident #122 verbalize or behave in an inappropriate sexual manner toward the residents when he was in the therapy room. During the interview, Occupational Therapist #1 stated he recalled one morning, he was unsure of the date, Resident #135 arrived for therapy upset. Occupational Therapist #1 explained Resident #135 asked him if he had heard what had happened to him. The Occupational Therapist stated he told Resident #135 he had not heard anything, and Resident #135 described being awakened by another gentleman next to him, trying to play with his genitals. Occupational Therapist #1 indicated each morning Resident #135 showed up in the therapy room between 9:30 A.M. and 9:45 A.M. and began his therapy. Therapy was stopped at 10:00 A.M., when Resident #135 was taken to the activity's room for coffee hour before returning to the therapy room to complete his therapy. Occupational Therapist #1 indicated, the morning Resident #135 arrived to therapy upset, Resident #135 declined to go to coffee hour at the activity room. The Occupational Therapist indicated this was the only time he was aware Resident #135 had not gone to coffee hour since his admission to the facility. The Occupational Therapist was unable to explain how Resident #135 seemed upset and stated Resident #135 had not voiced concerns to him about concerns Resident #122 would bother him again. A telephone interview was conducted with the Psychotherapist on 8/1/23 at 11:19 A.M. During the interview, the Psychotherapist indicated she was asked by the Social Worker to follow up with Resident #135 after an unwanted sexual encounter with another resident on 7/12/23. The Psychotherapist stated Resident #135 reported being humiliated and he was in the process of working through the event. An interview was conducted on 7/31/23 at 1:39 P.M. with the Director of Nursing (DON). The DON indicated on the morning of 7/12/23, Nurse #1 called her and told her Resident #122 had entered Resident #135's room without being invited and touched Resident #135 inappropriately on his genitals. The DON stated Nurse #2 told her the incident was reported to staff on 7/12/23 shortly after 4:00 A.M., but she was unaware of the time the incident between Resident #122 and Resident #135 occurred. During the interview, the DON indicated she had never observed or received any reports of Resident #122 being sexually inappropriate The DON further stated she had not received any reports of Resident #122 going into resident rooms without being invited and she had rarely observed Resident #122 out of his assigned room. The DON explained Resident #122 was able to transfer himself into his wheelchair and he used his upper body to propel the wheelchair through the facility. An interview was conducted on 8/1/23 at 1:49 P.M. with the Administrator. During the interview, the Administrator indicated the DON called him on 7/12/23 at 6:00 A.M. and made him aware of inappropriate sexual contact between Resident #135 and Resident #122. The Administrator indicated he verified Resident #122 was placed on 1:1 supervision to protect the other residents until the investigation was completed. The Administrator indicated he checked the sex offender registry and Resident #122 was not listed as an offender. The Administrator stated the facility kept Resident #122 on 1:1 supervision until he was discharged on [DATE] and psychological services were offered to the residents. The Administrator further indicated the Quality Assurance Performance Improvement (QAPI) team had met and discussed Resident #122. During the QAPI meeting, the Administrator indicated the group was unable to identify any warning signs Resident #122 would sexually abuse other residents in the facility. The Administrator was notified of the Immediate Jeopardy on 8/1/23 at 3:07 P.M. The facility provided the following credible allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. It was reported to the Director of Nursing that there was sexual inappropriate touching between two male residents. The Director of Nursing directed the center to move the accused resident (Resident # 122) to a single room and placed him on 1:1 supervision immediately upon notification of the event. Police were notified by the nursing supervisor at the time of the event and the police responded with a documented time of 515am on 7/12/23 to include a report made but no charges filed. Skin assessment and incontinence care was completed by the licensed nurse on duty with no findings. The resident victim (resident # 135) was monitored throughout the duration of the shift for any changes with no changes noted. The Administrator and Medical Director were notified of the incident by the Director of Nursing upon identification of the incident. The Social Services Director interviewed resident # 135 the morning of 7/12/23 to ensure his feeling of safety and the resident reported that he felt safe. The Director of Nursing notified the center psych services professionals for additional psycho-social follow up with no additional concerns noted. APS (Adult Protective Services) return call conducted on 7/19/23 by Senior Administrator. All alert and oriented residents with BIMs score > 11, to include male and female residents were interviewed by Social Services to determine if any other residents had been involved in a resident to resident event with inappropriate touching on 7/12/23. One other resident was identified, and Social Services followed up with Resident # 49 to ensure his feeling of safety, referred him to psych services with no negative findings and the resident reports that he feels safe in the center with only an attempted interaction noted. Social Services educated residents on Resident Rights to be Free from Abuse during their interviews. All residents received a skin check by licensed nurses/Assistant Director of Nursing on and validated by the Director of Nursing on 7/12/23. Senior Administrator reviewed the center grievance log on 7/13/23 for any abuse or negative resident interaction concerns for the last 30 days with no negative findings. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Education provided to staff (Full Time, Part Time and Agency staff in all disciplines Nursing, Therapy, Housekeeping, Dietary, Laundry, Activities and Administrative Staff) on Abuse Policy and Resident to Resident events on 7/12/23 with no staff working prior to education provided by the Director of Nursing/designee. This education included the types of abuse (Physical, Sexual, Emotional, Neglect and Financial) Education detailed how to report, who to report to, and prevention of abuse. Training detailed what is considered Sexual Abuse; ie: unwanted sexual contact and non contact such as sexual harassment. Education included that staff should immediately protect the resident when abuse is identified and that anyone can be a perpetrator of abuse. Newly hired and contracted staff will also receive abuse training upon hire by the Assistant Director of Nursing/designee. The education is tracked by the Director of Nursing and Assistant Director of Nursing. Center alert and oriented residents were educated by Senior Director of Nursing and Nurse Practice Educator on reporting abuse 7/19/23 with no additional concerns identified. Regional Nurse Consultant reviewed previous 60 days from date of event (7/12/23 to 5/12/23) of incident logs to include resident to resident events and state reportable incidents with no negative findings on 7/13/23. Resident # 122 remained on 1:1 until discharge on [DATE]. Alleged date of IJ Removal 7/20/23 The credible allegation was verified on 8/1/23 as evidenced by interviews completed with staff from different departments and who worked different shifts were interviewed and verified, staff had received training about the types of abuse (physical, sexual, emotional, neglect, and financial), how to report abuse, who to report abuse to, and the prevention of abuse. Interviews with staff verified the training was provided following the incident on 7/12/23 prior to the staff being allowed to work with residents. A review was completed of educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were reviewed, staff names were randomly selected and verified to have received training. Interviews completed with alert and oriented residents were completed and verified residents had received education from staff on their right to be free from abuse and to report incidents to staff immediately. Review of resident interviews showed one resident (#49) also reported a Resident (#122) entered his room without being invited. During an interview with Resident #49, he confirmed Social Services followed up with him. Review of residents' skin checks was completed and showed no unidentified wounds. Documentation showed the regional nurse consultant had reviewed the last 60 days of the incident log and the last 30 days of grievances. The facility's alleged date of immediate jeopardy removal was validated to be effective 7/20/23. 2. Resident #49 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, acquired absence of left leg, and acquired absence of right leg. The comprehensive MDS dated [DATE] showed Resident #49 was moderately cognitively impaired. Resident #122 was admitted to the facility on [DATE] with diagnoses that included Parkinsons' disease, cognitive communication deficit, and spinal stenosis lumbar region with neurogenic claudication (narrowing of the space around your lower spine, which can compress the blood vessels). The admission MDS assessment dated [DATE] showed Resident #122 was cognitively intact. No wandering or physical/verbal behaviors were noted. Review of the facility's 5-day working report dated 7/18/23 showed on the night of 7/12/23 Resident #122 entered Resident #49's room and attempted to touch his penis. The report showed Resident #49 kicked Resident #122 out of his room. Review of facility records showed a form titled Continuous 1:1 Supervision with Resident #122's name handwritten at the top of the form. The form showed Resident #122 had 1:1 supervision with a start date/ time of 7/12/23 at 4:30 A.M. and an end date/time of 7/14/23 at 3:00 P.M., when Resident #122 was discharged to the community from the facility. An interview was conducted on 7/31/23 at 1:13 P.M. with the Social Service Specialist. The Social Service Specialist stated when she arrived for work on the morning of 7/12/23, she was made aware there was a reported resident-to-resident sexual abuse allegation. The Social Service Specialist said she was instructed by management to interview all alert and oriented residents and asked each resident if another male resident made them feel uncomfortable or had another male resident entered the resident's room uninvited. The Social Service Specialist stated when she asked Resident #49 those questions he responded yes to both questions. The Social Service Specialist stated Resident #49 told her Resident #122 had entered his room the previous night and asked to watch television with him. Resident #49 told the Social Service Specialist, Resident #122 self-propelled his wheelchair to the left side of Resident #49's bed and moved his bedside table out of the way, which allowed Resident #122 to move his wheelchair closer to the bed. The Social Service Specialist was told by Resident #49, after Resident #122 moved the bedside table out of the way, Resident #122 laid his hand on top of a blanket on Resident #149's penis. The Social Service Specialist stated Resident #49 told Resident #122 I don't play that and told him to leave. The Social Service Director indicated when she asked Resident #49 why he didn't report the incident to staff, he replied I handled it and took care of it. I can protect myself. During the interview, the Social Service Specialist stated prior to this investigation, she had not received reports from staff or residents that Resident #122 had entered other resident's rooms without being invited or had inappropriately touched other residents. An interview was conducted on 7/31/23 at 10:40 A.M. with Resident #49. During the interview, Resident #49 stated about two to three weeks ago, Resident #122 entered his room and without being given permission, touched his penis. Resident #49 stated he was unsure of the exact date the incident happened, but stated it was at approximately 11:30 P.M. Resident #49 stated he was lying in his bed, under a blanket and sheet, watching television when Resident #122 self-propelled his wheelchair into Resident #49's room without being invited. Resident #122 wheeled himself passed Resident #49's bed, (the first bed on the right), to the second bed, stopped his wheelchair near the foot of the bed and looked at Resident #49's roommate. Resident #49 stated he asked Resident #122 what he was doing, because his roommate was asleep. Resident #122 did not respond and did not disturb Resident #49's roommate. Resident #49 stated Resident #122 turned his wheelchair around to face the bedroom door, rolled to the foot of Resident #49's bed and started watching television. The television was positioned on a dresser lined up at the foot of Resident #49's bed. There was a walkway wide enough for Resident #122's wheelchair between the foot of the bed and the dresser. Resident #49 explained Resident #122 did not stay at the foot of the bed long, he was unsure the length of time, when Resident #122 self-propelled his wheelchair down the left side of Resident #49's bed. Resident #122 stopped the wheelchair at an over bed table that was positioned halfway the bed over Resident #49's waist and moved the over bed table away from Resident #49's bed. Resident #49 explained Resident #122 laid his hand on Resident #49's groin and tried to manipulate his penis through the blanket. Resident #49 indicated he told Resident #122 I don't play that s . and told him he'd better leave. Resident #122 asked Resident #49 You're not going to hit me, is you and when Resident #49 answered no, Resident #122 left his room. Resident #49 indicated he was unsure where Resident #122 went when he left his room. During the interview, Resident #49 stated he had never had anyone touch him inappropriately like that before and he did not like it. He said he did not tell the nurse when she went to check on him after the incident because it was late and the girls can't do anything about it. Resident #49 indicated he told the Social Service Specialist about the event the following day when she went into his room and asked him questions. Resident #49 stated the police were contacted and they came to the facility to interview him. Resident #49 did not provide a reason to why he did not press charges with the police against Resident #122. Resident #49 verbalized he was able to protect himself and he felt safe in the facility. Resident #49 stated Resident #122 had never been invited into his room and he had only seen Resident #122 in the hallway a few times but had not spoken with him. Attempted to interview Resident #49's roommate on 7/31/23 at 11:25 A.M. The roommate was severely cognitively impaired per the admission MDS dated [DATE] and was unable to provide any information about the allegation. At the time of the investigation, Resident #122 no longer resided in the facility and was unable to be interviewed. A telephone interview was conducted on 8/1/23 at 12:19 A.M. with Nurse #2 who was the nurse for both Resident #49 and Resident #122 on the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M. During the interview, Nurse #2 stated she checked on residents about every two hours, in addition to when she had walked through the halls to complete other assigned tasks. Nurse #2 indicated she had observed Resident #122 in his bed throughout her shift, and never in the hallway or in another resident's room. During the interview, Nurse #2 confirmed Resident #49 had not reported to her Resident #122 had entered his room during the night. Nurse #2 indicated Resident #49's behaviors were at his baseline, and she was unaware an incident had occurred on 7/11/23 until she returned to work the evening of 7/12/23. An interview was conducted on 8/1/23 at 12:52 P.M. with Nurse #9. During the interview, Nurse #9 indicated when she arrived for work on 7/12/23 she was made aware of an incident where a resident was inappropriately touched by Resident #122 that morning. Nurse #9 indicated she was made aware a second resident (Resident #49) had also been touched inappropriately by Resident #122 and was told by the Director of Nursing to call the police. During the interview, Nurse #9 stated she had observed Resident #122 around the facility. He had no difficulty propelling himself in a wheelchair and had not been observed to be sexually inappropriate with staff or residents. During the interview, Nurse #9 indicated Resident #49 had the ability to speak for himself and had good relationships with the staff. Nurse #9 stated she was unsure why Resident #49 had not spoken up and reported the incidents with Resident #122. Nurse #9 further explained, I'm not sure he (Resident #49) would have ever said anything if he hadn't been asked. Revi [TRUNCATED]

Based on record reviews, resident, staff, Nurse Practitioner and Medical Director (MD) interviews, the facility failed to hold an anticoagulant for a resident (Resident #345) who had oral surgery resulting in significant bleeding and emergency treatment, the facility also failed to wait for a nurse to asses a resident for injuries prior to moving her up off the floor (Resident #106). This was for 2 of 2 residents reviewed for standards of care. The findings included: 1. Resident #345 was admitted on [DATE]. The resident's discharge Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact and required assistance with activities of daily living. The resident's medical record contained a visit summary from the dentist dated 4/14/2023. The summary noted the resident needed referral to oral surgeon for extraction (removal) of all maxillary teeth and recommended complete denture for maxillary and partial denture for mandibular. The summary noted the resident was on Eliquis (anticoagulant). The resident's medical record contained a physician's order for Eliquis 5 milligrams (mg) twice daily for treatment of atrial fibrillation (irregular heart rhythm) with a start date of 3/18/2022. Resident #345's medical record contained a report of consultation from an oral surgeon dated 5/5/2022. The report read, removed all decayed teeth and removed lesion on right side of tongue. Sutures placed and will resolve on their on. The resident's progress notes by Nurse #7 dated 5/5/2022 3:01PM read in part, resident noted to have moderate amount of bleeding since return. Encouraged resident to keep applying gauze and pressure. Nurse #7 documented the following on 5/5/2022 at 3:48PM, resident returned from dental appointment. Had numerous teeth pulled resulting in no teeth in mouth as well as tongue mass removal. Resident noted to have moderate amount of bright red bleeding since return, starting to clot at this time. On 5/5/2022 at 6:29PM Nurse #7 documented bleeding continued but as slower pace. Also noted resident complained of swallowing blood. On 5/6/2022 at 9:12AM Nurse #8 noted that resident continued to bleed from mouth. She encouraged resident to keep gauze in place. A progress noted dated 5/6/2022 at 12:26PM by Nurse #8 indicated the physician had been in to evaluate resident and gave new order for resident to be transported to the Emergency Department for continued bleeding from oral surgery. An after-visit summary from the Emergency Department Dated 5/6/2022 indicated the resident was seen for hemorrhage after dental procedure that was now controlled. The resident's laboratory findings were normal. The resident was made NPO (nothing by mouth) and pressure was applied to the gums. Three hours after the bleeding stopped, the resident was discharged back to the facility. The after-visit summary instructed to hold Eliquis until 5/9/2022. Attempts to contact Nurse #7 were not successful. A phone interview was conducted with Nurse #8 on 7/19/2023 at 2:12PM. The nurse stated she vaguely recalled the incident. It occurred over a year ago and she did not recall if she administered the Eliquis (anticoagulant). Resident #345's May 2022 Medication Administration Record (MAR) indicted both doses (9:00AM and 9:00PM) of the resident's Eliquis were held 5/4/2022 as well as the 9:00AM dose on 5/5/2022. However, the MAR indicated the resident received the evening dose (9:00PM) on 5/5/2022 by Nurse #7. Resident #345's MAR also indicated the resident received the morning (9:00AM) dose of Eliquis on 5/6/2022 by Nurse #8. On 7/19/2023 at 1:26 PM an interview was conducted with the Medical Director and the Director of Nursing (DON). The Medical Director stated he was made aware of the resident's oral surgeon visit at the last minute and he did request the Eliquis be held the day before and the day of the procedure. He did not recall an order to hold the Eliquis after the procedure. He stated he was under the impression the resident was just having extractions, he was not aware a mass under the tongue was being biopsied. The Medical Director stated he did not get a call from the facility the night of the procedure, but he did get a call the morning after. He requested the staff send the resident to the emergency room due to staff reports of excessive bleeding. On 7/20/2023 at 9:59 AM an interview was conducted with Nurse Practitioner #1. She stated Resident #345 had been added to her case load at the beginning of May 2022. The morning of 5/6/2023 she went into examine the resident due to staff reports of bleeding. She stated it was the first time she had seen the resident and had not had an opportunity to review his history or medication. She stated she walked into the room and found him bleeding heavily from the mouth. She did not feel like a dental procedure would cause bleeding to that extent and therefore requested staff send him out to the emergency room . She was not aware he was receiving Eliquis. Nurse Practitioner #1 stated the nurses did not call her during the night or that morning to notify her of the resident's bleeding. She further stated the staff may not have know to call her since the resident had just been added to her caseload. On 7/20/2023 at 12:22PM an interview was conducted with the DON. She stated she expected staff to hold an anticoagulant and notify the Nurse Practitioner or Medical Director any time a resident has active bleeding. 31227 2. Resident #106 was admitted on [DATE] with cumulative diagnoses of Congestive Heart Failure and acute/chronic renal failure. Review of Resident #106's comprehensive care plan read she was a total staff assistance of 2 for transfers using sit to stand lift on 5/26/22. Her annual Minimum Data Set (MDS) dated [DATE] indicated Resident #106 was cognitively intact, experienced no falls, requiring extensive staff assistance of 2 for transfers. Review of a nursing note dated 7/15/23 at 11:37 AM read Resident #106 was being transferred from the bed to her wheelchair with 1 staff assistance when her knee gave out and she was lowered to the floor. There were no complaints of pain so she was lifted off the floor using a total mechanical lift. This note was written by Nurse #3. Review of the incident report investigation note dated 7/17/23 read the root cause was Resident #106 was transferring from the bed to her wheelchair when her leg gave out and she was lowered to the floor. The intervention was 2 staff assistance with transfers when she appeared weak. There was no documentation as to how Resident #106 was to be transferred. The investigation note was documented by Nurse Supervisor #1. An interview with Resident #106 was completed on 7/17/23 at 11:30 AM. She stated the aide was transferring her by standing her up and pivoting her into the wheelchair. She stated that was how they had been transferring her for long time. She stated once the aides got her up into her wheelchair the nurse came in and assessed her for injuries. Resident #106 stated she did not think she was injured at the time but now her left ankle was a little painful. A telephone interview was completed with Nursing Assistant (NA) #2 on 7/19/23 at 11:35 AM. She stated she was assigned Resident #106 at the time of her fall on 7/15/23 and asked NA #3 to assist her with transferring Resident #106 when her legs just gave out and was assisted to the floor. NA #2 stated she did not think to get a nurse to assess Resident #106 prior to transferring her off the floor because she reported no injuries. An interview was completed on 7/19/23 at 12:30 PM with NA #3. She stated NA #2 asked her to assist with transferring Resident #106 from the bed to her wheelchair when Resident #106's leg gave out and she was assisted to the floor. She stated they lifted her off the floor with the total mechanical lift before letting the nurse know she was on the floor. She stated Nurse #3 reminded her not to move a fallen resident until a nurse completed an assessment. A telephone interview was completed on 7/19/23 at 11:25 AM with Nurse #3. She stated Nurse Supervisor #2 came and got her to go with her to Resident #106's room due to a reported fall. She stated when she got into the room, Resident #106 had already been moved from the floor into her wheelchair using a total mechanical lift. Nurse #3 stated she reminded aides not to move a fallen resident until they were assessed by a nurse. She stated Resident #106 reported no pain and appeared absent of injuries. A telephone interview was completed on 7/19/23 at 11:20 AM with Nurse Supervisor #2. She recalled the fall on 7/15/23 for Resident #106. She stated NA #2 came to her and told her she was needed in Resident #106's room. Nurse Supervisor #2 stated when she arrived in the room, Resident #106 had already been moved from the floor into her wheelchair using a total mechanical lift. An interview was completed on 7/18/23 at 11:34 AM with the Director of Nursing (DON). The DON stated it was her expectation that Resident #106 be transferred as care planned and how it appeared on the Kardex transferred using the safest method to prevent falls and injuries to Resident #106 and the staff. She also stated she expected a fallen resident was not to be moved prior to a nursing assessment for injuries. An interview was completed on 7/19/23 at 1:07 PM with the MD. He stated he expected no resident including Resident #106 to be moved off the floor from a fall until that resident was evaluated by a nurse and determined to have no injuries.

