Every finding on record at Skyland Terrace and Rehabilitation

Based on record review and staff interviews, the facility failed to update a care plan to reflect a change of code status for 1 of 18 residents reviewed for care plans (Resident #40).Findings included:Resident #40 was admitted on [DATE] with diagnoses of dementia and epilepsy.Resident #40's care plan was observed on [DATE] and noted as most recently updated on [DATE]. A death with dignity care plan noted Resident #40's wishes included to attempt cardiopulmonary resuscitation (CPR).A progress note written by the Social Worker on [DATE] at 1:27 PM noted Resident #40's family changed the code status to Do Not Resuscitate (DNR).A physician's order for Do Not Resuscitate (DNR) was written on [DATE].Resident #40's comprehensive Minimum Data Set (MDS) dated [DATE] noted he was rarely or never understood.On [DATE] at 2:28 PM during an interview, the SW stated that any new or updated code status forms which were completed would be placed into the physician's notebook for their review and signature. The physician would also write an order for the code status in the resident's chart. The SW confirmed Resident #40's code status was changed from Full Code to DNR on [DATE]. She indicated she did not recall if she had informed the MDS nurses of the change in code status or if it had been discussed in the morning meeting after the order had been written.On [DATE] at 3:45 PM an interview was conducted with MDS Nurse #1 and MDS Nurse #2. Both MDS Nurses stated they were responsible for making updates to the care plans including any code status changes. MDS Nurse #1 stated care plans were reviewed quarterly during the resident's care plan meeting. MDS Nurse #1 explained she was not aware Resident #40's code status had been changed. Both MDS Nurses said they relied on information reported during the morning meeting for any change of orders or resident conditions. They stated they did not recall Resident #40's code status change had been reported. During an interview on [DATE] at 3:16 PM the Administrator stated Resident #40's current code status should be reflected on the care plan. The Administrator explained the care plan should have been updated when Resident #40's code status was changed.

Based on a record review and staff interviews, the facility failed to have a nurse assess a resident who had fallen prior to moving the resident for 1 of 2 residents reviewed for falls (Resident #34). Findings included:Resident #34 was admitted on [DATE] with diagnoses of dementia and heart failure.Resident # 34's annual Minimum Data Set (MDS) dated [DATE] coded her with severe cognitive impairment. She required moderate assistance for transfers. She was coded for having behaviors and falls since her last MDS assessment.Resident #34 was care planned on 1/28/26 for participation in restorative care due to being at risk for falls during transfers and demonstrating poor safety awareness. The care plan included providing moderate assistance during all transfers as an intervention to promote safety. Furthermore, the resident was care planned for a history of physical aggression towards others on 12/1/25. Interventions included to remove the resident from any situation that may be escalating or causing agitation and to assess and anticipate the resident's needs for food, thirst, toileting needs, comfort level, body positioning and pain.A progress note written by Nurse #3 on 2/18/26 at 7:42 AM was reviewed. The note stated that Nurse Aide (NA) #1 notified Nurse #3 that while assisting Resident #34 with dressing and transferring, the resident became combative. NA #1 reported that she had to lower Resident #34 to the floor during the transfer for safety. Upon assessment, Nurse #3 noted no visible deformities and identified a skin tear on the resident's right forearm. Resident #34 reported pain in the right arm. The wound was cleansed, and bandages were applied. Vital signs were obtained and were within normal limits. The provider, Director of Nursing (DON), and the resident's family were notified.NA #1 was interviewed on 2/19/26 at 12:05 PM via phone and confirmed she worked from 11:00 PM on 2/17/26 until 7:00 AM on 2/18/26 (3rd shift). She stated on 2/18/26 she was ending her shift, and she went into Resident #34's room to provide care and dress Resident #34 for the day. NA #1 said she explained to Resident #34 what she was going to do with her. NA #1 said she was able to provide incontinent care with no aggression from the resident. The NA then assisted the resident to the edge of the bed and moved the wheelchair close to the bed in preparation to transfer the resident. She transferred Resident #34 bear hug style while not touching the resident's arms. As NA #1 was lifting the resident from the bed, the resident began to be aggressive with hitting and yelling and NA #1 lowered the resident to the fall mat beside the bed. NA #1 stated she called for help and went to the door of the room and asked NA #2 for help. NA #2 and the NA #3 went into the room and transferred the resident from the fall mat into her wheelchair. NA #1 stated once NA #2 and NA #3 entered the room, she had no further interaction with Resident #34 and let NA #2 handle the incident.NA #2 was interviewed on 2/19/26 at 12:35 PM via phone. The NA stated that on 2/18/26 around 6:45 AM, NA #1 was asking for help outside Resident #34's room. NA #1 told her Resident #34 was hitting her when she was trying to transfer the resident and she had to lower the resident onto the floor. NA #2 and NA #3 went into Resident #34's room and found her sitting on the fall mat with her back against the bed. NA #2 said the resident did not complain of any pain while on the fall mat. NA #3 helped her pick the resident from the mat and place her in the wheelchair. The NA then removed the resident's night gown and found a large skin tear to her right forearm. NA #2 stated she went to get Nurse #3 to look at the skin tear. Furthermore, NA #2 reported that NA #1 told her Resident #34 had been lowered onto the fall mat and that she did not consider this to be a fall. NA #2 stated this was the reason she did not notify the nurse to assess Resident #34 before moving her off the fall mat.On 2/19/26 at 3:29 PM, NA #3 was interviewed via phone. She was with NA #2 on 2/18/26 around 6:45 AM when NA #1 came out of Resident #34's room asking for help. NA #3 stated it was her first shift working at the facility and NA #2 was training her. NA #1 