Based on record review, interviews with resident, staff, and Medical Director, the facility failed to discontinue a resident's antiepileptic medication per neurologist recommendation for 2 months in 1 of 6 residents (Resident #95) reviewed for unnecessary medications. The findings included: Resident #95 was admitted to the facility 6/8/2021 with diagnoses that included a history of seizures. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. Resident #95's comprehensive care plan was last revised 6/22/2023 and included a focus for risk of seizure activity. An interview was conducted with Resident #95 on 7/17/2023 at 9:38AM. He stated he knew the seizure medication had been discontinued by the neurologist and he made the nurses aware. The nurses told him they did not have a copy of the after-visit summary. Resident #95 stated he gave the summary to the nurse at the nurse station when he returned to the facility on [DATE]. He finally became frustrated and refused to take the medication on 6/27/2023. At that time, he pulled up his after-visit summary on his MyChart (electronic medical record for patients) and showed Nurse #6 where the levetiracetam had been discontinued. The facility discontinued the medication at that time. The resident's medical record included a neurology after visit summary dated 5/4/2023. The medical record indicated the summary was uploaded into the medical record on 5/16/2023. The summary by the neurologist indicated the resident had not had any seizure activity since his hospitalization and recommended the seizure medication, Levetiracetam (Keppra), be reduced to 1000mg nightly for one week then discontinued. Resident #95's May 2023 Medication Administration Record (MAR) indicated the Levetiracetam was not discontinued. The resident continued to receive 1000 milligrams (mg) twice daily for the remainder of May 2023. Resident #95's June MAR revealed the resident received Levetiracetam at 1000mg twice daily until June 27th when the resident refused the medication. An interview was conducted with Nurse #6 on 7/19/2023 at 12:40PM. He stated he did not work the date the resident returned from the neurologist, 5/4/2023. Nurse #6 further stated Resident #95 did tell him the levetiracetam had been discontinued by the neurologist but not until 6/27/2023. He did not recall the resident mentioning it prior to that date. On 7/19/2023 at 12:50 an interview was conducted with the Medical Records Coordinator. She reviewed the resident's medical records and stated Resident #95 did have an after-visit summary from the neurologist dated 5/4/2023. She further stated the summary was uploaded into the resident's medical record on 5/16/2023. She did not recall how she obtained a copy of the after-visit summary. Typically, the resident will bring a copy back from the appointment and give it to one of the nurses. The nurse will then give her a copy to upload into the medical record. If the resident does not return with a copy of the visit summary, she could obtain the visit via going online or call the physician's office and request a summary be faxed to her. An interview was conducted with the Medical Director on 7/19/2023 at 1:22PM. He stated he did not recall being notified of the neurology after-visit summary recommendations. When he was made aware, he discontinued the levetiracetam. It is his expectation that staff review the after-visit summary and make him aware of any new orders or recommendations. The Director of Nursing (DON) was interviewed on 7/19/2023 at 1:30PM and stated when a resident returns from an appointment, they return with an after-visit summary that should be given to the nurses to review. If there are any new orders, the nurse should relay them to the Medical Director or the Nurse Practitioner. Then, the summary should be given to Medical Records to upload into the resident's medical record. That did not happen with Resident #95. It was unclear where the process failed.

Based on observations and staff interviews, the facility failed to date sliced fruit stored inside the reach in refrigerator and the Dietary Manager (DM) and dietary aide #1 failed to wear hair coverings for 2 of 5 staff working in the kitchen. These practices had the potential to affect food served to residents. The findings included: During a kitchen tour on 7/16/23 at 11:20 AM with the DM there was observed in the reach in refrigerator sliced peaches in a metal container with clear wrap covering it. There was no date observed. The DM stated they were to be served at lunch today and that was why they were inside the reach in cooler. He stated they should have been labeled. In the cooler, there was observed a metal container of sliced carrots covered with clear wrap on a metal rack stored underneath a metal pan with a cooked pork roast covered with clear wrap. The DM stated the vegetable should be stored above the meat. The DM's head appeared clean shaven and absent of a hair covering during the tour. He stated he forgot his hat in the car and should be wearing it. During a lunch meal preparation observation on 7/18/23 at 11:55 AM, dietary aide #1 who had short, twisted hair was observed in the meal area not wearing a hair covering. She stated she forgot to put on a hair covering and that she would get one immediately. The DM was also present in the meal area and made no comment. An interview was completed on 7/20/23 at 12:04 PM with the interim Administrator. He stated food should be dated when made, no vegetables should be stored underneath meat and all dietary staff should be wearing hair coverings in the kitchen.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey conducted on 03/17/22 and during a complaint investigation on 6/12/23. This was for 4 deficiencies that were cited in the areas of Safe/Clean/Comfortable/Homelike Environment, Care Plan Timing and Revision, Free of Accident Hazards/Supervision/Devices, Food Procurement, Store/Prepare/Serve-Sanitary, which were previously cited on 03/17/22, and Free of Accident Hazards/Supervision/Devices was cited on 06/12/23. All 4 of these deficient practice areas were recited on the current recertification, follow up, and complaint survey of 8/2/23. The duplicate citations during three federal surveys of record shows a pattern of the facility ' s inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1) F584-Based on observations and staff interviews, the facility failed to 1) replace 2 bed side commodes with visible rust on the legs and frame for 2 of 6 resident bathrooms and 2) failed to repair or replace broken Packaged Terminal Air Conditioner (PTAC) air filters for 1 out of 12 resident rooms reviewed for comfortable, clean, and homelike environment. During the facility's recertification survey of 03/17/22, the facility failed to ensure resident rooms and a resident bed were in good repair. In addition, the facility failed to ensure a resident's bathroom, resident wheelchairs, and dining room were clean and sanitary. This was for 11 of 11 areas reviewed for environmental concerns. 2) F657-Based on staff interviews and record review, the facility failed to revise the comprehensive care plan in the area of transfer status for 2 (Resident #106 and Resident #30) of 30 residents reviewed for care plan revision. During the facility's recertification survey of 03/17/22, the facility failed to review and revise the care plan in the area of nutrition for 1 of 29 residents reviewed. 3) F689-Based on resident, staff, Medical Director (MD) and Therapy Director interviews and record review, the facility failed to transfer a resident using a sit to stand lift (a mechanical lift that assist a resident with limited mobility in standing up from a seated position) as care planned and according to the physical therapy discharge summary (Resident #106). The facility also failed to transfer a resident requiring a total mechanical lift (portable total body lift used to minimize physical effort) for transfers resulting in a fall without injury (Resident #30). This was for 2 of 8 residents reviewed for accidents. During a complaint investigation on 6/12/23, the facility failed to effectively monitor a resident who had a history of noncompliance with the smoking policy, for proper storage of smoking materials including lighters for 1 of 3 sampled residents reviewed for smoking. During the facility's recertification survey of 03/17/22, the facility failed to prevent a resident from falling out of bed during a bed bath when one staff provided assistance for a resident who was dependent on two staff for bathing. The facility also failed to thoroughly investigate and analyze falls to determine causative factors and implement appropriate interventions to reduce the risk for further falls. This was for 2 of 9 residents reviewed for accidents. 4) F812-Based on observations and staff interviews, the facility failed to date sliced fruit stored inside the reach in refrigerator and staff failed to wear hair coverings when working in the kitchen. These practices had the potential to affect food served to residents. During the facility's recertification survey of 03/17/22, the facility failed to label, and date opened food items in 1 of 2 nourishment refrigerators reviewed for food storage. An interview was conducted with the administrator and Senior Administrator on 07/20/23 at 11:31 AM. The Senior Administrator stated she felt the repeat citations were due to the facility's management turnover. She indicated the facility's Administrator retired June 2022, and she was only standing in temporarily and they have recently hired a new administrator that will be starting 09/01/2023.

Based on observations and staff interviews, the facility failed to 1) replace 2 bed side commodes with visible rust on the legs and frame for 2 of 6 resident bathrooms (room [ROOM NUMBER] and 106) and 2) failed to repair or replace broken Packaged Terminal Air Conditioner (PTAC) air filters for 1 out of 12 resident rooms (room [ROOM NUMBER]) reviewed for comfortable, clean, and homelike environment. The findings included: 1) On 07/16/23 from 11:22 AM through 11:41 AM and on 07/17/23 from 10:42 AM through 10:51 AM the following were observed: - room [ROOM NUMBER] ' s bathroom had a bedside commode over the toilet. All four legs and the metal frame of the bedside commode had visible rough texture of rust located on the metal surface. Small pieces of light colored rust and paint crumbled off when touched. The room was occupied with continent residents that utilize the bedside commode. The surface was not smooth and not cleanable. - room [ROOM NUMBER] ' s bathroom had a bedside commode over the toilet. All four legs and the metal frame of the bedside commode had visible rough texture of rust located on the metal surface. Small pieces of light colored rust and paint crumbled off when touched. The room was occupied with continent residents that utilize the bedside commode. The surface was not smooth and not cleanable. An interview and observation were conducted with the Director of Nursing (DON) on 07/17/23 at 4:01 PM. She confirmed that the bed side commodes in rooms [ROOM NUMBERS] had rust on the metal frames and they both needed to be replaced. The DON indicated that she had not been notified by staff that the bed side commodes needed to be replaced. She then went to the storage room between 300 and 400 halls and located 2 bedside commodes that were ready for use and there was no visible rust. The 2 bedside commodes in rooms [ROOM NUMBERS] were replaced. The two bedside commodes with rust were disposed of. 2) On 07/16/23 from 11:52 AM through 11:58 AM and on 07/17/23 from 10:59 AM through 11:05 AM the following was observed: - room [ROOM NUMBER] PTAC air filters (2) were observed not fully inserted with visible breaks on both sides approximately 3 inches down from the top of the filter frames. The filter screen was incased by the frame. Both filters were folded over at the break and hanging at the top of the PTAC unit. When the Maintenance Director attempted to remove the filters, the broken areas prevented the filters from being inserted past the breaks and were getting caught on the plastic frame making it difficult to remove. The hard plastic frame was exposed. The room was occupied and the PTAC was running at the time of the observation. An interview and observation were conducted with the Maintenance Director on 07/18/23 at 01:16 PM. The Maintenance Director confirmed the top of 2 filters were hanging down from the front of the PTAC unit. He indicated he was unaware the 2 PTAC filters were broken. He stated housekeeping cleans the filters during their daily rounds and if they find anything broken or damaged, they report the issue to the nurse or to him. He stated it had not been reported to him the filters were broken. He removed the broken filters and replaced them. The filters had a thin layer of light gray dust present. An interview was conducted with the District Housekeeping Manager on 07/18/23 at 1:25 PM. He indicated housekeeping should have reported the broken PTAC filter when it was first observed. An interview and observation were conducted with Housekeeper #2 on 07/18/23 at 1:32 PM. She confirmed she was the assigned housekeeper for the 200 hall up until today. She stated she did see the broken PTAC filters when she cleaned them, but she did not think to report it to nursing or to maintenance. She also stated if she comes across anything broken or damaged, she knows the process to report it. An interview was conducted with the Maintenance Director on 07/20/23 at 10:15 AM. He stated he makes rounds monthly to check the PTAC units and the last round included a deep cleaning of the PTAC units. on May 3, 2023. He indicated the filters on the PTAC unit in room [ROOM NUMBER] were not damaged/broken at that time. An interview was conducted with the Administrator on 07/20/23 at 11:36 AM. He stated he would expect the PTACs and filters to be repaired of any damages.

Based on record review and staff and resident interviews, the facility failed to implement their policy for reporting an allegation of sexual abuse to the state agency within 2 hours for 1 of 3 residents reviewed for alleged sexual abuse investigations (Resident #49). Findings included: The facility abuse policy, last revised 10/24/22, read in part, Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. (Refer to External Abuse reporting Requirements table). 7.1 Enter allegations into PCC Risk Management Portal. 7.2 Report allegation involving abuse physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. 7.3 Report allegation to the appropriate state and local authority(s) involving neglect, exploitation, mistreatment (including injuries of unknown source), suspected criminal activity and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury. Resident #49 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, acquired absence of left leg, and acquired absence of right leg. The comprehensive MDS dated [DATE] showed Resident #49 was moderately cognitively impaired. Review of a statement from Resident #49 dated July 12, 2023, revealed Resident #49 indicated he said that man up and the hall came in here. I was watching TV and he asked if he could watch TV. I told him it's okay. Resident #49 reports Resident #122 then moved the bedside table and touched his penis on top of the covers. I told him I don't play that sh--- and he better get the h--- out of my room, and he left. Resident #49 indicated that Resident #122 had ever done this before and Resident #49 indicated No. Resident #49 reports that he did not tell anyone when it happened because he felt he took care of it. Resident #49 was interviewed on 07/19/23 at 10:30 am and stated he had been touched by Resident #122 during the evening on 07/11/23 and was not sure of the time. He had reported this information to the Social Worker (SW) on 07/12/23. Resident #49 indicated that Resident #122 had touched his penis from on top of the blanket. Resident #49 indicated he felt safe in the facility and knew how to protect himself. An interview was conducted with the Social Worker (SW)on 07/19/2023 at 11:00 am, and she indicated that she had interviewed residents in the facility on 7/12/23 regarding sexual abuse allegation by a resident to another resident. During her investigation Resident #49 alleged he had been touched inappropriately by Resident #122. The SW indicated that this information was given to the Director of Nurse and the Administrator on 07/12/23. The SW stated a part of the facility policy was to interview all residents after any allegation of resident abuse. Review of facility's Initial Allegation Reports to the state agency revealed there was not a report completed for Resident #49's allegation of sexual abuse on 7/12/23. During an interview with the Director of Nursing (DON) on 07/20/23 at, she indicated that her expectation for resident-to-resident sexual abuse was for staff to follow the facility abuse protocols and make sure all residents are safe. During an interview with the Administrator on 07/20/23 1:30pm, he indicated that all staff members need to follow the facility abuse protocols and that all residents are to be safe. He also indicated that the facility has a zero tolerance of abuse.

Based on record review, observation and interviews with the resident and staff, the facility failed to effectively monitor a resident who had a history of noncompliance with the smoking policy, for proper storage of smoking materials including lighters for 1 of 3 sampled residents reviewed for smoking (Resident #1). Resident #1, who was on oxygen, was found to have lighters in her possession on 1/4/23, 5/18/23 and 5/30/23. On 5/30/23, she lit a cigarette in the room with the oxygen concentrator on which resulted in a small fire, burning the floor mat, privacy curtain and the oxygen tubing. Resident #1 was assessed with no injury noted. Resident #4 (Resident #1's roommate) was assessed with no physical injury noted and commented she was okay but angry. This incident had a high likelihood of serious injury to residents. Immediate jeopardy began on 1/4/23 when Resident #1 was found smoking in the room and the facility failed to have a monitoring system in place for unsecured smoking material. Immediate jeopardy was removed on 06/10/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Findings included: The facility's smoking policy with the revision date of 10/24/22 included smoking will only be allowed in designated smoking areas, oxygen use is prohibited in smoking areas, smoking supplies (including but not limited to tobacco, matches, and lighter) will be labeled with the patient's name, room number, and bed number, maintained by the staff and stored in a suitable cabinet kept at the nursing station and patients will not be allowed to maintain their own lighter, lighter fluid or matches. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD) and was dependent on supplemental oxygen. Resident #1 had a physician's order dated 11/5/21 for oxygen at 3 Liters (L) per minute via nasal canula continuously. On 5/19/23, the oxygen was increased to 5L/minute continuously. Resident #1 had a smoking assessment dated [DATE] and the resident was deemed independent with smoking. A nursing note written by Nurse #1 dated 1/4/23 at 6:38 PM revealed Resident #1 was observed smoking in the room. The resident was sent to the hospital on 1/5/23 and was admitted due to respiratory distress. The resident was readmitted on [DATE] and was placed on 1:1 supervision until 1/19/23 due to the smoking incident that happened on 1/4/23. From 1/19/23 through 1/23/23, Resident #1 was placed on a 15-minute check. Resident #1 was reeducated on facility's smoking policy. Nurse #1 was not available for interview. Resident #1 had a smoking reassessment dated [DATE] and she was deemed supervised with smoking due to non-compliance with the smoking policy. Resident #1's care plan problem initiated on 1/16/23 revealed resident may smoke with supervision per smoking assessment. The approaches included lighters, lighter fluid or matches must be maintained by the center staff, ensure no oxygen use in smoking areas, monitor resident's compliance to smoking policy and maintain resident's smoking materials at nurse's station. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had moderate cognitive impairment and she was independent with locomotion, transfers, and ambulation. The assessment further indicated that the resident was receiving oxygen therapy. A progress note written by the Social Worker (SW) dated 5/18/23 at 11:45 AM revealed 2 lighters and a partial pack of cigarettes were found in Resident #1's pocketbook and were confiscated. The resident was reeducated on facility's smoking policy. A smoking assessment was completed, and the resident remained supervised with smoking. The SW was interviewed on 6/5/23 at 12:28 PM. The SW verified that Resident #1 was non-compliant with the facility's smoking policy. The resident was caught smoking in her room (1/4/23) and was observed having lighters in her possession (5/18/23). The SW reported Resident #1 had been educated on the facility's smoking policy. She stated there was no scheduled monitoring of smoking materials in residents' rooms. The SW also stated that she did not know where the resident was getting the lighters. She indicated twice a week, Resident #1 goes to PACE (Program of All-Inclusive Care for the elderly), a Medicare/Medicaid program that helps people meet their health care needs in the community and at times she goes on leave of absence with a friend. A nursing note written by Nurse #2 dated 5/31/23 at 12:42 AM revealed Nurse #2 heard Resident #1 and Resident # 4 shouting and observed them coming out of the room. He then saw smoke and heard the residents saying there was a fire. The Nurse helped the two residents out of the room safely, went into the room and observed a small fire. He grabbed the fire extinguisher and put out the fire, then closed the door. The fire alarm system sounded, and the staff began closing the residents' doors, and cleared the hallway. The fire department came and cleared the scene. A statement written by Nurse #2 dated 5/31/23 was reviewed. The note revealed it was around 10:30 PM on 5/30/23, Nurse #2 heard Residents #1 and #4 shouting at each other. From the hallway, he saw smoke coming out from the room of Residents #1 and #4 and both residents were coming out of the room. He assisted both residents out of the room away from harm. When he entered the room, he saw a fire on the floor between Resident #1's bedside table and oxygen concentrator. The flame was moving towards the oxygen concentrator, he turned the concentrator off and got the fire extinguisher. He put out the fire and closed the door. Before he could pull the alarm, the overhead alarm system went off. He then told the nurse aides (NAs) to remove everything from the hallway, close all the residents' doors and ensure no residents came out into the hallway. He informed the Nurse Supervisor that there was a fire in room of Residents #1 and #4 and he was able to put it out. The two residents were moved to the nurse's station and Resident #1 was placed on oxygen 5L/minute via nasal cannula. When assessed, Resident #1's left shoe was burnt but she had no injuries noted. Resident #1 reported that she was trying to put the fire out. When asked what happened, Resident #1 stated she didn't know. The note further revealed when Nurse #2 went into room of Resident #1, he found a half-burnt cigarette in the area where he saw the flame. Nurse #2 was interviewed on 6/5/23 at 1:29 PM. Nurse #2 reported he worked from 7P-7A on 5/30/23 and was assigned to Resident #1. He verified that the nursing note and his written statement were accurate. A statement written by the Maintenance Director dated 5/30/23 revealed at 10:40 PM on 5/30/23, he received a phone call from the Director of Nursing (DON) that a staff member just put out a fire in a resident's room. When he arrived at the facility, he discovered that a resident who was on oxygen had been smoking in her room and the oxygen tubing had caught fire. He confirmed that the fire was out, and the resident was safe. The fire department was getting all the smoke out of the building. He proceeded to reset the fire alarm panel. When he went back to Resident #1's room, he found a cigarette on the floor where the oxygen tubing was. The note further indicated he and the Nurse Supervisor checked Resident #1 for smoking materials and found two lighters and some cigarettes. The statement also revealed that a room sweep of residents who smoked was conducted and 4 residents including Resident #1 had smoking materials in their possession and their smoking materials were confiscated. The Maintenance Director was interviewed on 6/5/23 at 11:48 AM. The Maintenance Director verified his written statement was accurate. He added he was instructed by the Fire Department to remove the burnt floor mat, tubing, and curtain from the room to prevent reignition. He stated that the oxygen tubing was burnt and melted, 1 and 1/2 foot of the floor mat and about 2 inches of the curtain were burnt. He added that the resident was moved to another room and a new concentrator, tubing and floor mat were provided to Resident #1. A statement written by the Nurse Supervisor dated 5/30/23 revealed at approximately 10:10 PM on 5/30/23, the fire alarm sounded. She checked the panel and called code red (alerts staff of fire of probable fire) to 400 halls. She was informed that both residents in room [ROOM NUMBER] had been moved out of the room and the nurse had already put out the fire. She completed a quick skin check on both residents and there were no injuries. Both residents denied respiratory distress. She conducted another skin check on both residents and Resident #1 was noted to have her shoe slightly burnt and she had a black ash on her right hand. The resident did not have redness, blisters, or respiratory distress. Resident #1's oxygen saturation was 94% on oxygen. When the Fire department personnel arrived, Resident #1's room was checked, and they used fans to clear the smoke. The fire department silenced the alarm and the maintenance director reset the panel. She announced code red all clear. Accompanied by the Maintenance Director, she checked Resident #1's room for smoking paraphernalia and they found a cigarette lighter, half a smoked cigarette, a pack of cigarettes with one cigarette in it. They also found a cigarette lighter in her pocket. An audit was conducted of all smokers to check if their smoking materials were properly stored. Another note written by the Nurse Supervisor dated 5/30/23 indicated that she interviewed Resident #1 on how the fire happened. Resident #1 reported the fire started on its own on her oxygen tubing. She did not remember smoking or lighting a cigarette. The resident stated that she was okay and was not physically hurt but needed a cigarette for her nerves. Another statement written by the Nurse Supervisor dated 5/30/23 revealed that she interviewed Resident #1's roommate. The roommate stated that she did not know how the fire started. She looked and there was a fire on her roommate's side of room and her roommate saying to get out of the room. The roommate denied any physical or mental distress from the incident. The Nurse Supervisor was interviewed on 6/5/23 at 2:50 PM and she verified that her written statements were accurate. The Director of Nursing (DON) was interviewed on 6/5/2 at 2:55 PM. She reported that Residents #1 and #2 were assessed by the Nurse Practitioner on 5/31/23 and there were no injuries noted. Resident #1 was interviewed on 6/5/23 at 10:15 AM. She reported she had been a smoker for a long time. She was aware of the facility's smoking policy to smoke only in designated smoking areas and not to keep smoking materials including lighters with her. She reported that she was a supervised smoker since she violated the smoking policy by keeping smoking material with her and smoking in undesignated smoking areas. She stated that she had been keeping smoking material just like other residents. She also reported she had smoked in the room several months ago, but it did not catch fire. Resident #1 admitted that she smoked in her room a week ago. She stated she knew she was not supposed to smoke in her room, it was not safe, and she would break the smoking policy, but she did not know why she did it. She indicated that her oxygen saturation might have been low, which made her out of it and confused. She reported she was sitting on the side of bed. She did not remember how the cigarette ended on the floor mat, but she tried to stomp on the cigarette with her foot to put the flame out. She also could not remember if she had the oxygen cannula in her nose, but she saw the tubing and the floor mat on fire. Resident #1 stated that the staff came and helped her and her roommate out of the room. Nurse #3 was interviewed on 6/9/23 at 9:01 AM. The Nurse reported that Resident #1 goes to PACE twice a week. She was not aware of any monitoring or search for smoking materials when she came back from PACE. She knew Resident #1 was currently on 1:1 due to the incident on 5/30/23 and she was not smoking anymore. Nurse #3 added that Resident #1 had a physician order for a Nicorette inhaler. Nurse Aide (NA) #1 was interviewed on 6/9/23 at 9:12 AM. The NA reported that she had known Resident #1 as a smoker. Resident #1 was a supervised smoker, and she goes at least 3 -4 times a day to smoke. She indicated residents' smoking materials were kept at the nurse's station. A staff member was assigned during smoking time to supervise residents in the smoking area. The staff member gives residents 2 cigarettes and light the cigarettes for the residents. NA #1 reported she had not seen Resident #1 with smoking materials in her possession. On 6/5/23 at 3:50 PM, room [ROOM NUMBER] was observed. There was no damage to the floor, walls, or ceiling. There was a new curtain hanging on the wall on the door side of the room. Resident #4, roommate of Resident #1, was admitted to the facility on [DATE]. The annual MDS assessment dated [DATE] indicated that Resident #4's cognition was intact. Resident #4 was interviewed on 6/5/23 at 9:56 AM. She reported she knew Resident #1 smoked and was on oxygen. She always had the privacy curtain pulled between their beds and she could not see if she was smoking in bed or had smoking materials in her possession. She reported it was nighttime, she did not remember the exact date and time when she saw a flame on her roommate's side of bed through the curtain and Resident #1 was telling her to get out of the room. She was trying to get out of the room when a staff member came and assisted her. She stated she was okay but angry. A follow up interview with the Maintenance Director was conducted on 6/5/23 at 4:31 PM. The Fire Department checked the room of Resident #1 and instructed him to remove and to discard the burnt floor mat, curtain, and tubing from the room. They brought in fans to get rid of the smoke. Residents #1 and #2 were moved to another room that night. The Maintenance Director stated that Resident #1 was provided a new oxygen concentrator, tubing, and floor mat on 5/30/23. The Director of Nursing (DON) was interviewed on 6/5/23 at 3:10 PM. The DON reported that Resident #1 was non-compliant with the facility's smoking policy. She was aware the resident was caught in the past trying to smoke in the room and the resident was also caught with smoking materials in her possession. She was reeducated on the facility's smoking policy. She reported there was no scheduled monitoring of smoking materials. The DON stated she had investigated the 5/30/23 incident where Resident #1's room caught a small fire. The DON reported that Resident #1 was placed on 1:1 after the 5/30/23 incident and remained 1:1 to date. She stated that after talking with the PACE and the Ombudsman, Resident #1 was provided a nicotine patch and was not allowed to smoke. Administrator #2 stated on 6/5/23 at 6:05 PM that she was the acting Administrator since the administrator was out. She stated that the staff had interviewed Resident #1 and the resident denied smoking or lighting a cigarette in the room. However, a lit cigarette was found on top of the floor mat, beside the burnt oxygen tubing. She indicated that the staff did a good job in putting out the fire and in keeping the residents safe. The Assistant Director of Nursing (ADON) was interviewed on 6/9/23 at 9:20 AM. She stated that Resident #1 was scheduled to go to PACE twice q week. She also reported that she went on leave of absence (LOA) with a friend on 4/23/23. The ADON indicated there was no monitoring of smoking materials when she came back from PACE or LOA. Administrator #2 was interviewed on 6/9/23 at 9:49 AM. He reported that the Corporate had informed him it was a violation of resident's rights dated October 2022 (rule of participation) to physically search a resident, so the facility was not doing the search when Resident #1 came back from LOA or PACE. Administrator #2 was notified of immediate jeopardy on 6/5/23 at 6:19 PM. The corrective action with a compliance date of 6/3/23 was as follows: 1. Resident #1 noted to be smoking in their room with oxygen in place causing a small fire. Staff immediately removed the resident and roommate to safety and extinguished the fire. Skin assessments completed on both residents with RN noting no concerns on 5/30/23. Both residents were referred to the medical team for complete assessment. Respiratory assessments completed on both residents by Respiratory Therapist on 5/31/23 noting no concerns. Medical team examinations were completed on 5/31/23 for both patients without concern noted. The nursing supervisor, on 5/30/23 at time of incident ensured that new oxygen tubing was placed for Resident #1 and there were no other smoking materials unsecured. Resident #1 was placed on one-on-one care by the Director of Nursing immediately following the incident in a private room. The Director of Nursing or designated nursing supervisor is responsible for scheduling the one-on-one supervision for Resident #1 and has designated direct care staff to maintain that supervision. The center Director of Nursing provided Resident#1 with additional footwear on 5/31/23. 2. All residents have the potential to be affected. The center Administrator reviewed the non-smoking signage in the center and found that it was in place at the time of the incident. A new smoking assessment was completed for all smokers by Nurse Leadership to include Unit Managers and Assistant Director of Nursing on 5/31/23 to ensure safe smoking and supervision provided as indicated. All current residents that smoke was assessed to ensure that their smoking materials were secured per policy by the Social Services Department/designee on 5/31/23. The center determined there were six additional residents that were also found to have a history of non-compliance with the center smoking policy and the Director of Nursing and Administrator in conjunction with the Social Services Department revised their smoking assessment(s) to make them supervised smokers on 6/2/2023 or prior. Upon completion of the updated smoking evaluation, care plans for the identified residents were updated by the Unit managers, Assistant Director of Nursing and Social Services Department. Updates reflected on the care plans were communicated to the direct care staff by the Director of Nursing and Assistant Director of Nursing at the time of the updates on 5/31/23, 6/1/23, 6/2/23 and ongoing. Room sweeps were conducted by the RN nursing supervisor and Maintenance Director on 5/30/23 (At time of incident) to ensure there were no other unsecured smoking items to include cigarettes and lighters. Additionally, smoking residents with oxygen use were reviewed by the QAPI committee to include the Director of Nursing, Assistant Director of Nursing, Medical Director, Social Services Department, Unit Managers, and the center Administrator for additional recommendations on 5/31/23. 3. Education was completed by the Nurse Practice Educator/designee on the smoking policy (Genesis Healthcare Smoking Policy and Procedure named Operations Policy 137) on or before 6/2/23 for all staff to include agency staff members regarding smokers, supervised and unsupervised no staff will work prior to education being completed. Staff members were educated verbally via phone by the Nurse Practice Educator/designee if they were not in the center at time of education. Any employees returning to work that have not been educated will be educated by the Nurse Practice Educator and the education completion will be tracked by the Director of Nursing and Assistant Director of Nursing. Education included assistance with utilization of lighting cigarettes, supervising smoking in accordance with assessed needs, ensuring disposal receptacles are available in smoking areas, monitoring compliance with policy, maintaining resident smoking materials at the nurse's station and smoking assessments to be completed quarterly and with significant changes. Ongoing education to be completed during New Employee Orientation by the Nurse Practice Educator/designee. All current resident smokers are to be educated on smoking policy by the center Administrator on 5/31/23. Ongoing education to be completed with new admissions by the Admissions Director/designee on facility smoking policy. This process was reviewed with the Admissions Director by the Administrator on 5/31/23. 4. The Director of Nursing/designee will complete an audit of all resident smokers, supervised and unsupervised, for smoking safety and proper storage of smoking materials Daily x4 weeks, then bi-weekly x2 weeks, then weekly x1 month, randomly thereafter beginning 5/31/23. Results of these audits will be brought before the Quality Assurance Performance Improvement Committee (QAPI) for any additional monitoring or modification of this plan monthly for 3 months for additional recommendations and to ensure the facility remains in compliance. Date of compliance: 6/3/23 The facility provided a corrective action plan on 6/6/23. The plan was not thorough, and the Administrator was notified. An acceptable credible allegation was provided by the Administrator on 6/9/23. F689 Accidents/Hazards 1. Resident (#1) noted to be smoking in their room with oxygen in place causing a small fire. Staff immediately removed the resident and roommate to safety and extinguished the fire. Skin assessments completed on both residents with RN noting no concerns on 5/30/23. Both residents were referred to the medical team for complete assessment. Respiratory assessments completed on both residents by Respiratory Therapist on 5/31/23 noting no concerns. Medical team examinations were completed on 5/31/23 for both patients without concern noted. The nursing supervisor, on 5/30/23 at time of incident ensured that new oxygen tubing was placed for resident #1 and there were no other smoking materials unsecured. Resident (#1) was placed on one-on-one care by the Director of Nursing immediately following the incident and will remain until the center determines that she is no longer a risk to herself and others. The Director of Nursing or designated nursing supervisor is responsible for scheduling the one-on-one supervision for resident (#1) and has designated direct care staff to maintain that supervision. The center Director of Nursing provided resident (#1) with additional footwear on 5/31/23. Center policy is for the staff to secure all resident smoking materials at the nursing station to include cigarettes, lighters, vapes and all other materials that one may use to light and smoke within the center. Staff then bring the materials to the smoking area and either light the cigarettes for the residents or give them their lighters for the smoking session and collect them at the end of the smoking session. The center has supervised smoking where the center staff monitor the smoking residents to ensure that they are smoking safely including but not limited to lighting, disposing, extinguishing, and handling their cigarette or other smoking apparatus. This policy/process has been in place at the center prior to this event. 2. All residents have a potential to be affected. The center Administrator reviewed the non-smoking signage in the center and found that it was in place at the time of the incident. A new smoking assessment was completed for all smokers by Nurse Leadership to include Unit Managers and Assistant Director of Nursing on 5/31/23 to ensure safe smoking and supervision provided as indicated. All current residents that smoke was assessed to ensure that their smoking materials were secured per policy by the Social Services Department/designee on 5/31/23. The center determined there were six additional residents that were also found to have a history of non-compliance with the center smoking policy by center staff noting resident smoking materials unsecured and the Director of Nursing and Administrator in conjunction with the Social Services Department revised their smoking assessment(s) to make them supervised smokers on 6/2/2023 or prior. Upon completion of the updated smoking evaluation, care plans for the identified residents were updated by the Unit managers, Assistant Director of Nursing and Social Services Department. Updates reflected on the care plans were communicated to the direct care staff by the Director of Nursing and Assistant Director of Nursing at the time of the updates on 5/31/23, 6/1/23, 6/2/23 and ongoing. Room sweeps were conducted by the RN nursing supervisor and Maintenance Director on 5/30/23 (At time of incident) to ensure there were no other unsecured smoking items to include cigarettes and lighters. Additionally, smoking residents with oxygen use were reviewed by the QAPI committee to include the Director of Nursing, Assistant Director of Nursing, Medical Director, Social Services Department, Unit Managers, and the center Administrator for additional recommendations on 5/31/23. Beginning 6/9/23, the center initiated additional steps to assess resident, #1, belongings and person upon return to the center from any absence from the center or upon any visitation from outside community members to ensure that she did not have any newly acquired smoking materials in her possession. This process will be conducted by the Director of Nursing, Assistant Director of Nursing, Admissions Director, Nursing Supervisors, Nurse Practice Educator, Skin Health Team Lead, Infection Preventionist, Minimum Data Set Nurse, Social Workers and licensed nurses as scheduled by the Director of Nursing/ Assistant Director of Nursing/ Administrator. The center Administrator and Assistant Director of Nursing met with the resident, #1, to discuss the additional steps on 6/9/23. 3. Education was completed by the Nurse Practice Educator/designee on the smoking policy (Genesis Healthcare Smoking Policy and Procedure named Operations Policy 137) on or before 6/2/23 for all staff (activities staff, dietary staff, housekeeping staff, therapy staff, department managers, licensed nurses and nursing assistants) to include agency staff members regarding smokers, supervised and unsupervised no staff will work prior to education being completed. Staff members were educated verbally via phone by the Nurse Practice Educator/designee if they were not in the center at time of education. Any employees returning to work that have not been educated, will be educated by the Nurse Practice Educator and the education completion will be tracked by the Director of Nursing and Assistant Director of Nursing. Education included assistance with utilization of lighting cigarettes, supervising smoking in accordance with assessed needs, ensuring disposal receptacles are available in smoking areas, monitoring compliance with policy, maintaining resident smoking materials at the nurse's station and smoking assessments to be completed quarterly and with significant changes. Ongoing education to be completed during New Employee Orientation by the Nurse Practice Educator/designee. All current resident smokers to be educated on smoking policy by the center Administrator on 5/31/23. Ongoing education to be completed with new admissions by the Admissions Director/designee on facility smoking policy. This process was reviewed with the Admissions Director by the Administrator on 5/31/23. Administrator/designee will educate the Director of Nursing, Assistant Director of Nursing, Admissions Director, Nursing Supervisors, Nurse Practice Educator, Skin Health Team Lead, Infection Preventionist, Minimum Data Set Nurse, Social Workers, and licensed nurses on 6/9/2023 the expectation to assess resident, #1, upon return from any absence from the center to verify the resident does not have any smoking materials. No named staff will work until education is completed and the Director of Nursing/Assistant Director of Nursing will be responsible for tracking the staff education. 4. The Director of Nursing/designee will complete an audit of all resident smokers, supervised and unsupervised, for smoking safety and proper storage of smoking materials Daily x4 weeks, then bi-weekly x2 weeks, then weekly x1 month, randomly thereafter beginning 5/31/23. The Administrator will audit the resident (#1) belongings and resident assessments completed by the Director of Nursing, Assistant Director of Nursing, Admissions Director, Nursing Supervisors, Nurse Practice Educator, Skin Health Team Lead, Infection Preventionist, Minimum Data Set Nurse, Social Workers, and licensed nurses upon resident, #1, return from LOAs beginning 6/9/2023 daily x4 weeks, then bi-weekly x2 weeks, then weekly x1 month, randomly thereafter beginning 6/9/23. Results of these audits will be brought before the Quality Assurance. Performance Improvement Committee (QAPI) for any additional monitoring or modification of this plan monthly for 3 months for additional recommendations and to ensure the facility remains in compliance. Date of IJ Removal: 6/10/23 On 6/12/23, the facility's credible allegation for immediate jeopardy was validated. Review of the facility's corrective action plan revealed evidence of 100% staff education regarding the smoking policy and that all smoking materials were kept at the nurse's station on 5/31/23 and 100% room audits for smoking materials on 5/30/23 and 5/31/23. The facility provided evidence of daily Quality Assurance auditing regarding smoking materials returned after smoke break starting 5/31/23 and ongoing. The facility also provided additional in-servicing beginning 6/9/23 on assessing Resident #1 and her belongings, upon return to the facility from any medical appointment, leave of absence or PACE program, for smoking materials. The facility provided evidence of daily Quality Assurance auditing regarding Resident #1's belongings being free of smoking materials starting 6/9/23 and ongoing. Observations and interviews revealed correct storage of smoking materials at the nurse's station. The facility's corrective action plan was validated as 6/10/23.

Based on record review, observation and staff and resident interview, the facility failed to closely monitor the skin and protect the skin from rubbing against a knee brace which resulted in the development of an unstageable pressure ulcer to the right medial knee for 1 (Resident #25) of 2 sampled residents with pressure ulcers. Findings included: Resident #25 was re-admitted to the facility on [DATE] status [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #25's cognition was intact and she had an unstageable pressure ulcer. The nursing admission assessment dated [DATE] indicated that the resident was admitted with skin impairment to the right stump. The resident's nurse's notes from 9/7/15 through 9/18/15 were reviewed. There were no documentation that Resident #25 was wearing a brace to her right leg or the skin surrounding the brace was closely monitored for skin breakdown except for the notes dated 9/15/15. The notes dated 9/15/15 at 11:00 AM indicated that an area was noted to the right inner knee and it appeared to be from the resident's stump brace. The resident's weekly skin checks were reviewed. The weekly skin checks were conducted on the 7: 00 AM to 3:00 PM shift every Monday. The skin checks completed on 9/14/15, 9/21/15 and 9/28/15 indicated that the resident had previously noted skin injury/wound. The checks did not indicate that the resident had a new skin breakdown. The resident's weekly skin integrity reports were reviewed. The report indicated that on 9/18/15, Resident #25 was noted to have an unstageable pressure ulcer on the right medial knee. The ulcer had 90% slough and 10% granulation measuring 1.5 centimeter (cm) x (by) 5.3 cm. On 10/16/15, the report indicated that the ulcer on the resident's right medial knee had 80% slough and 20% granulation measuring 1 cm x 5 cm. On 10/14/15, there was a physician's orders [REDACTED]. On 10/20/15 at 2:15 PM, interview with administrative staff #1 was conducted. She stated that Resident #25 had developed an unstageable pressure ulcer on the right medial knee. She indicated that the pressure ulcer was from the resident's knee brace. Administrative staff #1 stated that Resident #25 was re-admitted to the facility on [DATE] with a brace to her right leg to support the stump. On 10/21/15 at 9:40 AM, observation of a dressing change to Resident #25's right knee was conducted. Nurse #1 performed the dressing change. The pressure ulcer on the resident's right medial knee had slough in the center. The ulcer was cleaned with wound cleaner, calcium alginate was applied to the wound bed, covered with a foam dressing and secured with kerlix. On 10/21/15 at 9:50 AM, Nurse #1 was interviewed. She indicated that Resident #25 was re-admitted on [DATE] status [REDACTED]. The resident was admitted with a brace on her right leg to support the stump. The resident had to wear the brace at all times. She added that she noticed the redness on the resident's right knee and she thought that the dressing to the stump was too tight that caused the redness. Later on, she realized that the redness was from the resident's knee brace rubbing against the skin so she removed the brace from the resident's leg. Nurse #1 described the brace as a hard plastic material. On 10/22/15 at 9:50 AM, Resident #25 was interviewed. She stated that her knee brace was made of a clear white, hard plastic material. She added that the end of the brace was rubbing the back of her knee but she didn't know that there was an open area at the back of her knee. On 10/22/15 at 10:15 AM, administrative staff #1 was interviewed. She stated that the skin breakdown that Resident #25 experienced on her knee from the use of the knee brace could have been avoided. She indicated that when the resident was admitted , the nurse should have called the physician and obtained an order for [REDACTED]. records. On 10/22/15 at 10:35 AM, the resident's knee brace was observed. The brace was white and made of a hard plastic material. The front part of the brace that was protecting the resident's stump was padded but the rest of the brace had no padding on it. On 10/22/15 at 10:50 AM, Nurse #1 was interviewed. She stated that a doctor's order should have been obtained for Resident #25 on admission for the use of the brace including the instruction on how and when to apply it. She also stated that the application and observation of the resident's skin to prevent the skin from breakdown should have been completed by staff and documented in the resident's medical records.

Based on medical record reviews, staff interviews, and physician interviews the facility failed to prevent resident to resident altercations for one (1) of one (1) residents with aggressive behaviors (Resident #2) exhibited towards two (2) other residents. (Residents #1and #3) which resulted in injury. The immediate jeopardy (IJ) for Resident #1 began on February 2, 2014 when Resident #1 was hit by Resident #2 in a physical altercation. The immediate jeopardy (IJ) for Resident #3 began on December 31, 2013 when Resident #2 punched Resident #3 on forehead with the resident's fist. The Administrator was notified of Immediate Jeopardy on 3/3/14 at 5:30 PM. The IJ was removed on 3/5/14 at 5:30 PM after an acceptable credible allegation was validated through staff interviews and record reviews. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy (D) for completion of employee training and implement monitoring. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial care plan for Resident #1 with a revision date of 1/15/14 indicated the following focus areas: progressive decline in memory/cognition secondary to Dementia, impaired hearing, inappropriate sexual and verbal behaviors, and use of psychoactive medications. Staff was instructed to use interventions for the identified behaviors of monitoring behaviors and remove (the resident) from situation as needed, staff to involve resident in activity such as singing/music, redirect resident ' s thoughts to alternate topic when needed. Review of the quarterly Minimum Data Set (MDS) for Resident #1 dated 2/20/14 revealed he had no physical behaviors toward others, had long and short term memory impairment, was independent with bed mobility, transfers, walking in room and halls. Review of the medications for Resident #1 included Aricept for Dementia, Ativan for anxiety twice a day, and trileptal (mood stabilizer) twice a day. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The transfer form (FL2) indicated Resident #2 had dementia, and required a locked unit due to wandering. Upon admission, Resident #2 resided in the locked dementia unit. There were no identified behaviors of physical or verbal abuse on the FL2. Resident #2 was assessed as having short term memory impairment. The " Dementia Functional Assessment Tool " dated 11/22/13 indicated Resident #2 had " Moderately severe cognitive decline (early dementia). On this assessment, Resident #2 was unable to recall most recent events, had purposeless wandering and could not complete a two-stage command. The care plan for Resident #2 dated 12/31/13 addressed a problem of "exhibits behaviors of physical (phys) aggression as evidenced by (AEB) recent resident to resident altercations involving hitting another resident - related to: cognitive impairment." The stated goals included the resident would not strike others, he would have reduced incidents of aggression and angry outbursts and staff would recognize and prevent behaviors that provoke aggressiveness. The approaches included document behaviors/interventions as indicated, remove resident from public area when behavior is disruptive, talk with resident in a low pitch, calm voice to decrease undesired behavior and provide diversional activity and report any change in mood or behavior to nurse immediately. Additionally, an update was added for the same date (12/31/13) for one on one sitter as needed to monitor. Review of the Minimum Data Set (MDS) a quarterly, dated 1/7/14 revealed Resident #2 had long term memory impairment, behavioral symptoms of physical symptoms directed toward others, independent with bed mobility, transfers, walking in room and halls and eating. Review of Resident #2's nurse' notes dated 2/2/14 at 9:40 AM revealed Resident #2 had a physical altercation with Resident #1. Resident #1 had blood from his nose and mouth with left facial bruise. When asked by the nurse what happened, Resident #1 stated "He (Resident #2) hit me. The resident was assessed for injuries, physician and responsible party notified and sent via EMS (Emergency Medical Services) to the hospital. Per interview with the Administrator on 3/5/14 at 2:40 PM a 24-Hour report was transmitted to the Division of Health Services Regulation. The two residents were both transported to the emergency roiagnom on [DATE]. Resident #1 was hospitalized with bilateral subdural hematoma, facial fractures and lacerations to the face. Resident #2 was arrested at the hospital and transported to the local jail. Interview with Nurse #1 on 3/5/14 at 10:15 AM revealed she was the nurse that worked the first shift on 2/2/14. Nurse #1 explained she was on her med pass, and had been in Resident #1's room to give him medications about ten minutes earlier. There was no indication of a change in his demeanor. Resident #1 was asleep, and she planned to return later to give his medications to him. Aide # 7 called to her from Residents ' #1 and 2 ' s room. Upon entering, Resident #1 was sitting on the side of the bed. He had blood from his nose and mouth. At first, nurse #1 explained she thought it was a nose bleed. Upon speaking with aide #7 and Resident #1, she was informed Resident #2 had hit Resident #1 in the face. Nurse #1 said she informed her supervisor, and assessed Resident #1 further. Resident #2 was lying in bed with the covers pulled up to his head. Resident #2 did not say anything during the questioning of Resident #1. During the interview, Nurse #1 explained Resident #2 responded " yes " when asked if he had hit his roommate. She further explained she asked Resident to see his hands and found blood on the wet cloth when she cleaned his hands. Interview with aide #7 on 3/5/14 at 10:50 AM revealed she was working first shift on 2/2/14. Aide #7 explained it was some time after breakfast, and she saw Resident #2 going into the bathroom in his room. Aide #7 was working in the room next door, making beds. As she went up the hall for linen, she saw Resident #1 sitting on the side of his bed and his nose was bleeding. Aide #7 went into the room and asked Resident #1 what happened. Resident #1 reported his roommate got up and hit him. At that time, Resident #2 was in bed, with the covers pulled up like he was asleep. Aide #7 stated " he wasn ' t asleep " and I asked him what he did. Resident #2 responded " He disrespected me. " When aide #7 was asked to explain if she knew what the resident meant, she stated Resident #2 told her Resident #1 had called him names, like the " N " word. Aide #7 continued to explain she had not heard any noise, or commotion coming from their room prior to the incident. Aide #7 was asked if she had heard Resident #1 call Resident #2 names before and she stated " yes " and the social worker was informed. Interview on 3/5/14 at 11:05 AM with the social worker revealed she was not aware of the " name calling " by Resident #1. The social worker explained she had not been told by staff or she would have moved them. The method of communicating between nursing and the social worker included written notes in her box or under her door and by receiving report with the staff at the desk. The social worker further explained the staff had reported the two residents were getting along well. Interview on 3/5/14 at 11:15 AM with aide #7 revealed she had informed the social worker about Resident #1 calling Resident #2 names. She reported the information during a report time at the nurse ' s desk. Aide #7 stated again " It was reported to the social worker. " An interview was conducted with the Social Worker on 3/3/14 at 4:00 PM. The social worker indicated there were no behaviors exhibited by Resident #2. He chose to stay in his room, most of the time. A psychiatric consult was not requested since his behavior was that of wandering. She explained she would do something the first time a resident was physically aggressive, such as request a psych consult. The administrative staff talked about him in the morning meetings. During the interview, the social worker was asked to explain the difference between the previous altercations Resident #2 had with a resident, and the incident on 2/2/14. She replied the incident on 2/2/14 was unprovoked. She further explained nothing was reported that the two residents (#1 and #2) were not getting along, it was unprovoked. Further interview revealed the social worker would spot what are the triggers for residents and explained staff can ' t watch every single second. The social worker stated she " was surprised at what happened. " (Between Residents #2 and #1) Interview with aide #1 on 3/4/14 at 12:00 PM revealed she worked on the second shift with Resident #1 and #2. Resident #2 was not able to participate in diversional activities; his attention span was too short. During the interview, aide #1 explained Resident #1 had made comments about Resident #2 ' s race. Interview on 3/4/14 at 2:20 PM with the primary physician (the medical director) revealed he was aware of one resident to resident altercation involving Resident #1. During the interview he was asked if the SBARs (Situation - Background - Assessment - Request) were reviewed on his visits and he stated yes, the chart would be reviewed as well. The nurse practitioner had been informed about some of the incidents. The physician was asked how information was communicated to him by the nurse practitioner and he responded they met each morning through the week. The " on call " is alternated between the nurse practitioner and himself. During the interview, the physician was not aware of any injuries for any resident until the 2/2/14 incident. His expectations for the nursing staff included separating the residents, and he would not expect the Zyprexa to be given to Resident #2. The explanation included, Resident #2 did not remain agitated, calmed down after the incident and would not require medication. He was informed on the day of the incident that Resident #1 was hit by Resident #2. The staff was instructed to send both residents to the emergency room . Interview on 3/5/14 at 11:05 AM with the social worker revealed she was not aware of the " name calling " by Resident #1. The social worker explained she had not been told by staff or she would have moved them. The method of communicating between nursing and the social worker included written notes in her box or under her door and by receiving report with the staff at the desk. The social worker further explained the staff had reported the two residents were getting along well. Interview on 3/5/14 at 11:15 AM with aide #7 revealed she had informed the social worker about Resident #1 calling Resident #2 names. She reported the information during a report time at the nurse ' s desk. Aide #7 stated again " It was reported to the social worker. " 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The transfer form (FL2) indicated Resident #2 had dementia, and required a locked unit due to wandering. Upon admission, Resident #2 resided in the locked dementia unit. There were no identified behaviors of physical or verbal abuse on the FL2. Resident #2 was assessed as having short term memory impairment. The " Dementia Functional Assessment Tool " dated 11/22/13 indicated Resident #2 had " Moderately severe cognitive decline (early dementia). On this assessment, Resident #2 was unable to recall most recent events, had purposeless wandering and could not complete a two-stage command. The care plan for Resident #2 dated 12/31/13 addressed a problem of "exhibits behaviors of physical (phys) aggression as evidenced by (AEB) recent resident to resident altercations involving hitting another resident - related to: cognitive impairment. " The stated goals included the resident would not strike others, he would have reduced incidents of aggression and angry outbursts and staff would recognize and prevent behaviors that provoke aggressiveness. The approaches included document behaviors/interventions as indicated, remove resident from public area when behavior is disruptive, talk with resident in a low pitch, calm voice to decrease undesired behavior and provide diversional activity and report any change in mood or behavior to nurse immediately. Additionally, an update was added for the same date (12/31/13) for one on one sitter as needed to monitor. Review of the Minimum Data Set (MDS) a quarterly, dated 1/7/14 revealed Resident #2 had long term memory impairment, behavioral symptoms of physical symptoms directed toward others, independent with bed mobility, transfers, walking in room and halls and eating. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for Resident #3 revealed an antianxiety medication had been administered as needed 3 times in December 2013 and 8 times in January 2014. The original date of this order was 10/17/13. Resident #3 was not on psychotropic medications. Review of Resident #2's nurse's notes dated 12/27/13 at 3:30 PM indicated Resident #2 was observed striking another resident (#3) on her arm with an open hand. Resident #2 was told that was not " nice " and we don ' t allow it. " No incident report was provided by the facility for this incident in the nurse ' s note. An incident report dated 12/27/13 at 4:15 PM indicated Resident #2 was sitting in his wheelchair in the door way to his room. Resident #3 walked up to him and agitated him by her actions of constantly repeating " mama, mama " and " touching him. " Resident #2 "touched the other pt (patient) on the forehead a little roughly with his open hand." Residents were redirected by the aide. Review of Resident #2's "SBAR" (Situation Background Assessment Request form) for communication and progress note for new symptoms, signs and other changes in condition dated 12/27/13 indicated the physician was notified on that date at 4:15 PM. This SBAR was written for Resident #2. The SBAR informed the physician of the second incident. This form included keeping the two residents apart made the condition better, Resident #2 was " becoming combative " and the request was " other " monitor pt (patient). Notes made by the nurse on the back of the form indicated the physician was in the facility, was made aware of the situation and discussed types of dementia with the nurse. The nurse documented no new orders were given by the physician. Review of Resident #2's nurse's notes dated 12/27/13 at 5:00 PM indicated Resident#2 was observed "touching roughly" another resident (#3) in the face open handed when she went up to him. The nurse informed Resident #2 his behavior was unacceptable and not allowed. Review of the incident report dated 12/30/13 at 4:45 PM revealed Resident #2 was in his room when Resident #3 entered his room. Resident #2 " pushed (Resident #3) onto the floor. " Resident #3 did not receive any injuries. The incident report indicated the physician was notified on that date. There were no entries made in the nurse ' s notes for this incident. No SBAR was provided by the facility for this incident. Review of the incident report dated 12/31/13 at 4:20 PM revealed Resident #2 was sitting in a stationary chair in the hallway. He was approached by Resident #3 that " patted resident (#2) on arms, resident (#2) then punched (Resident #3) on forehead with resident ' s fist. Due to cognition resident unable to tell staff why he hit (Resident #3). " This incident documented Resident #2 as " the aggressor. " Review of the SBAR for Resident #2 dated 12/31/13 at 5:00 PM revealed Resident #2 had punched female resident on forehead with fist. He had approached " same (Resident #3) each time. " The assessment included " more confused. " The nurse included documentation of the incident on the back of the form. Resident #3 was " observed " to have " small bump on (L) left forehead. " No new orders were given. For " Request " the nurse checked the box for " lab work ...other tests " and to " monitor vital signs and observe " for Resident #2. Review of the nurse ' s notes for Resident #2 dated 12/31/13 at 10:00 PM revealed Resident #2 was on " One-on-one sitter @ (at) all times. No further behavior issues noted. The social worker ' s notes for Resident #2, dated 12/30/13 and 12/31/13, indicated she was made aware of incidents that occurred on 12/27/13 and 12/30/13. Staff was to monitor the resident ' s behavior (Resident #2) and the location of Resident #3. The care plan was updated with this approach. Review of the incident reported dated 1/5/14 at 6:30 PM indicated Resident #2 was seated in a straight back chair at the nurses' station. Resident #3 came up to his side and touched his chair. Resident #2 hit Resident #3 on the right side of the head with the back of his hand. No injuries were noted and Resident #2 was identified as the aggressor. There were no entries made in the nurse ' s notes for this incident for Resident #2. Review of the SBAR dated 1/5/14 at 7:00 PM revealed the nurse practitioner was notified of the incident with no injuries. There were no new orders at that time. Review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 had long and short memory problems, severely impaired decision making abilities, wandering behaviors and verbal/physical behaviors towards others. This MDS assessed the resident as being independent with bed mobility, transfers and walking. The care plan dated 2/21/14 for Resident #3 indicated behaviors of wandering with interventions that included redirecting the resident, provide diversional activity and monitor her whereabouts. An interview was conducted with the Social Worker on 3/3/14 at 4:00 PM. The social worker indicated there were no behaviors exhibited by Resident #2. He chose to stay in his room, most of the time. A psychiatric consult was not requested since his behavior was that of wandering. She explained she would do something the first time a resident was physically aggressive, such as request a psych consult. The administrative staff talked about him in the morning meetings. There was one resident that was very aggravating to most of the residents back there. (Resident #3) She expected the staff to monitor residents, all staff was to observe Resident#3 when she was pacing. She further explained staff should always know her whereabouts. During the interview, the social worker was asked to explain the difference between the previous altercations Resident #2 had with a resident, and the incident on 2/2/14. She replied the incident on 2/2/14 was unprovoked. Further interview revealed the social worker would spot what are the triggers for residents and explained staff can ' t watch every single second. She did not assess Resident #2 as having patterns of behaviors; the altercations were with just this one Resident (#3). Interview with aide #1 on 3/4/14 at 12:00 PM revealed she worked on the second shift with Residents #2 and #3. Aide #1 explained she was working when Resident #2 had hit Resident #3 in the face. At the time of the altercation, she saw Resident #3 was in Resident #2 ' s face, but could not get to them to intervene before she was hit. Resident #3 was redirected and given diversional activities. Resident #2 was not able to participate in diversional activities; his attention span was too short. Aide #1 reported she did not remember any interventions in place to prevent Resident #3 from going into Resident #2 ' s room. Interview with aide #2 on 3/4/14 at 12:11 PM revealed she was working on second shift when Resident #3 went into Resident #2 ' s room. Aide #2 explained what agitated Resident #2 would be a resident getting in his face or tapping on him/his chair. She further explained he would hit you in these situations. During her shift, she had heard Resident #2 telling a resident to " quit. " She went to Resident #2 ' s room, but was unable to get to them soon enough to prevent the altercation. After the altercation, Resident #3, on her own, left the room. The nurse was informed of the incident and she tried to monitor where Resident #3 was located. Aide #2 was asked how she monitored Resident #3 and she explained every time she went by their rooms, she checked on them. Interview with aide #3 on 3/4/14 at 12:20 PM revealed she had provided 1:1 supervision with Resident #2. Aide #3 was not aware of what behaviors or incidents had occurred while watching him 1:1. She explained she was told he had behavior issues, and she had heard he had pushed Resident #3 down. Interview on 3/4/14 at 2:20 PM with the primary physician (the medical director) revealed he was aware of one incidence between Resident #2 and #3. The physician saw Resident #3 as the problem and a family meeting was held with her responsible party. He was not aware of all of the incidents between Resident #2 and #3. During the interview he was asked if the SBARs were reviewed on his visits and he stated yes, the chart would be reviewed as well. The nurse practitioner had been informed about some of the incidents. The physician was asked how information was communicated to him by the nurse practioner and he responded they met each morning through the week. The " on call " is alternated between the nurse practitioner and himself. His expectations for the nursing staff included separating the residents, and he would not expect the Zyprexa to be given to Resident #2. The explanation included, Resident #2 did not remain agitated, calmed down after the incident and would not require medication. A psychiatric evaluation was not ordered; due to the facility staff presented the situation as Resident #3 was in Resident #2 ' s space. Interview with the nurse practitioner on 3/4/14 at 4:05 PM revealed she did not remember the facility informing her of altercations between Resident #2 and #3. The primary physician had asked her about any altercations earlier that day. She stated she recalled one, (incident on 1/5/14), and there were no injuries. Further interview revealed the one incident did not seem to " be a big deal. " She had no further information to provide about either resident. Interview with the ADON (Assistant Director of Nursing) on 3/5/14 at 4:00 PM revealed Resident #2 had one-on-one sitters for the following dates: - 12/31/13 second and third shift - 1/1/14 first, second and third shift - 1/2/14 first and second shift. The nursing administration decided to stop the one-on-one sitters due to no further aggressive physical behaviors were exhibited by Resident #2. Interview with the ADON (Assistant Director of Nursing) on 3/5/14 at 4:00 PM revealed Resident #2 had one-on-one sitters started again on 1/5/14 for second and third shift. Nursing administration decided to end the one-on-one due to no further aggressive physical behaviors were noted during the one-on-one. Interview on 3/5/14 at 2:40 PM with the administrator revealed the facility saw Resident #3 as the instigator in the altercations. He would expect the staff to monitor the resident, redirect her, but he didn ' t know if they could assure she was safe at all times. During the interview he was asked what was done for Resident #2 and he stated he was not the problem, but Resident #3 was in his space. The Administrator was notified of Immediate Jeopardy on 3/3/14 at 5:30 PM. The allegation of compliance was received on 3/5/14 at 1:40 PM. The allegation of compliance was accepted on 3/5/14 at 4:36 PM. The Corrective Plan of Action: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: - On February 2, 2014, a resident-to-resident altercation occurred between two residents in Room 515 in the facility ' s Special Care Dementia Unit on the 500 Hall. Following the documented incident, the facility took the following action: - Immediately following the discovery of the incident, Residents in Room 515-1 (Resident #2) and 515-2 (Resident #1) were assessed by the facility ' s licensed nursing staff. The residents were immediately separated and one-on-one C.N.A. supervision for each resident was provided until both residents were transported to the local hospital. The resident ' s physicians were notified and orders were given to transport both residents to the local hospital ' s emergency room . The responsible parties for each resident were notified as well as the facility ' s Administrator, Director of Nurses and Assistant Director of Nurses. Under the coordination of the Administrator and Nursing Administration, an investigation of the incident was immediately initiated. A 24-Hour report was transmitted to the Division of Health Services Regulation. The two residents were both transported to the emergency roiagnom on [DATE]. Resident #1 ' s known injuries included bilateral subdural hematoma, facial fractures and lacerations to the face. Resident #1 was hospitalized and then returned to the facility on [DATE]. Resident #2 was arrested at the hospital and transported to the local jail. As of this date, Resident #2, who was discharged from the facility, had not returned. The facility reviewed the incident, the resulting outcomes and interventions with the facility ' s Medical Director via telephone 2/2/14. On February 2, 2014, a resident-to-resident altercation occurred between two residents in Room 515 in the facility ' s Special Care Dementia Unit on the 500 Hall. Following the documented incident, the facility took the following action: 1. Immediately following the discovery of the incident, Residents in Room 515-1 and 515-2 were assessed by the facility ' s licensed nursing staff. The residents were immediately separated and one-on-one C.N.A. supervision for each resident was provided until both residents were transported to the local hospital. The resident ' s physicians were notified and orders were given to transport both residents to the local hospital ' s emergency room . The responsible parties for each resident were notified as well as the facility ' s Administrator, Director of Nurses and Assistant Director of Nurses. Under the coordination of the Administrator and Nursing Administration, an investigation of the incident was immediately initiated. A 24-Hour report was transmitted to the Division of Health Services Regulation. The two residents were both transported to the emergency roiagnom on [DATE]. Resident #1 ' s known injuries included bilateral subdural hematoma, facial fractures and lacerations to the face. Resident #1 was hospitalized and then returned to the facility on [DATE]. Resident #2 was arrested at the hospital and transported to the local jail. As of this date, Resident #2, who was discharged from the facility, has not returned. The facility reviewed the incident, the resulting outcomes and interventions with the facility ' s Medical Director via telephone on 02/02/14. 2. All residents on the facility ' s Special Care Dementia Unit were interviewed on 02/02/14 to ascertain whether they had been subjected to any abuse. All facility residents were given a head-to-toe assessment by the Assistant Director of Nurses, the Day RN Supervisor, the MDS Nurse and four LPN Charge Nurses on 02/02/14 for any signs of abuse and none were noted. The Plans of Care for all residents in the facility, with identified behaviors, were reviewed on 02/02/14 by the Director of Nurses, the Assistant Director of Nurses, the Day RN Supervisor and the MDS Coordinator. The Plans of Care and Resident Care Cards were updated as appropriate. On 02/02/14, facility staff were re-inserviced on resident abuse and dealing with behaviors by the Staff Development Coordinator and the Day RN Supervisor. Facility staff, who were unavailable on 02/02/14, were required to be re-inserviced prior to returning to work. Additionally, direct care nursing staff received education on the development of behavioral care plans and reporting observations that require interventions to the Director of Nurses or the Assistant Director of Nurses, on 02/02/14. Education on resident abuse and dealing with behaviors is included as part of the orientation of newly hired facility staff by the Staff Development Coordinator. The facility ' s Director of Nurses, or the Assistant Director Nurses if unavailable, if not in the facility, will be contacted by telephone for any observed behaviors that require assessment and intervention. The interventions for behaviors are reviewed with the Director of Nurses or Assistant Director of Nurses as the behaviors occur, 7-days per week. All observed behaviors are reviewed by the facility ' s InterDisciplinary Team with recommendations for action made as appropriate including modifications of the resident's Plan of Care, at the facility ' s Clinical Morning Meeting 5-days per week. Behaviors observed on weekends will be reviewed by the InterDisciplinary Team, utilizing the facility's 24-Hour Report, nurses notes, physician orders [REDACTED]. On 03/05/14, facility direct care staff were re-inserviced on identifying behaviors on the Behavior Monitoring Sheet, how to complete the Behavior Monitoring Sheet and the use of the INTERACT and Stop and Watch Tools as a communication tool from CNA's to licensed nurses by the Staff development Coordinator and the Day RN Supervisor. Facility direct care staff, who were unavailable on 03/05/14, were required to be re-inserviced prior to returning to work. Behavior Monitoring Sheet education is included in the orientation of all newly hired licensed nurses by the facility ' s Staff development Coordinator. The Behavior Monitoring Sheets for all facility residents were audited to ensure that all behaviors were identified by the Director of Nurses, Assistant Director of Nurses, Day RN Supervisor and two charge licensed nurses on 03/05/14. Resident #3's Plan of Care was reviewed, after exhibiting behaviors on 12/27/13, by the facility's Interdisciplinary Team and made the following addition; Resident to be re-directed to activities or TV room. Resident #3's Care Card was updated and the 500 Hall direct care staff provided re-direction to activities. On 12/31/14, Resident #3's Plan of Care was reviewed by the facility ' s Interdisciplinary Team and made the following addition; Monitor resident closely and re-direct when resident enters other resident ' s personal space. Resident #3's Care Card was updated and the 500 Hall direct care staff provided re-direction when Resident #3 entered the personal space of other residents. The facility ' s Interdisciplinary Team also updated the Plan of Care with the following; Conduct a medication review for Resident #3 and the medication review was completed on 1/5/14. On 12/31/14, the facility's Interdisciplinary Team requested a formal meeting with Resident #3 ' s Responsible Party. A meeting was held on 1/10/14 with the facility ' s Interdisciplinary Team, the Assistant Director of Nurses, the facility's Administrator, Resident #3's attending physician, the Responsible Party and other family members to discuss the results of the medication review, physician recommendations and family suggestions for late afternoon and early evening activities and other interventions. The Responsible Party informed Resident #3 ' s attending physician that she did not want any medication interventions and would prefer to take Resident #3 home if adequate services could be obtained. The Responsible Party offered no suggestions for activities and interventions. The staff scheduling for the Special Care Unit on the 500 Hall was re-aligned starting on 03/04/14 by the Director of Nurses and the Assistant Director of Nurses to provide for one CNA and one Activity person to work split shifts, i.e. 10:00 a.m. to 6:00 p.m., to provide re-direction and intervention for Resident #3 during the late afternoon, when she and other reside

Based on observation, record review, physician, nurse practitioner, staff and Emergency Medical Services (EMS) interviews, the facility failed to immediately notify the physician of a significant change in a resident's condition for 1 of 4 residents, Resident #188, reviewed for notification of changes. Immediate Jeopardy began on [DATE] when facility staff became aware of Resident #188's change in condition including: lethargy, periodic thrashing, moaning, and elevated blood sugar, and failed to notify the physician. The Immediate Jeopardy is present and ongoing. Findings included: Resident #188 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, did not reject care, participated in the assessment, needed extensive assistance with activities of daily living (ADLs), was on oxygen, and received [MEDICAL TREATMENT]. A review of the February 2013 physician orders [REDACTED]. There was an order originally dated [DATE] for [MEDICATION NAME] ,[DATE] milligrams (mg) orally, as needed every 6 hours for pain. The nurse's note dated [DATE] at 9:30 am indicated the resident had a temperature of 100.3 degrees, was alert and verbal, made her needs known, and was up in her wheelchair. The nurse's note dated [DATE] at 10:30 am indicated the resident was transported to [MEDICAL TREATMENT] with no complaints of nausea or pain. Other than the Change of Condition Documentation, there were no other nurse's notes written on Resident #188 from [DATE] at 10:30 am to [DATE] at 9:45 am. The Change of Condition Documentation form, completed by Nurse #1 and dated [DATE], stated, "At 2:30 am (Nurse Aide #1) reported resident non-verbal and fluttering eye lids. Nurse noted resident lethargic, both eyes reddened (with) yellowish green matter. Cheeks flushed (and) warm. Temp 100.6. Periodically thrashing both arms during examination (and) moaning (with) sound similar to a cat ' s meow. Nasal cannula out of nostrils (and oxygen saturation) 84%. Reapplied (oxygen at) 4 L (with oxygen saturation increased to) 98%. [MEDICAL CONDITION] replaced. Cleansed eyes, removing matter. Gave [MEDICATION NAME] ,[DATE]mg (orally). Crushed (due to) decreased (level of consciousness). Checked blood sugar due to quality of moaning (with) reading HI. Decreased stimulus. Resident said ,[DATE] words but still not clear headed. At 3:45 am (temperature) 99.1. (No) nausea or vomiting. Continue to moan (and) throw arm slowly at times." Vitals signs were documented at 2:30 am as: blood pressure ,[DATE], pulse 56, temperature 100.6, respirations 20, and blood sugar "HI". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation indicating if pain medication was effective. Nurse #2's note dated [DATE] at 9:45 am stated, "Resident unresponsive. Opens eyes then roll back in head. Moans with movement of any kind by staff. Unable to verbalize anything. (Blood glucose level) 57. Refused breakfast this a.m. Hands cold to touch." A Physician order [REDACTED]." The nurse's note dated [DATE] at 10:15 am stated, "Nurse notified supervisor at 9:45 am that resident was non responsive. Assessed (patient) - decreased (level of consciousness) noted. Pupils equal, reactive to light, sluggish." Nurse #2's note dated [DATE] at 10:30 am indicated Emergency Medical Services (EMS) was at the facility to transport the resident to the hospital and the Nurse Practitioner was notified. The Emergency Medical Service (EMS) transport report dated [DATE] stated, "Per nursing staff at nursing home, (Resident #188) began experiencing decreased (level of consciousness) last (night). She is a [MEDICAL TREATMENT] (patient) and (non-insulin-dependent diabetic). She had her [MEDICAL TREATMENT] yesterday then early this (morning) (around 2 am) began experiencing decreased (level of consciousness) with fever. Per nurse her (blood glucose level) at that time was over 400. This (morning), (resident) is not responding. Lies in bed and yells and moans (no words). Nursing staff calls 911." The chief complaint indicated on the report was "Unresponsive patient. Duration: 9 hours" and the [DIAGNOSES REDACTED]." During a telephone interview with the EMS Supervisor, on [DATE] at 5:40 pm, he indicated "Duration" time on an EMS report was "the amount of time the signs and symptoms had been occurring prior to EMS being called." A review of the hospital discharge summary, dated [DATE], indicated Resident #188 was admitted on [DATE] and passed away on [DATE] from cardiopulmonary arrest secondary to septic shock. The discharge summary stated, "In (the emergency department) (patient) was found to be agitated, yelling nonsensically, and had multiple loose stools. She was subsequently intubated and admitted to the medical (intensive care unit). She was partially resuscitated, requiring vasopressor support (medication to maintain her blood pressure), and a surgical consultation was obtained. Due to evidence of peritonitis (inflammation of the lining of the abdomen), an exploratory laparotomy (incision to examine the inside of the abdominal cavity) was performed, which demonstrated bowel perforation. Bowel resection was performed and the patient was transferred to the surgical intensive care unit. Aggressive attempts at resuscitation and stabilization were unsuccessful. Abdominal [DIAGNOSES REDACTED] (elevated intra-abdominal pressure) was recognized and a bedside laparotomy (incision into the abdominal cavity) was performed with relief of intra-abdominal pressure. However, the patient was not able to recover, and she expired." During an interview on [DATE] at 12:05 pm, Nurse #2 stated, "Her blood sugar was low that morning that she was sent to the (emergency room ). I had gotten report from (Nurse #1) that she was acting different and her blood sugars were elevated. (Nurse #1) said she filled out a Change In Condition form. When you fill out the form, you automatically notify the physician. The resident had behaviors that morning. She was usually very alert and oriented and would answer questions appropriately. She took her medicine for me that morning but didn't eat breakfast. When I talked to her after breakfast, she was not talking to me as much as before breakfast so I checked her blood sugar. She wouldn't respond when I said her name. I don't recall (Nurse #1) saying anything other than she had filled out the change in condition form." During an interview on [DATE] at 12:30 pm, the Director of Nursing stated, "Intermittant (blood glucose monitoring) would be documented in the nurse's notes because it would not be on the MAR. If the reading said 'HI', I would expect the blood sugar to be rechecked. If it remained 'HI', I would expect the physician to be contacted, depending on the resident's condition and level of consciousness or a change for that particular resident. When I came in the nurse told me about her change in mental status and that the Nurse Practitioner was called and EMS was called." The DON indicated that had she known of the resident's condition, including change in behavior and elevated blood sugar, at 2:30 am she would have called EMS. She further indicated the change in behavior and low blood sugar that resulted in transport to the hospital on [DATE] at 10:30am would have been the same reason to transport the resident on [DATE] at 2:30 am when she had a documented change in behavior and high blood sugar. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:39 am, she stated, "If there was an elevated blood sugar, there would be a doctor's note stating to give insulin. If someone was in distress and a blood sugar was checked, it would be documented in the nurse's notes. I see a blood sugar of 57 on [DATE]. I do not see any documentation of an elevated blood sugar." "The night nurse would have faxed the change in condition to the physician. We don't keep the face sheets as part of the record so there is no way to know what time the physician was notified by fax. There is an on-call so I would expect the physician would have been called, not just a fax sent, since it was 2:30 in the morning when the change occurred." During a telephone interview with Nurse #1 on [DATE] at 12:00 pm, she stated, "I think (Resident #188's) behavior led me to check her blood sugar. She wasn't really talking. This was different for her. She usually spoke in full sentences and was easy to understand. I took her blood sugar as a vital sign. 'HI' would mean it was over 500. She was not diagnosed with [REDACTED]. She started acting normal about an hour later and maintaining eye contact so I faxed the doctor the change in condition form. I did not call because she started acting better. I did not get an order for [REDACTED]. I can't remember writing a note about her condition improving. I did not recheck her blood sugar because she did not have an order for [REDACTED]. During a telephone interview with the Nurse Practitioner on [DATE] at 3:39 pm, she indicated when she is in the office, and not in the facility, she may not immediately receive an incoming fax and further stated, "If there is a change in a resident at night they should call the on-call provider. There is always someone on call. That is the expectation especially if the resident is acting differently. Even if they can't contact a provider, they should go ahead and call EMS with a high blood sugar and the resident being symptomatic. The expectation is the same if the blood sugar is low and they are symptomatic. They should call the physician and call EMS. They should not wait on a response from a fax that may not even get seen right away. I remember that day I was called and told she was sent out and I did not receive the faxed change in condition until after she had already left the facility." During a telephone interview with the Physician on [DATE] at 3:51 pm, he stated, "If there is a change in a resident's condition, the facility should immediately contact EMS and contact the on-call physician. My group policy is a ,[DATE] minute call back. They should never wait. If the nurse is filling out a change in condition form, they should be calling the physician. They have my primary contact, secondary contact, and even my cell phone. I can always be contacted." The physician indicated, regarding Resident #188, the nurse should have called the physician at 2:30 am when the change in condition was recognized. During an interview with the Administrator on [DATE] at 1:25 pm, he stated, "I would expect in a change of condition for the nurse to follow protocol and procedure and follow her nursing judgment and then contact the physician and or family." The Administrator was notified on [DATE] at 1:40 pm of the Immediate Jeopardy. The Immediate Jeopardy is present and ongoing.

Based on record review, physician, nurse practitioner, staff and Emergency Medical Services (EMS) interviews, the facility failed to identify and assess the need for medical intervention for a resident with a significant change of condition; and failed to immediately initiate emergency medical services for 1 of 4 residents (Resident #188) reviewed for change of condition. Immediate Jeopardy began on [DATE] when facility staff became aware of Resident #188's acute change in condition including: lethargy, periodic thrashing, moaning, and elevated blood sugar, failed to identify and assess her need for emergency medical interventions, and delayed calling EMS for 30 minutes after acute change in condition was recognized (receiving hospital was approximately an hour away). The Immediate Jeopardy is present and ongoing. Findings included: Resident #188 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. There was a physician order dated [DATE] for [MEDICATION NAME] 4 milligrams (mg) orally, as needed every ,[DATE] hours for nausea or vomiting. The January Medication Administration Record [REDACTED]. There was a physician order dated [DATE] for [MEDICATION NAME] ,[DATE]mg orally, as needed every 6 hours for pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, did not reject care, participated in the assessment, needed extensive assistance with activities of daily living (ADLs), was on oxygen, and received [MEDICAL TREATMENT]. The social work note dated [DATE] indicated the resident had no [MEDICAL CONDITION] or behaviors, was tired all the time with occasional lack of interest in doing things, "is understood and understands." The Medication Administration Record [REDACTED]. There was no documentation indicating location of pain or if pain medication was effective. The nurse's note dated [DATE] indicated Resident #188 had decreased nausea after her [MEDICATION NAME] (phosphorus-binding medication) was discontinued on [DATE]. The nurse's note dated [DATE] at 9:00 am stated, "(Resident) continues to refuse (appointment) for (upper gastrointestinal exam). (Physician) in facility and in to assess (resident regarding) refusal. (Resident) continues to refuse despite discussion with (physician)." The physician assessment dated [DATE] stated, "Patient is being seen for routine monthly examination. Patients case and care discussed with nursing staff. Patient is seen and examined. Patient expresses no concerns or new issues. Patient is doing well and no complaints." [DIAGNOSES REDACTED]." The Medication Administration Record [REDACTED]. There was no documentation indicating location of pain or if pain medication was effective. A review of the February 2013 physician orders revealed there were no orders for blood glucose monitoring, oral or subcutaneous glucose medications. A review of the Behavior Monthly Flow Sheet for February 2013 revealed the resident exhibited no behaviors. The nurse's note dated [DATE] at 9:30 am indicated the resident had a temperature of 100.3 degrees, was alert and verbal, made her needs known, and was up in her wheelchair. There were no physician orders for a fever reducer, no nurse's notes of interventions for the resident's elevated temperature, or reassessment of Resident #188's temperature on [DATE]. The nurse's note dated [DATE] at 10:30 am indicated the resident was transported to [MEDICAL TREATMENT] with no complaints. The February MAR indicated [REDACTED]. The Change of Condition Documentation form, completed by Nurse #1 and dated [DATE], stated, "At 2:30 am (Nurse Aide #1) reported resident non-verbal and fluttering eye lids. Nurse noted resident lethargic, both eyes reddened (with) yellowish green matter. Cheeks flushed (and) warm. Temp 100.6. Periodically thrashing both arms during examination (and) moaning (with) sound similar to a cat ' s meow. Nasal cannula out of nostrils (and oxygen saturation) 84%. Reapplied (oxygen at) 4 L (with oxygen saturation increased to) 98%. [MEDICAL CONDITION] replaced. Cleansed eyes, removing matter. Gave [MEDICATION NAME] ,[DATE]mg (orally). Crushed (due to) decreased (level of consciousness). Checked blood sugar due to quality of moaning (with) reading HI. Decreased stimulus. Resident said ,[DATE] words but still not clear headed. At 3:45 am (temperature) 99.1. (No) nausea or vomiting. Continue to moan (and) throw arm slowly at times." Vitals signs were documented at 2:30 am as: blood pressure ,[DATE], pulse 56, temperature 100.6, respirations 20, and blood sugar "HI". The Medication Administration Record [REDACTED]. The as-needed Pain Management Flow Sheet indicated the resident was cognitively impaired and in mild pain at 2:30 am and cognitively impaired and in no pain at 6:30 am. During a telephone interview with Nurse Aide #1 on [DATE] at 10:15 am, when asked about Resident #188's usual mental status and how she was different on [DATE], she stated, "That night she seemed like she was in a lot of pain. She complained a lot about pain that night and was screaming so loud she was waking up other residents. I reported it to the nurse (Nurse #1). (The resident) was not acting like herself that night." During a telephone interview with Nurse #1 on [DATE] at 12:00 pm, she stated, "I think (Resident #188's) behavior led me to check her blood sugar. She wasn't really talking. This was different for her. She usually spoke in full sentences and was easy to understand. I took her blood sugar as a vital sign. 'HI' would mean it was over 500. She was not diagnosed with [REDACTED]. I did not check her sugar with another machine. I cannot remember if I ran controls on the machine. She started acting normal about an hour later and maintaining eye contact so I faxed the doctor the change in condition form. I did not call because she started acting better. I did not get an order for [REDACTED]. I can't remember writing a note about her condition improving. I did not recheck her blood sugar because she did not have an order for [REDACTED]. Other than the Change of Condition Documentation, there were no other nurse's notes written on Resident #188 from [DATE] at 10:30 am to [DATE] at 9:45 am. Nurse #2's note dated [DATE] at 9:45 am stated, "(Temperature) 98.6, (pulse) 60, (respirations) 18, (blood pressure) ,[DATE], (oxygen saturation) 84%. Resident unresponsive. Opens eyes then roll back in head. Moans with movement of any kind by staff. Unable to verbalize anything. (Blood glucose level) 57 on facility accucheck machine. Refused breakfast this a.m. Hands cold to touch." During an interview on [DATE] at 12:05 pm, Nurse #2 stated, "Her blood sugar was low that morning that she was sent to the (emergency room ). I had gotten report from (Nurse #1) that she was acting different and her blood sugars were elevated. (Nurse #1) said she filled out a Change In Condition form. When you fill out the form, you automatically notify the physician. The resident had behaviors that morning. She was usually very alert and oriented and would answer questions appropriately. She took her medicine for me that morning but didn't eat breakfast. When I talked to her after breakfast, she was not talking to me as much as before breakfast so I checked her blood sugar. She wouldn't respond when I said her name. I know (Nurse #1) didn't give any insulin because we would have to have an order for [REDACTED]. A Physician order dated [DATE] at 10:14 am stated, "Send to (emergency department) for (evaluation) unconsciousness." The nurse's note dated [DATE] at 10:15 am stated, "Nurse notified supervisor at 9:45 am that resident was non responsive. Assessed (patient) - decreased (level of consciousness) noted. Pupils equal, reactive to light, sluggish." Nurse #2's note dated [DATE] at 10:30 am indicated Emergency Medical Services (EMS) was at the facility to transport the resident to the hospital and the Nurse Practitioner was notified. The Emergency Medical Service (EMS) transport report dated [DATE] stated, "Per nursing staff at nursing home, (Resident #188) began experiencing decreased (level of consciousness) last (night). She is a [MEDICAL TREATMENT] (patient) and (non-insulin-dependent diabetic). She had her [MEDICAL TREATMENT] yesterday then early this (morning) (around 2 am) began experiencing decreased (level of consciousness) with fever. Per nurse her (blood glucose level) at that time was over 400. This (morning), (resident) is not responding. Lies in bed and yells and moans (no words). Nursing staff calls 911." The chief complaint indicated on the report was "Unresponsive patient. Duration: 9 hours" and the [DIAGNOSES REDACTED]." A review of the EMS assessment, dated [DATE] indicated: At 10:18 am EMS received call EMS arrived at 10:24 am. At 10:25 am, the resident was agitated and combative, "eyes open but does not converse. (Patient) moans and yells", decreased level of consciousness, pulse 112, blood pressure ,[DATE], and had a blood glucose of 34. At 10:35 am, EMS gave an intramuscular injection of [MEDICATION NAME] 1mg. At 10:40 am, the resident's blood glucose was rechecked and was 20. Vascular access was started at 10:45 am. At 10:48 am, [MEDICATION NAME] 25grams was administered through the vascular access. At 10:50 am, the resident's blood glucose was rechecked and was 211. At 11:05 am, there was no change in the resident's condition. She continued to not respond, yell, and moan. At 11:25 am, the resident's blood glucose was rechecked and was 200. At 11:45 am, the resident was released to the care of the emergency department and there was "no change in (patient) status throughout EMS care." During a telephone interview with the EMS Supervisor, on [DATE] at 5:40 pm, he indicated "Duration" time on an EMS report was "the amount of time the signs and symptoms had been occurring prior to EMS being called." A review of the emergency department assessment, dated [DATE] at 11:51 am indicated Resident #188 was anxious, appeared to be in pain, was agitated, had a blood pressure of ,[DATE], heart rate of 120, respiratory rate of 26, temperature of 99, oxygen saturation of 96% on 2 liters of oxygen, had a soft, nontender abdomen, cool skin, was "confused, combative and disoriented to person, place and time.", had incoherent responses, and inappropriate speech. A review of the hospital discharge summary, dated [DATE], indicated Resident #188 was admitted on [DATE] and passed away on [DATE] from cardiopulmonary arrest secondary to septic shock. The discharge summary stated, "In (the emergency department) (patient) was found to be agitated, yelling nonsensically, and had multiple loose stools. She was subsequently intubated and admitted to the medical (intensive care unit). She was partially resuscitated, requiring vasopressor support (medication to maintain her blood pressure), and a surgical consultation was obtained. Due to evidence of peritonitis (inflammation of the lining of the abdomen), an exploratory laparotomy (incision to examine the inside of the abdominal cavity) was performed, which demonstrated bowel perforation. Bowel resection was performed and the patient was transferred to the surgical intensive care unit. Aggressive attempts at resuscitation and stabilization were unsuccessful. Abdominal [DIAGNOSES REDACTED] (elevated intra-abdominal pressure) was recognized and a bedside laparotomy (incision into the abdominal cavity) was performed with relief of intra-abdominal pressure. However, the patient was not able to recover, and she expired." During an interview on [DATE] at 12:30 pm, the Director of Nursing stated,"Intermittant (blood glucose monitoring) would be documented in the nurse's notes because it would not be on the MAR. If the reading said 'HI', I would expect the blood sugar to be rechecked. If it remained 'HI', I would expect the physician to be contacted, depending on the resident's condition and level of consciousness or a change for that particular resident. When I came in the nurse told me about her change in mental status and that the Nurse Practitioner was called and EMS was called." The DON indicated that had she known of the resident's condition, including change in behavior and elevated blood sugar, at 2:30 am she would have called EMS. She further indicated the change in behavior and low blood sugar that resulted in transport to the hospital on [DATE] at 10:30 am would have been the same reason to transport the resident on [DATE] at 2:30 am when she had a documented change in behavior and high blood sugar. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:39 am, she stated, "If there was an elevated blood sugar, there would be a doctor's note stating to give insulin. If someone was in distress and a blood sugar was checked, it would be documented in the nurse's notes. I see a blood sugar of 57 on [DATE]. I do not see any documentation of an elevated blood sugar." "The night nurse would have faxed the change in condition to the physician. We don't keep the face sheets as part of the record so there is no way to know what time the physician was notified by fax. There is an on-call so I would expect the physician would have been called, not just a fax sent, since it was 2:30 in the morning when the change occurred." During a telephone interview with the Nurse Practitioner on [DATE] at 3:39 pm, she indicated when she is in the office, and not in the facility, she may not immediately receive an incoming fax and further stated, "If there is a change in a resident at night they should call the on-call provider. There is always someone on call. That is the expectation especially if the resident is acting differently. Even if they can't contact a provider, they should go ahead and call EMS with a high blood sugar and the resident being symptomatic. The expectation is the same if the blood sugar is low and they are symptomatic. They should call the physician and call EMS. They should not wait on a response from a fax that may not even get seen right away. I remember that day I was called and told she was sent out and I did not receive the faxed change in condition until after she had already left the facility." During a telephone interview with the Physician on [DATE] at 3:51 pm, he stated, "If there is a change in a resident's condition, the facility should immediately contact EMS and contact the on-call physician. My group policy is a ,[DATE] minute call back. They should never wait. If the nurse is filling out a change in condition form, they should be calling the physician. They have my primary contact, secondary contact, and even my cell phone. I can always be contacted." The physician indicated, regarding Resident #188, the nurse should have called the physician at 2:30 am when the change in condition was recognized. During an interview with the Administrator on [DATE] at 1:25 pm, he stated, "I would expect in a change of condition for the nurse to follow protocol and procedure and follow her nursing judgment and then contact the physician and or family." The Administrator was notified on [DATE] at 1:40 pm of the Immediate Jeopardy.

Based on record review, physician, nurse practitioner, staff and Emergency Medical Services (EMS) interviews, the facility failed to identify and assess the need for medical intervention for a resident with a significant change of condition; and failed to immediately initiate emergency medical services for 1 of 4 residents (Resident #188) reviewed for change of condition. Immediate Jeopardy began on [DATE] when facility staff became aware of Resident #188's acute change in condition including: lethargy, periodic thrashing, moaning, and elevated blood sugar, failed to identify and assess her need for emergency medical interventions, and delayed calling EMS for 30 minutes after acute change in condition was recognized (receiving hospital was approximately an hour away). Immediate jeopardy began on [DATE] and was identified on [DATE] at 1:40 PM. Validation of the facility's credible allegation was conducted on [DATE]. Residents on all halls (100, 200, 300, 400 and 500) in the facility records were reviewed and observations were conducted on residents who had changes in conditions. The observations included interventions associated with change in conditions , staff reporting/communication process from shift to shift, staff documentation of observed changes in condition in accordance with the facility newly developed guidelines/tools ([DATE]). The SBAR (Situation, Background, Assessment and Recommendation/Request)/Change in Condition Review Audit form for all residents from [DATE] -[DATE] were reviewed. Record reviews were completed to verify the implementation of the assessment tools and the functional process of staff communication regarding resident change of condition use of the Stop and Watch tool and glucometer training with all shifts of medical staff. Staff interviews were conducted with all three shift to verify the implementation of the newly developed SBAR(Situation, Background, Assessment, Recommendation/Request) form, Guidelines for Change in Condition form , Glucometer training ,Early Warning " Stop and Watch " and the SBAR form indicating review of the assessment and knowledge of the resident change of condition had been completed by [DATE] per the Credible Allegation. Direct Care, and Management Staff interviews were conducted to verify current staff and agency staff had been in-serviced in the new systemic changes and protocols. The completion date for all in-services for nursing and nursing assistant became effective [DATE]. The Quality Assurance Audit reports since [DATE] through [DATE] were reviewed along with all the supportive documentation of the Credible Allegation of Compliance, to verify the implementation of the facility's Credible Allegation of Compliance. The survey found that immediate jeopardy was removed for the area of Assessment of Resident Change of Condition as a result of lethargy, periodic thrashing, moaning, and elevated blood sugar, (F309) on [DATE]. The facility remains out of compliance at the D level (No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy), in order to continue implementation of the process and monitor systems. Findings included: Resident #188 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. There was a physician order dated [DATE] for [MEDICATION NAME] 4 milligrams (mg) orally, as needed every ,[DATE] hours for nausea or vomiting. The January Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was a physician order dated [DATE] for [MEDICATION NAME] ,[DATE]mg orally, as needed every 6 hours for pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, did not reject care, participated in the assessment, needed extensive assistance with activities of daily living (ADLs), was on oxygen, and received [MEDICAL TREATMENT]. The social work note dated [DATE] indicated the resident had no [MEDICAL CONDITION] or behaviors, was tired all the time with occasional lack of interest in doing things, "is understood and understands." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation indicating location of pain or if pain medication was effective. The nurse's note dated [DATE] indicated Resident #188 had decreased nausea after her [MEDICATION NAME] (phosphorus-binding medication) was discontinued on [DATE]. The nurse's note dated [DATE] at 9:00 am stated, "(Resident) continues to refuse (appointment) for (upper gastrointestinal exam). (Physician) in facility and in to assess (resident regarding) refusal. (Resident) continues to refuse despite discussion with (physician)." The physician assessment dated [DATE] stated, "Patient is being seen for routine monthly examination. Patients case and care discussed with nursing staff. Patient is seen and examined. Patient expresses no concerns or new issues. Patient is doing well and no complaints." [DIAGNOSES REDACTED]." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation indicating location of pain or if pain medication was effective. A review of the February 2013 physician orders revealed there were no orders for blood glucose monitoring, oral or subcutaneous glucose medications. A review of the Behavior Monthly Flow Sheet for February 2013 revealed the resident exhibited no behaviors. The nurse's note dated [DATE] at 9:30 am indicated the resident had a temperature of 100.3 degrees, was alert and verbal, made her needs known, and was up in her wheelchair. There were no physician orders for a fever reducer, no nurse's notes of interventions for the resident's elevated temperature, or reassessment of Resident #188's temperature on [DATE]. The nurse's note dated [DATE] at 10:30 am indicated the resident was transported to [MEDICAL TREATMENT] with no complaints. The February MAR indicated [REDACTED]. The Change of Condition Documentation form, completed by Nurse #1 and dated [DATE], stated, "At 2:30 am (Nurse Aide #1) reported resident non-verbal and fluttering eye lids. Nurse noted resident lethargic, both eyes reddened (with) yellowish green matter. Cheeks flushed (and) warm. Temp 100.6. Periodically thrashing both arms during examination (and) moaning (with) sound similar to a cat ' s meow. Nasal cannula out of nostrils (and oxygen saturation) 84%. Reapplied (oxygen at) 4 L (with oxygen saturation increased to) 98%. [MEDICAL CONDITION] replaced. Cleansed eyes, removing matter. Gave [MEDICATION NAME] ,[DATE]mg (orally). Crushed (due to) decreased (level of consciousness). Checked blood sugar due to quality of moaning (with) reading HI. Decreased stimulus. Resident said ,[DATE] words but still not clear headed. At 3:45 am (temperature) 99.1. (No) nausea or vomiting. Continue to moan (and) throw arm slowly at times." Vitals signs were documented at 2:30 am as: blood pressure ,[DATE], pulse 56, temperature 100.6, respirations 20, and blood sugar "HI". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The as-needed Pain Management Flow Sheet indicated the resident was cognitively impaired and in mild pain at 2:30 am and cognitively impaired and in no pain at 6:30 am. During a telephone interview with Nurse Aide #1 on [DATE] at 10:15 am, when asked about Resident #188's usual mental status and how she was different on [DATE], she stated, "That night she seemed like she was in a lot of pain. She complained a lot about pain that night and was screaming so loud she was waking up other residents. I reported it to the nurse (Nurse #1). (The resident) was not acting like herself that night." During a telephone interview with Nurse #1 on [DATE] at 12:00 pm, she stated, "I think (Resident #188's) behavior led me to check her blood sugar. She wasn't really talking. This was different for her. She usually spoke in full sentences and was easy to understand. I took her blood sugar as a vital sign. 'HI' would mean it was over 500. She was not diagnosed with [REDACTED]. I did not check her sugar with another machine. I cannot remember if I ran controls on the machine. She started acting normal about an hour later and maintaining eye contact so I faxed the doctor the change in condition form. I did not call because she started acting better. I did not get an order for [REDACTED]. I can't remember writing a note about her condition improving. I did not recheck her blood sugar because she did not have an order for [REDACTED]. Other than the Change of Condition Documentation, there were no other nurse's notes written on Resident #188 from [DATE] at 10:30 am to [DATE] at 9:45 am. Nurse #2's note dated [DATE] at 9:45 am stated, "(Temperature) 98.6, (pulse) 60, (respirations) 18, (blood pressure) ,[DATE], (oxygen saturation) 84%. Resident unresponsive. Opens eyes then roll back in head. Moans with movement of any kind by staff. Unable to verbalize anything. (Blood glucose level) 57 on facility accucheck machine. Refused breakfast this a.m. Hands cold to touch." During an interview on [DATE] at 12:05 pm, Nurse #2 stated, "Her blood sugar was low that morning that she was sent to the (emergency room ). I had gotten report from (Nurse #1) that she was acting different and her blood sugars were elevated. (Nurse #1) said she filled out a Change In Condition form. When you fill out the form, you automatically notify the physician. The resident had behaviors that morning. She was usually very alert and oriented and would answer questions appropriately. She took her medicine for me that morning but didn't eat breakfast. When I talked to her after breakfast, she was not talking to me as much as before breakfast so I checked her blood sugar. She wouldn't respond when I said her name. I know (Nurse #1) didn't give any insulin because we would have to have an order for [REDACTED]. A Physician order dated [DATE] at 10:14 am stated, "Send to (emergency department) for (evaluation) unconsciousness." The nurse's note dated [DATE] at 10:15 am stated, "Nurse notified supervisor at 9:45 am that resident was non responsive. Assessed (patient) - decreased (level of consciousness) noted. Pupils equal, reactive to light, sluggish." Nurse #2's note dated [DATE] at 10:30 am indicated Emergency Medical Services (EMS) was at the facility to transport the resident to the hospital and the Nurse Practitioner was notified. The Emergency Medical Service (EMS) transport report dated [DATE] stated, "Per nursing staff at nursing home, (Resident #188) began experiencing decreased (level of consciousness) last (night). She is a [MEDICAL TREATMENT] (patient) and (non-insulin-dependent diabetic). She had her [MEDICAL TREATMENT] yesterday then early this (morning) (around 2 am) began experiencing decreased (level of consciousness) with fever. Per nurse her (blood glucose level) at that time was over 400. This (morning), (resident) is not responding. Lies in bed and yells and moans (no words). Nursing staff calls 911." The chief complaint indicated on the report was "Unresponsive patient. Duration: 9 hours" and the [DIAGNOSES REDACTED]." A review of the EMS assessment, dated [DATE] indicated: At 10:18 am EMS received call EMS arrived at 10:24 am. At 10:25 am, the resident was agitated and combative, "eyes open but does not converse. (Patient) moans and yells", decreased level of consciousness, pulse 112, blood pressure ,[DATE], and had a blood glucose of 34. At 10:35 am, EMS gave an intramuscular injection of [MEDICATION NAME] 1mg. At 10:40 am, the resident's blood glucose was rechecked and was 20. Vascular access was started at 10:45 am. At 10:48 am, [MEDICATION NAME] 25grams was administered through the vascular access. At 10:50 am, the resident's blood glucose was rechecked and was 211. At 11:05 am, there was no change in the resident's condition. She continued to not respond, yell, and moan. At 11:25 am, the resident's blood glucose was rechecked and was 200. At 11:45 am, the resident was released to the care of the emergency department and there was "no change in (patient) status throughout EMS care." During a telephone interview with the EMS Supervisor, on [DATE] at 5:40 pm, he indicated "Duration" time on an EMS report was "the amount of time the signs and symptoms had been occurring prior to EMS being called." A review of the emergency department assessment, dated [DATE] at 11:51 am indicated Resident #188 was anxious, appeared to be in pain, was agitated, had a blood pressure of ,[DATE], heart rate of 120, respiratory rate of 26, temperature of 99, oxygen saturation of 96% on 2 liters of oxygen, had a soft, nontender abdomen, cool skin, was "confused, combative and disoriented to person, place and time.", had incoherent responses, and inappropriate speech. A review of the hospital discharge summary, dated [DATE], indicated Resident #188 was admitted on [DATE] and passed away on [DATE] from cardiopulmonary arrest secondary to septic shock. The discharge summary stated, "In (the emergency department) (patient) was found to be agitated, yelling nonsensically, and had multiple loose stools. She was subsequently intubated and admitted to the medical (intensive care unit). She was partially resuscitated, requiring vasopressor support (medication to maintain her blood pressure), and a surgical consultation was obtained. Due to evidence of peritonitis (inflammation of the lining of the abdomen), an exploratory laparotomy (incision to examine the inside of the abdominal cavity) was performed, which demonstrated bowel perforation. Bowel resection was performed and the patient was transferred to the surgical intensive care unit. Aggressive attempts at resuscitation and stabilization were unsuccessful. Abdominal [DIAGNOSES REDACTED] (elevated intra-abdominal pressure) was recognized and a bedside laparotomy (incision into the abdominal cavity) was performed with relief of intra-abdominal pressure. However, the patient was not able to recover, and she expired." During an interview on [DATE] at 12:30 pm, the Director of Nursing stated,"Intermittant (blood glucose monitoring) would be documented in the nurse's notes because it would not be on the MAR. If the reading said 'HI', I would expect the blood sugar to be rechecked. If it remained 'HI', I would expect the physician to be contacted, depending on the resident's condition and level of consciousness or a change for that particular resident. When I came in the nurse told me about her change in mental status and that the Nurse Practitioner was called and EMS was called." The DON indicated that had she known of the resident's condition, including change in behavior and elevated blood sugar, at 2:30 am she would have called EMS. She further indicated the change in behavior and low blood sugar that resulted in transport to the hospital on [DATE] at 10:30 am would have been the same reason to transport the resident on [DATE] at 2:30 am when she had a documented change in behavior and high blood sugar. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:39 am, she stated, "If there was an elevated blood sugar, there would be a doctor's note stating to give insulin. If someone was in distress and a blood sugar was checked, it would be documented in the nurse's notes. I see a blood sugar of 57 on [DATE]. I do not see any documentation of an elevated blood sugar." "The night nurse would have faxed the change in condition to the physician. We don't keep the face sheets as part of the record so there is no way to know what time the physician was notified by fax. There is an on-call so I would expect the physician would have been called, not just a fax sent, since it was 2:30 in the morning when the change occurred." During a telephone interview with the Nurse Practitioner on [DATE] at 3:39 pm, she indicated when she is in the office, and not in the facility, she may not immediately receive an incoming fax and further stated, "If there is a change in a resident at night they should call the on-call provider. There is always someone on call. That is the expectation especially if the resident is acting differently. Even if they can't contact a provider, they should go ahead and call EMS with a high blood sugar and the resident being symptomatic. The expectation is the same if the blood sugar is low and they are symptomatic. They should call the physician and call EMS. They should not wait on a response from a fax that may not even get seen right away. I remember that day I was called and told she was sent out and I did not receive the faxed change in condition until after she had already left the facility." During a telephone interview with the Physician on [DATE] at 3:51 pm, he stated, "If there is a change in a resident's condition, the facility should immediately contact EMS and contact the on-call physician. My group policy is a ,[DATE] minute call back. They should never wait. If the nurse is filling out a change in condition form, they should be calling the physician. They have my primary contact, secondary contact, and even my cell phone. I can always be contacted." The physician indicated, regarding Resident #188, the nurse should have called the physician at 2:30 am when the change in condition was recognized. During an interview with the Administrator on [DATE] at 1:25 pm, he stated, "I would expect in a change of condition for the nurse to follow protocol and procedure and follow her nursing judgment and then contact the physician and or family."

Based on resident observations, staff interviews, medical director interview and record review, the facility failed to prevent staff from physically abusing 2 of 8 sampled residents. During care, 2 nursing assistants (NAs #1 and # 7) " rough handled " 2 residents (Resident #2 and #8). The facility failed to prevent staff from verbally abusing one of 8 sampled residents (Resident#8). Findings include: Immediate jeopardy began on 5/11/11 with Resident #2 and was identified on 8/3/11 at 10:56 a.m. for Resident #2 and #8. Immediate Jeopardy was removed on 8/4/11 at 7 p.m. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. 1. Resident #2 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Initial Care Plan dated 4/11/11 showed that a plan of care was initiated in the area behavior. Resident exhibited behaviors of verbal and physical aggression by being combative during care, refusing medications, and refusing to go to bed. The behavior/mood interventions read, " Approach the resident slowly and from the front. Do not argue with resident; involve family when needed. Encourage resident to call upon staff for help in coping. Remove to a quiet area. Spend time with resident and reassure resident of personal safety and stay with resident during periods of anger if appropriate or if resident wishes. Report any change in mood or behavior to charge nurse or DNS (Director of Nursing Services) immediately. Allow resident time to respond to directions or request. Be sure you have the resident's attention before speaking or touching. Give resident a clear, concise explanation of anything about to occur, avoid information overload since the angry, aggressive resident cannot assimilate many details. If strategies are not working, leave resident and re-approach in 10 minutes. " Resident #2 's Admission Minimum Data Set ((MDS) dated [DATE], revealed he had short/long-term memory problems. The resident's decision-making skills were moderately impaired. Resident was hard of hearing in both ears. He had exhibited signs and symptoms of [MEDICAL CONDITION], which fluctuate, [MEDICAL CONDITION], and other behavioral symptoms not directed to others. The resident required extensive assistance from two people for bed mobility, transfers, dressing, and personal hygiene. He was totally dependent for toileting and bathing. The resident was listed as incontinent of bowel and bladder. The healthcare personnel registry 24-hour initial report dated 5/17/11 read in part, " (resident ' s initial ) incident date: 5/11/11, allegation description: allegation made that employee (NA # 1) forced resident to sit down forcefully pushing resident in chest with hands. " The healthcare personnel registry 5-day report dated 5/24/11, read in part, " Witness stated that on 5/11/11, she witnessed CNA (NA#1) in resident ' s face hollering at him, and then she jerked him down by pulling on his upper arm. When the resident stood back up, she pushed him down with both hands on his chest. On 5/12/11, the CNA (NA#1) taking care of the resident reported to the nurse that the resident had a bruise on his chest from sternum to breast line. After speaking with the witness, the accused CNA (NA#1), CNAs on the hall, and hall nurses, it was determined that the allegation was substantiated and the accused CNA was terminated. The resident had a bruise to chest and no other injuries. Resident has advanced dementia and does not recall incident. The accused CNA (NA#1) was suspended during the investigation, and after completion she was then terminated. " During a phone interview on 8/2/11 at 12:30 p.m. with NA #2 (the aide who witnessed the alleged abuse) she stated that " (Resident #2) (name of the resident) used to be on the 500 Hall and he was moved to the 300 Hall. While he was on the 300 Hall, he became combative and disoriented. On 5/11/11 while breakfast was going on, I heard fussing in his room. I pushed the door and saw (NA #1) in the resident ' s face hollering and telling him to sit down. The resident stood up and she pulled him down by his upper arm. The resident immediately stands back up and she pushed him down forcefully with the palm of both hands. She pushed him hard enough that the wheelchair rolled back against the wall. (NA #1) saw me and shoved the door in my face. During an interview on 8/2/11 at 10:00 a.m. with SN #1, who was assigned to the resident the day of the alleged abuse and was the first staff nurse the bruise was reported to, stated that at " (NA #1) went to do care on (Resident #2) and she came and got me immediately and showed me the bruise on (Resident #2 ' s) chest. It was a large black and purplish bruise covering one nipple to another nipple. She further stated that it was the same day (5/11/11) when he was moved back to the 500 Hall. SN#1 indicated that she did not witness the abuse. During a phone interview on 8/2/11 at 12:00 noon with NA #1, who allegedly caused the bruising to Resident #2's chest, she stated that " the Director of Nursing called me at home on 5/17/11 and told me that I should make an appointment to come and see her at 3:30 p.m. on 5/18/11, because someone made an allegation about me on 5/11/11. I told her that I did not do care on the resident on 5/11/11. On 5/12/11 at 11:00 a.m., I took the resident ' s shirt off to do a.m. care, and I saw a large, black-purplish bruise all over his chest, from one nipple to another, going down into his upper stomach. I went and got my supervisor (Staff Nurse (SN) #1), and she came and look(ed) at it, and she got the nursing supervisor. They call me back on May 24th and substantiated the investigation and let me go. " When asked by the surveyor what happened on 5/11/11, she stated that nothing happened. During an interview on 8/2/11 at 11:00 a.m. and again on 8/4/11 at 11:30 a.m. with the Director of Nursing (DON), she stated that the resident was moved on 4/29/11 to the 300 Hall. Upon being moved, the resident became very agitated, more verbally abusive, and loud, so he was moved back to the 500 Hall on 5/12/11. The DON stated " it was reported to me on 5/17/11 by (NA #2) that (NA #1) abused Resident #2. " She further stated that on 5/11/11 while NA #1 was providing care to Resident #2, NA #2 heard " fussing " in Resident #2 ' s room; NA #2 entered the room and saw NA #1 forcefully push the resident down in the wheelchair by pulling on his upper arm. The DON further stated that NA #2 reported that when the resident stood back up, the aide pushed him down in his wheelchair with both hands and the wheelchair rolled into the wall. The DON further stated that on 5/17/11, " I assessed the resident and he had a purplish-yellowish large bruise at the center of his chest from one nipple to another nipple; no other bruises or redness was noted. The resident denied pain. The DON further stated that the resident had a fall on 5/11/11 and the incident report stated he fell on his bottom with no injury. She added, " When I assessed the resident on 5/17/11, the bruise was from nipple to nipple, large, and encompassed the entire chest. It was impossible for the resident to fall on his bottom and sustain a bruise to his chest. " The DON stated that " I felt (NA #1) had hit the resident willfully and put him in the chair. " When asked by the surveyor what evidence she used to substantiate the abuse allegation, the DON stated, " I had noticed earlier in the week that (NA #1) had spoken loudly to (Resident #2), out in the hallway, and I came out of my office when I heard the disturbance and asked (NA #1) if everything was ok. (NA #1) stated, ' everything is fine; I ' m just frustrated. ' " When asked what the DON had done about NA#1 behavior she indicated she offered to move the aide off Hall 300 and/or change the assignment. NA #1 told her she would be off the next day and everything was fine. A review of the facility ' s daily staffing revealed NA #1 and NA #2 were assigned and worked on the 300 Hall on 5/11/11 during the 7-3 shift. A review of the facility ' s daily staffing revealed NA #1 worked on the 300 Hall on 5/12/11 during the 7-3 shift. During a phone interview on 8/4/11 at 12:55 p.m. with the medical director (MD), he stated " I was over at the facility on 5/19/11 when it was brought to my attention that an aide allegedly abused (Resident #2). When I saw the chest, it was yellowish; the bruise was several days old, maybe 1 week old. 2. Resident #8 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Care Plan dated 6/13/11 showed that a plan of care was initiated in the areas of self-care deficit and impaired mobility, cognition, and behavior. According to the plan, " Resident exhibits behaviors of verbal, physical aggression, easily agitated, slapping and cursing staff. " The behavior/mood interventions read, " Allow resident time to respond to directions or request, (d/t (due to) dementia more time to absorb instruction). Do not argue with resident; report any change in mood or behavior to charge nurse immediately. Report any verbal or physical, sexual or aggressive expression to the charge nurse immediately. Psychiatric consult as needed. " Resident #8 ' s minimum data set ((MDS) dated [DATE] revealed she had short/long-term memory problems. The resident ' s decision-making skills were moderately impaired. She had exhibited signs and symptoms of [MEDICAL CONDITION] present, which fluctuate, and physical and verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed to others. The resident required extensive assistance of two people for bed mobility, transfers, dressing, and personal hygiene. She was totally dependent for toileting and bathing. A review of the note that NA # 8 (the witness of the abuse) left under the Director of Nursing ' s (DON) door dated 7/17/11 read, " on July 17, 2011, I worked on the 100 Hall with (name of the aide (NA#7)). We were in (Resident #8 ' s) room. (Resident #8) became combative and hit (name of the aide), then (name of the aide) grabbed (Resident #8 ' s) arm and punched her left upper arm and held her hands down. " The healthcare personnel registry 24-hour initial report dated 7/20/11 read in part, " allegation description: CNA (NA# 8) reported that on Sunday 7/17/11 she worked with the accused CNA (NA# 7). She (NA#8) stated the accused CNA hit a resident in the shoulder while providing care. She also states that the accused CNA told the resident she did not belong in this facility, that she belongs in mental institution. " The healthcare personnel registry 5-day report dated 7/27/11 read in part, " the CNA who was in the room with the accused CNA at the time of the incident stated that while putting the resident to bed, the resident became combative. When this happened, the CNA stated that the accused CNA hit the resident in the arm and grabbed her hand. The accused CNA stated that while putting the resident to bed, she (the resident) became combative. She (NA#7) states the resident swung at her, and then she grabbed the resident arm to keep her from hitting her. The resident has dementia and is confused. She was unable to answer questions about the injury. The investigation determined that the allegations were substantiated and the CNA was terminated. " During a phone interview on 8/4/11 at 10:40 a.m., with NA #7, she stated, " I went to help NA #8 put Resident #8 to bed. " NA #7 further stated, " I started to put on (Resident #8 ' s) night gown, and the resident hit me. I caught her hand and held it for while, and I told her not to hit me. I was not verbally abusive to her. I did not tell my supervisor because I do not think it was important. " NA #7 further stated that, she worked 7/18/11 and 7/19/11, but Resident #8 was not assigned to her. She added, " I only had her that night because I went to help (NA #8). " During an interview on 8/4/11 at 11:00 a.m., with the DON, she stated that the alleged abuse occurred on 7/17/11. " The aide put a note under my office door. The DON further stated that " the note stated that one aide was assisting another aide with getting a resident to bed. The resident became combative, and the accused aide became physically and verbally abusive to the resident. The DON added that on 7/19/11, " I assessed the resident for any bruising secondary to alleged abuse. I completed a full-body assessment: no bruising was found. I assessed the left upper shoulder, both arms, no bruising or redness was noted. The DON further stated that " I substantiated the allegation because the aide who allegedly physically and verbally abused (Resident #8) told me that when the resident became combative she held the resident ' s hand for a while and she also made a statement that ' that type of resident does not belong in this facility. ' " That statement is consistent with the witness ' s statement. During an interview on 8/11/11 at 10:05 a.m., with NA #8 who witnessed the abuse, she stated that on 7/17/11, " a little after dinner I requested help from (NA #7). We lifted Resident #8 from her chair to the bed with the lift. The resident became combative. The resident hit (NA #7), and (NA#7) grabbed the resident ' s shoulder and punched her in the shoulder and held the resident ' s arm in a restrained position. She looked at the resident and told her that she ' does not belong in the facility ' ; she ' belongs to a mental institution. ' I went outside and I did not see the supervisor; someone said she went to get meds (medications). On 8/2/11 at 10:56 a.m., the facility Interim Administrator and the Director of Nursing were notified of the Immediate Jeopardy. An acceptable allegation of compliance was provided by the facility on 8/4/11 at 5:45p.m. Credible Allegation of Compliance The following plan of action outline immediate interventions taken by the Center to abate any further concerns surrounds the above issue: Specific Residents Identified Resident (#2) was assessed by Director of Nursing Services (DNS) on 5/17/11 to have a bruise on chest with no other findings and documented on skin assessment sheet. CNA, (NA #1), was suspended on 5/18/11 pending investigation. A 24 hour report was completed on 5/17/11 and sent to Health Care Personnel Registry by Director of Nurses. 5 day investigation report completed on 5/24/11 and sent to Health Care Personnel Registry by Director of Nurses. CNA, (NA#1) was terminated post investigation on 5/24/11. Resident physician was notified on 5/17/11 with no change in orders. Family was notified on 5/17/11 by DNS. Nursing Management completed a center wide full body assessment on all residents in house on 8/3/11 and no identified injuries of unknown origin were found. Re-education of the staff was completed following the abuse allegation of Resident (#2) on 5/26/11, 5/31/2011 and 6/1/2011 by the Director of Nursing Services. 109 staff members attended. Re-education included types of abuse, who abuse is reported to, timeline for reporting, how to care for residents that resist care and how to let an agitated resident have time to calm and then re-approach in an appropriate timeline. CNA (NA#2) received a final written warning regarding failure to report alleged abuse immediately on 5/21/11 and was re-educated on reporting and abuse policy and procedures. The RD was suspended on 8/2/11 pending further investigation. Licensed nurse, (SN#1) was suspended on 8/3/11 pending further investigation. CNA (NA#9) was suspended on 8/4/11 pending further investigation. On 7/19/11 an allegation of abuse was found on a written note under the Director of Nursing ' s door at approximately 3:15pm by the Director of Nursing. The actual event allegedly occurred on 7/17/11 which resulted in the center submitting a late report of alleged abuse. Upon report, investigation and re-education of staff was started immediately. The alleged abuse of Resident (#8) was assessed for injuries with no finding of physical injury on 7/19/11 by Director of Nurses. The alleged CNA, (NA#7) was suspended on 7/20/11 pending investigation. The 24 hour report was sent to Health Care Personnel Registry on 7/20 by the Director of Nursing. CNA (NA#7) was terminated post investigation on 7/25/11 for abuse. The 5 day investigation report was completed and sent to the Health Care Personnel Registry on 7/27/11 by the Director of Nursing validating abusive behavior. CNA (NA#8) was suspended on 7/19/11 pending investigation and was terminated on 7/25/11 for not reporting abuse timely. Re-education of all facility staff was started on 8/3/11 and included types of abuse, who abuse is reported to, timeline for reporting, how to care for residents that resist care and how to let an agitated resident have time to calm and then re-approach in an appropriate timeline. This education was conducted by the Director of Nursing Services or designee; employees who were not scheduled will complete re-education prior to returning to work. 126 employees have been re-educated on the abuse, neglect and misappropriation policy and procedure as of 8/3/11. The re-education also includes where the phone numbers are posted for the Administrator, Director of Nurses, the Sun Quality Compliance number and the contact information for the Regional Human Resources for immediate reporting of the abuse should the caller want to remain anonymous. The contacts are available 24/7. Re-education is on-going and staff must attend prior to being allowed to return to work. Residents will be interviewed for any allegation of abuse beginning 8/4/11 and ongoing during daily ambassador rounds by department heads. Ambassador rounds have been in place for the last year but have not encompassed all of the components issues we will be implementing going forward from this date. The department heads will be assigned specific rooms to make rounds and interview residents so all residents will be interviewed/monitored. Non-interviewable residents ' family members will be interviewed as they are in the center and room-mates will be questioned as appropriate. The ambassador rounds questions include: have you been mistreated by staff and do you have concerns regarding missing property. Any concerns/allegations will be reported immediately to the Administrator/designee with investigation starting immediately. Ambassador rounds findings will be reviewed at the morning meeting with the department heads and Administrator present. Administrator will assure that concerns have been delegated to the appropriate staff for interventions and solutions. Trends will be monitored monthly at the Performance Improvement meeting. The Director of Social Work and the Director of Nursing will complete random interviews with 5 staff members on all shifts weekly x 4 weeks, questions will include types of abuse, where phone numbers are posted, who is the abuse coordinator and reporting of abuse immediately. Re-education of staff on the abuse policy that will also address residents that resist care will be completed weekly for one month then monthly times 3 months. The Credible allegation was validated via interviews with 3 licensed nurses, Director of Social Work, housekeeping staff and 8 nursing assistants that were on duty on 8/4/11 during the second shifts. 2) Record review of the in-services on types of abuse; who the abuse is reported to; timeline for reporting abuse; how to care for residents that resist care; were reviewed for all employees (not just nursing employees, all other disciplines as well - 126 signatures were recorded on the in-service records), 3) Staff abuse interviews including staff verification of recent abuse in-service on 8/3/11. 4) Record review of the facility ' s QI committee meeting dates and members attending. Validation was also accomplished via review of the records of all residents who received full body assessment on 8/3/11.

Based on resident observations, staff interviews and record review, the facility failed to immediately report allegations of abuse for 2 of 2 residents (Residents #2 and #8) and failed to report to the state agency within the 24 hour and five day timeframe. Findings include: Immediate jeopardy began on 5/11/11 with Resident #2 and was identified on 8/3/11 at 10:56 a.m. for Residents #2 and #8. Immediate Jeopardy was removed on 8/4/11 at 7p.m. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. 1. Resident #2 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The healthcare personnel registry 24-hour initial report dated 5/17/11 read in part, " (resident ' s initial ) incident date: 5/11/11, allegation description: allegation made that employee (NA#1) forced resident to sit down forcefully pushing resident in chest with hands. " The healthcare personnel registry 5-day report dated 5/24/11, read in part, " Witness stated that on 5/11/11, she witnessed CNA (NA#1) in resident ' s face hollering at him, and then she jerked him down by pulling on his upper arm. When the resident stood back up, she pushed him down with both hands on his chest. On 5/12/11, the CNA (NA#1) taking care of the resident reported to the nurse that the resident had a bruise on his chest from sternum to breast line. After speaking with the witness, the accused CNA (NA#1), CNAs on the hall, and hall nurses, it was determined that the allegation was substantiated and the accused CNA was terminated. The resident had a bruise to chest and no other injuries. Resident has advanced dementia and does not recall incident. The accused CNA (NA#1) was suspended during the investigation, and after completion she was then terminated. " During a phone interview on 8/2/11 at 12:30 p.m. with NA #2 (the aide who witnessed the alleged abuse) she stated that " (Resident #2) (name of the resident) used to be on the 500 Hall and he was moved to the 300 Hall. While he was on the 300 Hall, he became combative and disoriented. On 5/11/11 while breakfast was going on, I heard fussing in his room. I pushed the door and saw (NA #1) in the resident ' s face hollering and telling him to sit down. The resident stood up and she pulled him down by his upper arm. The resident immediately stands back up and she pushed him down forcefully with the palm of both hands. She pushed him hard enough that the wheelchair rolled back against the wall. (NA #1) saw me and shoved the door in my face. I went to (the Director of Nursing ' s (DON)) office crying. I attempted to tell her, but SN #1 came into the DON ' s office and started to accuse me of not giving care to my residents. I left the office (without telling the DON of what happened) and I saw the registered dietitian and I told her about the abuse that I saw. She told me that I should tell my supervisor. NA #2 added, " I told (name of the family member), and she took pictures of the bruise. " During an interview on 8/2/11 at 10:00 a.m. with SN #1, who was assigned to the resident the day of the alleged abuse and was the first staff nurse the bruise was reported to, stated that " (NA #1) went to do care on (Resident #2) and she came and got me immediately and showed me the bruise on (Resident #2 ' s) chest. It was a large black and purplish bruise covering one nipple to another nipple. I reported it to the nurse supervisor. She told me not to worry about it because she was going to put it in the incident report relating it to one of his falls. I do not normally document until the end of the shift and I forgot to document the bruise on resident #2 ' s chest. I never assessed (name of the resident), because that is not my job; that is my supervisor ' s job. " During a phone interview on 8/2/11 at 12:00 noon with NA #1, who allegedly caused the bruising to Resident #2's chest, she stated that " the director of nursing called me at home on 5/17/11 and told me that I should make an appointment to come and see her at 3:30 p.m. on 5/18/11, because someone made an allegation about me on 5/11/11. I told her that I did not do care on the resident on 5/11/11. On 5/12/11 at 11:00 a.m., I took the resident ' s shirt off to do a.m. care, and I saw a large, black-purplish bruise all over his chest, from one nipple to another, going down into his upper stomach. I went and got my supervisor (Staff Nurse (SN) #1), and she came and look(ed) at it, and she got the nursing supervisor. She further stated, " They call me back on May 24th and substantiated the investigation and let me go. " When asked by the surveyor what happened on 5/11/11, she stated that nothing happened. During an interview on 8/2/11 at 10:30 a.m. with the nurse supervisor, she stated that about the first week in May- " I do not know the date-(name of the resident) had the large bruise on his chest. I waited to document it because he had multiple falls. We (everyone in the facility) thought the bruise was from one of his falls. I did not look at the bruise. I did not assess him. A week later, the aide (NA #2) came forward and told us that (NA #1) pushed the resident in his chest. During the investigation, we found out that when (SN #1) found the bruise, she did not put any nursing notes in the chart and she did not assess the resident. I never saw the bruise on the resident ' s chest. From what I heard, it was a large bruise. " She further stated that injuries from unknown origin must be investigated immediately, or when a staff member notes a new injury such as bruising to the resident, the supervisor should be notified. An incident report is filled out and the resident is assessed. The floor supervisor also documents the incident in the chart. The nurse notifies the medical doctor and the family. She further added that this reporting procedure was not followed for the resident, because around that time he had multiple falls, on 4/17, 5/8/, 5/9, and 5/11, and no injuries were found. During an interview on 8/2/11 at 11:00 a.m. and again on 8/4/11 at 11:30 a.m. with the Director of Nursing (DON), she stated that the resident was moved on 4/29/11 to the 300 Hall. Upon being moved, the resident became very agitated, more verbally abusive, and loud, so he was moved back to the 500 Hall on 5/12/11. The DON stated " it was reported to me on 5/17/11 by (NA #2) that (NA #1) abused Resident #2. " She further stated that on 5/11/11 while NA #1 was providing care to Resident #2, NA #2 heard " fussing " in Resident #2 ' s room; NA #2 entered the room and saw NA #1 forcefully push the resident down in the wheelchair by pulling on his upper arm. The DON further stated that NA #2 reported that when the resident stood back up, the aide pushed him down in his wheelchair with both hands and the wheelchair rolled into the wall. The DON further stated that on 5/17/11, " I assessed the resident and he had a purplish-yellowish large bruise at the center of his chest from one nipple to another nipple; no other bruises or redness was noted. The resident denied pain. I immediately completed a 24-hr report, faxed it to the healthcare registry, and started the investigation. " The DON further stated that the resident had a fall on 5/11/11 and the incident report stated he fell on his bottom with no injury. She added, " When I assessed the resident on 5/17/11, the bruise was from nipple to nipple, large, and encompassed the entire chest. It was impossible for the resident to fall on his bottom and sustain a bruise to his chest. " The DON stated that " I felt (NA #1) had hit the resident willfully and put him in the chair. " When asked by the surveyor what evidence she used to substantiate the abuse allegation, the DON stated, " I had noticed earlier in the week that (NA #1) had spoken loudly to (Resident #2), out in the hallway, and I came out of my office when I heard the disturbance and asked (NA #1) if everything was ok. (NA #1) stated, ' everything is fine; I ' m just frustrated. ' " When asked what the DON had done about NA#1 behavior she indicated she offered to move the aide off Hall 300 and/or change the assignment. NA #1 told her she would be off the next day and everything was fine. A review of the facility ' s daily staffing revealed NA #1 and NA #2 were assigned and worked on the 300 Hall on 5/11/11 during the 7-3 shift. A review of the facility ' s daily staffing revealed NA #1 worked on the 300 Hall on 5/12/11 during the 7-3 shift. (NA#2 was not assigned to resident #2 but as a CNA team leader she had access to resident #2). A review of the facility ' s daily staffing revealed NA #1 worked on the 300 Hall on 5/16/11 during the 7-3 shift. (NA#2 was not assigned to resident #2 but as a CNA team leader she had access to resident #2). A review of the facility ' s daily staffing revealed that NA #1 worked on the 300 Hall on 5/17/11 during the 7-3 shift. (NA#2 was not assigned to resident #2 but as a CNA team leader she had access to resident #2). During an interview on 8/2/11 at 2:30 p.m. with the Registered Dietician (RD), she stated, " I remember I saw (NA #2) very upset sometime in May, and she mentioned something about someone roughing a resident, and I directed her to her supervisor. I thought everything was resolved. I did not follow up on it. " During an interview on 8/4/11 at 12:20 p.m. with SN #3, she stated that " the day after (Resident #2) came back to Hall 500 (5/13/11), at about 8:00 a.m. during my medication pass; I reported to the DON that (Resident #2) had a large bruise on his chest. SN #3 added that NA #6 (the aide who was assigned to Resident #2) called me to the resident ' s room and showed the bruise on the resident ' s chest. " It was brought to SN #3 ' s attention that the DON was not in the building on May 13. SN #3 insisted that the DON accompany her to the resident ' s room and look at the bruise and that (NA #6) (the aide assigned to the resident) witness the DON ' s observation. During an interview on 8/4/11 at 1:00 p.m. with SN #3, she stated " the bruise was purple and black, and there was no yellow. There were no marks on his abdomen, just the lower ribs and up. " SN #3 indicated " I really wanted someone to see this bruise, because I did not want it to come back on me. " SN #3 further indicated that she documented the bruise, and " all of my documentation was missing out of the record. " SN #3 added that she had received abuse training during orientation and several times since the allegation. She further stated that they were required to do the in-service training on the computerized training program. SN #3 stated that abuse allegations should be reported to the supervisor "just as soon as possible." During an interview on 8/4/11 at 1:16 p.m., the administrator stated he was an interim administartor and he was not here when the alleged allegation took place. He added that he has zero tolerance for abuse in the facility, and he expected an incident report to be completed immediately when an allegation of abuse or injury of unknown origin was made. He further added that any staff who allegedly abused a resident must leave the premises as soon as their statement was obtained. A 24-hour report is to be filled out immediately. The facility then has up to 5 days to complete an investigation.The administrator indicated that training files should be reviewed. A head-to-toe assessment was to be completed on the resident as soon as an allegation was made. If the allegation was made to the nurse, then she will conduct the assessment. During an interview on 8/4/11 at 5:13 p.m., the DON stated that her expections are that the nurse on the hall immediately inform her or the charge nurse of any allegations. The nurse should call the doctor and document the allegation in the nurse's notes. If the nurse is busy, she can tell the supervisor, administrator, or DON. An incident report should be filled out. If the allegation is made after an employee has gone home, the employee should be called and suspended. If the allegation is made during the employee's working hours, the employee is called into the office, where the employee is to write a statement. The employee is subsequently suspended with pay pending the outcome of an investigation. The facility has 24 hours to send in the initital report to the state agency and 5 days to complete the investigation. 2. Resident #8 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the note that NA # 8 (the witness of the abuse) left under the Director of Nursing ' s (DON) door dated 7/17/11 read, " on July 17, 2011, I worked on the 100 Hall with (name of the aide (NA#7)). We were in (Resident #8 ' s) room. (Resident #8) became combative and hit (name of the aide), then (name of the aide) grabbed (Resident #8 ' s) arm and punched her left upper arm and held her hands down. The healthcare personnel registry 24-hour initial report dated 7/20/11 read in part, " allegation description: CNA (NA# 8) reported that on Sunday 7/17/11 she worked with the accused CNA (NA# 7). She (NA#8) stated the accused CNA hit a resident in the shoulder while providing care. She also states that the accused CNA told the resident she did not belong in this facility, that she belongs in mental institution. " The healthcare personnel registry 5-day report dated 7/27/11 read in part, " the CNA who was in the room with the accused CNA at the time of the incident stated that while putting the resident to bed, the resident became combative. When this happened, the CNA stated that the accused CNA hit the resident in the arm and grabbed her hand. The accused CNA stated that while putting the resident to bed, she (the resident) became combative. She (NA#7) states the resident swung at her, and then she grabbed the resident arm to keep her from hitting her. The resident has dementia and is confused. She was unable to answer questions about the injury. The investigation determined that the allegations were substantiated and the CNA was terminated. " During a phone interview on 8/4/11 at 10:40 a.m., with NA #7, she stated, " I went to help NA #8 put Resident #8 to bed. " NA #7 further stated, " I started to put on (Resident #8 ' s) night gown, and the resident hit me. I caught her hand and held it for while, and I told her not to hit me. I was not verbally abusive to her. I did not tell my supervisor because I do not think it was important. " NA #7 further stated that, she worked 7/18/11 and 7/19/11, but Resident #8 was not assigned to her. She added, " I only had her that night because I went to help (NA #8). " During an interview on 8/4/11 at 11:00 a.m., with the DON, she stated that the alleged abuse occurred on 7/17/11. " The aide put a note under my office door. I was in Raleigh the following Monday (7/18/11), and it was not until late Tuesday evening (7/19/11) that I saw the note under a pile of papers on my desk. " The DON further stated that " the note stated that one aide was assisting another aide with getting a resident to bed. The resident became combative, and the accused aide became physically and verbally abusive to the resident. I suspended the aide on 7/20/11 because she was off on (7/19/11) pending the investigation, but she worked that Monday (7/18/11). I immediately suspended the other aide for not reporting the verbal and physical abuse immediately. " The DON further stated that " the aide who put the note under my door had just attended mandatory abuse training and completed the abuse procedure (the company ' s online abuse training program) on 5/26/11, with a 100% score. " The DON added that any alleged abuse has to be reported immediately. The DON further added that the abuse of the resident was not reported or investigated timely, " because we did not know. " The DON added that on 7/19/11, " I assessed the resident for any bruising secondary to alleged abuse. I completed a full-body assessment: no bruising was found. I assessed the left upper shoulder, both arms, no bruising or redness was noted. I immediately completed a 24-hr report and faxed it to the healthcare registry, and started the investigation. I faxed the 5-day investigation. I knew according to policy they were late, but we did not know of the abuse allegation because we (she and the administrator) were in Raleigh that Monday, and we encouraged the staff to report alleged abuse immediately to their supervisors. " The DON further stated that " I substantiated the allegation because the aide who allegedly physically and verbally abused (Resident #8) told me that when the resident became combative she held the resident ' s hand for a while and she also made a statement that ' that type of resident does not belong in this facility. ' " That statement is consistent with the witness ' s statement. During an interview on 8/11/11 at 10:05 a.m., with NA #8 who witnessed the abuse, she stated that on 7/17/11, " a little after dinner I requested help from (NA #7). We lifted Resident #8 from her chair to the bed with the lift. The resident became combative. The resident hit (NA #7), and (NA#7) grabbed the resident ' s shoulder and punched her in the shoulder and held the resident ' s arm in a restrained position. She looked at the resident and told her that she ' does not belong in the facility ' ; she ' belongs to a mental institution. ' I went outside and I did not see the supervisor; someone said she went to get meds (medications). There was a nurse on the floor but I do not trust that nurse. So I wrote a note and put it under (DON ' s) door. I was terminated because I did not report it to my supervisor. I know the chain of command, but the supervisors do not do anything when you report anything to them. During an interview on 8/4/11 at 1:16 p.m., the administrator stated he was an interim administartor and he was not here when the alleged allegation took place. He added that he has zero tolerance for abuse in the facility, and he expected an incident report to be completed immediately when an allegation of abuse or injury of unknown origin was made. He further added that any staff who allegedly abused a resident must leave the premises as soon as their statement was obtained. A 24-hour report is to be filled out immediately. The facility then has up to 5 days to complete an investigation.The administrator indicated that training files should be reviewed. A head-to-toe assessment was to be completed on the resident as soon as an allegation was made. If the allegation was made to the nurse, then she will conduct the assessment. On 8/2/11 at 10:56 a.m., the facility Interim Administrator and the Director of Nursing were notified of the Immediate Jeopardy. An acceptable allegation of compliance was provided by the facility on 8/4/11 at 5:45p.m. Credible Allegation of Compliance Resident (#2) was assessed by Director of Nursing Services (DNS) on 5/17/11 to have a bruise on chest with no other findings. CNA, (NA#1), was suspended on 5/18/11 pending investigation. A 24 hour report was completed on 5/17/11 and sent to Health Care Registry by Director of Nurses. 5 day investigation report completed on_5/24/11 and sent to Health Care Personnel Registry by Director of Nurses. CNA, (NA#1), was terminated post investigation on 5/24/11. Nursing Management completed a center wide full body skin assessment on all residents in house on 8/3/11 and identified no injuries of unknown origin. Appropriate reporting of bruising was included in all stated in-servicing related to abuse and neglect reporting. This in-service included all staff and as of 8/3/11 126 staff members have been in-serviced. Re-education of the staff was completed following the abuse allegation of Resident (#2) on 5/31/2011 and 6/1/2011 by the Director of Nursing Services. Re-education of all facility staff included types of abuse, who abuse is reported to, timeline for reporting, how to care for residents that resist care and how to let an agitated resident have time to calm and then re-approach in an appropriate timeline. CNA (NA#2) received a final written warning regarding failure to report alleged abuse immediately on 5/21/11 and was re-educated on reporting and abuse policy and procedures. The RD was suspended on 8/2/11 pending further investigation. Licensed nurse, (SN#1) was suspended on 8/3/11 pending further investigation. CNA (NA#9) was suspended pending further investigation. All nurses will be re-educated on doing weekly skin assessments as assigned. The Director of Nursing Service or designee will validate weekly skin assessments by completing random skin assessments on residents who were identified to have no skin integrity concerns by the licensed nurse. These validations will be completed on all shifts for 2 residents per shift per day for total of 6 residents per day x 4 weeks. The Credible allegation was validated via interviews with 3 licensed nurses, Director of Social Work, housekeeping staff and 8 nursing assistants that were on duty on 8/4/11 during the second shifts. 2) Record review of the in-services on types of abuse; who the abuse is reported to; timeline for reporting abuse; how to care for residents that resist care; were reviewed for all employees (not just nursing employees, all other disciplines as well - 126 signatures were recorded on the in-service records), 3) Staff abuse interviews including staff verification of recent abuse in-service on 8/3/11. 4) Record review of the facility ' s QI committee meeting dates and members attending. Validation was also accomplished via review of the records of all residents who received full body assessment on 8/3/11.

Based on resident interviews, staff interviews, record review, and facility policy review, the facility failed to implement their policies and procedures to report, investigate, and protect 2 of 2 residents from alleged physical and verbal abuse. (Resident #2 and #8). Immediate jeopardy began on 5/11/11 with Resident #2 and was identified on 8/3/11, at 10:56 a.m. for Residents #2 and #8. Immediate Jeopardy was removed on 8/4/11 at 7 p.m when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems is put in place and completion of employee training. Findings include: The facility policy dated January 2008, page 2 of 5, titled, "Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, " reads in part: POLICY STATEMENT It is the center policy that every reasonable effort within its control is taken to prevent the mistreatment, neglect, and abuse of residents and misappropriation of resident property. Staff must not engage in nor permit anyone else to engage in verbal, mental or physical abuse, neglect, mistreatment, or misappropriation of resident property. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, visitors, legal guardian, friends, or other individuals. PROTECTION The administrator or his/her designee investigates allegations of abuse, takes action to protect the resident during the investigation, and implements corrective action depending on the results of the investigation. The administrator/designee shall suspend all employees suspected of abuse pending the outcome of the investigation. PREVENTION The department Heads/designee educates staff on strategies to identify, corrects, and intervenes in situations in which abuse, neglect, or misappropriation of resident property is more likely to occur. IDENTIFICATION The administrator/designee identifies events such as suspicious bruising of resident, occurrences, pattern, and trends that may constitute abuse; and to determine the direction of the investigation. REPORTING The administrator or his/her designee reports alleged violations and substantiates incidents to the state agency and to all other agencies as required. INVESTIGATION The administrator or his/her designee investigates allegations of abuse, neglect, misappropriation of resident property, identifies staff member responsible for initial reporting, investigation of alleged violation and reporting of results to the proper authorities. 1. Resident #2 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #2 ' s Admission Minimum Data Set ((MDS) dated [DATE], revealed he had short/long-term memory problems. The resident ' s decision-making skills were moderately impaired. He had noted signs and symptoms of [MEDICAL CONDITION] present, which fluctuates, [MEDICAL CONDITION], and other behavioral symptoms not directed to others. Review of the Healthcare Personnel Registry 24-hour initial report dated 5/17/11 read in part, " (resident ' s initial ) incident date: 5/11/11allegation description: allegation made that employee (NA #1) forced resident to sit down forcefully pushing resident in chest with hands. " Review of the Healthcare Personnel Registry 5-day report dated 5/24/11, read in part, " Witness stated that on 5/11/11, she witnessed CNA (NA #1) in resident ' s face hollering at him, and then she jerked him down by pulling on his upper arm. When the resident stood back up, she pushed him down with both hands on his chest. On 5/12/11, the CNA (NA #1) taking care of the resident reported to the nurse that the resident had a bruise on his chest from sternum to breast line. After speaking with the witness, the accused C.NA (NA#1) on the hall, and hall nurses, it was determined that the allegation was substantiated and the accused CNA was terminated. The resident had a bruise to chest and no other injuries. Resident has advanced dementia and does not recall incident. The accused CNA (NA #1) was suspended during the investigation, and after completion she was the terminated. " During a phone interview on 8/2/11 at 12:30 p.m., NA #2 (the aide who witnessed the alleged abuse) she stated " On 5/11/11 while breakfast was going on, I heard fussing in his room. I pushed the door and saw (NA #1) in the resident ' s face hollering and telling him to sit down. The resident stood up and she pulled him down by his upper arm. The resident immediately stands back up and she pushed him down forcefully with the palm of both hands. She pushed him hard enough that the wheelchair rolled back against the wall. NA #1 (name of the aide who allegedly abused the resident) saw me and shoved the door in my face. I went to (the Director of Nursing ' s DON) office crying. I attempted to tell her, but SN #1 came into the DON ' s office and started to accuse me of not giving care to my residents. I left the office and I saw the registered dietitian and I told her about the abuse that I saw. She told me that I should tell my supervisor. I was afraid to tell my supervisor, because my supervisor and NA #1 are very good friends ,and I was afraid she would have me fired. " NA #2 added, " I told (name of the family member), and she took pictures of the bruise. " During an interview on 8/2/11 at 10:00 a.m. with SN #1, who was assigned to the resident the day of the alleged abuse and who worked on the hall and was the first staff nurse the bruise was reported to, stated NA #1 went to do care on Resident #2 and she came and got me immediately and showed me the bruise on Resident #2 ' s chest. It was a large black and purplish bruise covering one nipple to another nipple. I reported it to the nurse supervisor. I do not normally document until the end of the shift and I forgot to document what I saw. I never assessed (name of the resident), because that is not my job; that is my supervisor ' s job. " During an phone interview on 8/2/11 at 12:00 noon with NA #1, who allegedly caused the bruising to Resident #2's chest, she stated that " the director of nursing called me at home on 5/17/11 and told me that I should make an appointment to come and see her at 3:30 p.m. on 5/18/11, because someone made an allegation about me on 5/11/11. I told her that I did not do care on the resident on 5/11/11. On 5/12/11 at 11:00 a.m., I took the resident ' s shirt off to do a.m. care, and I saw a large, black-purplish bruise all over his chest, from one nipple to another, going down into his upper stomach. I went and got my supervisor (Staff Nurse (SN) #1), and she came and look(ed) at it, and she got the nursing supervisor I worked with him until about May 17th. I gave him care because I work all the halls. " She further stated, " They call me back on May 24th and substantiated the investigation and let me go. " When asked by the surveyor what happened on 5/11/11, she stated that nothing happened. During an interview on 8/2/11 at 10:30 a.m. with the nurse supervisor, she stated that about the first week in May-I do not know the date-(name of the resident) had the large bruise on his chest. I waited to document it because he had multiple falls. We (everyone in the facility) thought the bruise was from one of his falls. I did not look at the bruise. I did not assess him. A week later, the aide (NA #2) came forward and told us that (NA #1) pushed the resident in his chest. During the investigation, we found out that when SN #1 found the bruise, she did not put any nursing notes in the chart and she did not assess the resident. " She further stated that injuries from unknown origin must be investigated immediately, or when a staff member notes a new injury such as bruising to the resident, the supervisor should be notified. An incident report is filled out and the resident is assessed. The floor supervisor also documents the incident in the chart. The nurse notifies the medical doctor and the family. She further added that this reporting procedure was not followed for the resident. During an interview on 8/2/11 at 11:00 a.m. with the Director of Nursing (DON), she stated that " it was reported to me on 5/17/11 by (NA #2) (the aide who witnessed the alleged abuse) that (NA #1) abused Resident #2. " She further stated that on 5/11/11 while NA #1 was providing care to Resident #2, NA #2 heard " fussing " in Resident #2 ' s room; NA #2 entered the room and saw NA #1 forcefully push the resident down in the wheelchair by pulling on his upper arm. The DON further stated that NA #2 reported that when the resident stood back up, the aide pushed him down in his wheelchair with both hands and the wheelchair rolled into the wall. The DON further stated that on 5/17/11, " I assessed the resident and he had a purplish-yellowish large bruise at the center of his chest from one nipple to another nipple; no other bruises or redness was noted. The resident denied pain. I immediately completed a 24-hr report, faxed it to the healthcare registry, and started the investigation. " The DON further stated that, NA #1 was a team leader for the CNAs and she did not have to be assigned to Resident #2 ' s hall in order to have contact with him. She may just answer the resident ' s light or assist another aide giving care. DON added that NA#1 worked several days after 5/11/11. A review of the facility ' s daily staffing revealed NA #1 and NA #2 worked on the 300 Hall on 5/11/11 during the 7-3 shift. A review of the facility ' s daily staffing revealed NA #1 worked on the 300 Hall on 5/12/11 during the 7-3 shift. A review of the facility ' s daily staffing revealed NA #1 worked on the 300 Hall on 5/16/11 during the 7-3 shift A review of the facility ' s daily staffing revealed that NA #1 worked on the 300 Hall on 5/17/11 during the 7-3 shift. The DON further stated that " on Wednesday (5/11/11), I was present in the building and NA #2 came into my office upset and crying. I asked what was wrong, and she stated, ' those people on the 300 Hall are mean. ' I asked her what she meant by that. At the same time, SN #1 opened my office door and walked in. I asked her what was going on, on the hall. (SN #1) stated that ' all she did was to tell (NA #2) that a resident said she had not received her bath yet. ' (NA #2) stated the resident was given her bath before breakfast, and she left the office. " The DON stated that she had a discussion with SN #1 concerning the manner in which she speaks to the staff. During an interview on 8/4/11 at 11:30 a.m. with the DON, she stated that " I felt NA #1 had hit the resident willfully and put him in the chair. " She further added, " The nurse who did not report it (SN #1) was given a final warning. All decisions go through corporate HR (Human Resources). " The DON stated that the staff completed abuse in-service online after 5/17/11. During an interview on 8/4/11 at 12:20 p.m. with SN #3, she stated that " the day after Resident #2 came back to Hall 500 (5/13/11), at about 8:00 a.m. during my medication pass; I reported to the DON that Resident #2 had a large bruise on his chest. SN #3 added that NA #6 (the aide who was assigned to Resident #2) called me to the resident ' s room and showed the bruise on the resident ' s chest." It was brought to SN #3 ' s attention that the DON was not in the building on May 13. SN #3 insisted that the DON accompanied her to the resident ' s room and looked at the bruise and that NA #6 (the aide assigned to the resident) witnessed the DON ' s observation. During an interview on 8/4/11 at 5:13 p.m., the DON stated that her expections are that the nurse on the hall immediately inform her or the charge nurse of any allegations. The nurse should call the doctor and document the allegation in the nurse's notes. If the nurse is busy, she can tell the supervisor, administrator, or DON. An incident report should be filled out. If the allegation is made after an employee has gone home, the employee should be called and suspended. If the allegation is made during the employee's working hours, the employee is called into the office, where the employee is to write a statement. The employee is subsequently suspended with pay pending the outcome of an investigation. The facility has 24 hours to send in the initital report to the state agency and 5 days to complete the investigation. 2. Resident #8 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #8 ' s minimum data set ((MDS) dated [DATE] revealed she had short/long-term memory problems. The resident ' s decision-making skills were moderately impaired. She had noted signs and symptoms of [MEDICAL CONDITION] present, which fluctuates, and physical and verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed to others. A review of the note that NA # 8 (the witness of the abuse) left under the Director of Nursing ' s (DON) door dated 7/17/11 read, " on July 17, 2011, I worked on the 100 Hall with (name of the aide). We were in (Resident #8 ' s) room. (Resident #8) became combative and hit (name of the aide), then (name of the aide) grabbed (Resident #8 ' s) arm and punched her left upper arm and held her hands down." A review of the healthcare personnel registry 24-hour initial report dated 7/20/11 read in part, " allegation description: CNA (NA# 8) reported that on Sunday 7/17/11 she worked with the accused CNA (NA# 7). She stated the accused CNA hit a resident in the shoulder while providing care. She also states that the accused CNA told the resident she did not belong in this facility, that she belongs in mental institution. " A review of the healthcare personnel registry 5-day report dated 7/27/11 read in part, " the CNA who was in the room with the accused CNA at the time of the incident stated that while putting the resident to bed, the resident became combative. When this happened, the CNA stated that the accused CNA hit the resident in the arm and grabbed her hand. The accused CNA stated that while putting the resident to bed, she (the resident) became combative. She states the resident swung at her, and then she grabbed the resident arm to keep her from hitting her. The resident has dementia and is confused. She was unable to answer questions about the injury. The investigation determined that the allegations were substantiated and the CNA was terminated. " During a phone interview on 8/4/11 at 10:40 a.m., with NA #7, she stated, " I went to help (NA #8) put (Resident #8) to bed. " NA #7 further stated, " I started to put on (Resident #8 ' s) night gown, and the resident hit me. I caught her hand and held it for while, and I told her not to hit me. I was not verbally abusive to her. I did not tell my supervisor because I do not think it was important. " NA #7 further stated that, she worked 7/18/11 and 7/19/11, but Resident #8 was not assigned to her. She added, " I only had her that night because I went to help (NA #8). " During an interview on 8/4/11 at 11:00 a.m., with the DON, she stated that the alleged abuse occurred on 7/17/11. The aide put a note under her office door. The DON further stated that " the note stated that one aide was assisting another aide with getting a resident to bed. The resident became combative, and the accused aide became physically and verbally abusive to the resident. I suspended the aide on 7/20/11 because she was off on (7/19/11) pending the investigation, but she worked that Monday (7/18/11). I immediately suspended the other aide for not reporting the verbal and physical abuse immediately. " The DON added that on 7/19/11, " I assessed the resident for any bruising secondary to alleged abuse. I completed a full-body assessment: no bruising was found. I assessed the left upper shoulder, both arms, no bruising or redness was noted. I immediately completed a 24-hr report and faxed it to the healthcare registry, and started the investigation. I faxed the 5-day investigation. I knew according to policy they were late, but we did not know of the abuse allegation because we (she and the administrator) were in Raleigh that Monday, and we encouraged the staff to report alleged abuse immediately to their supervisors." The DON further stated that " I substantiated the allegation because the aide who allegedly physically and verbally abused Resident #8 told me that when the resident became combative she held the resident ' s hand for a while and she also made a statement that ' that type of resident does not belong in this facility. ' " That statement was consistent with the witness ' s statement. During an interview on 8/11/11 at 10:05 a.m., with the NA #8 who witnessed the abuse, she stated that on 7/17/11, " a little after dinner I requested help from (NA #7, the aide who allegedly physically and verbally abused the resident).We lifted (Resident #8) from her chair to the bed with the Hoyer lift. The resident became combative. The resident hit (NA #7), and (NA#7) grabbed the resident ' s shoulder and punched her in the shoulder and held the resident ' s arm in a restrained position. She looked at the resident and told her that she ' does not belong in the facility ' ; she ' belongs to a mental institution. ' I went outside and I did not see the supervisor; someone said she went to get meds (medications). " On 8/2/11 at 10:56 a.m., the facility Interim Administrator and the Director of Nursing were notified of the Immediate Jeopardy. An allegation of compliance was provided by the facility on 8/4/11 at 5:45p.m. Credible Allegation of Compliance Re-education on reporting abuse, assessing injuries of unknown cause, and care for residents who resist care for all facility staff was started on 8/3/11; all employees must complete re-education prior to returning to work. 126 employees were re-educated as of 8/3/11 and education is on-going. At time of re-education employees are being instructed where the phone numbers are posted for Administrator, Director of Nurses, the Sun Quality Compliance number and the contact information for the Regional Human Resource for immediate reporting of abuse in case the reported would like to remain anonymous. The contacts are available 24/7. All new employees will be educated on the first day of employment by the Director of Nursing Services or designee on abuse, neglect and misappropriation policy prior to contact with residents. The Director of Social Work and the Director of Nursing will do random interviews with 5 staff members on all shifts weekly x 4 weeks, questions will include, types of abuse, where phone numbers are posted, who is the abuse coordinator and reporting abuse immediately. Re-education of staff on the abuse, neglect and misappropriation policy will completed weekly x 4 then monthly x 3 months. Staff burn out will be managed thru schedule management that limits overtime. The Director of Nurses will review the overtime report daily. Beginning September 9, 2011 a new schedule will be implemented that follows a 4 days on 2 days off cycle. Director of Nursing/Supervisors will make daily rounds on all halls to monitor for any signs of burn out by speaking to staff and observing for burn out behavior. Burn out behavior could be identified as, but not limited to: frustration with peers, increased complains by individuals, short abrupt answers to peers, increased call outs, and reporting late to work. If burn out is identified the staff member will be removed from that assignment, encouraged to take time off or may be referred to Human Resources for additional support. Quality Assurance Measures The Center held on Ad hoc Performance Improvement Committee meeting on 8/3/11 at 2:00pm including the Medical Director to discuss the Plan of Correction. Discussion included steps taken to re-educate all staff on the abuse policy, immediate reporting of any allegations of abuse or suspected abuse, and assessment of injuries of unknown origins reported immediately. The Abuse policy and procedure was reviewed with no changes made. The allegation was validated via interviews with 3 licensed nurses, Director of Social Work, housekeeping staff and 8 nursing assistants that were on duty on 8/4/11 during the second shifts. 2) Record review of the in-services on types of abuse; who the abuse is reported to; timeline for reporting abuse; how to care for residents that resist care; were reviewed for all employees (not just nursing employees, all other disciplines as well - 126 signatures were recorded on the in-service records), 3) Staff abuse interviews including staff verification of recent abuse in-service on 8/3/11. 4) Record review of the facility ' s QI committee meeting dates and members attending. Validation was also accomplished via review of the records of all residents who received full body assessment on 8/3/11.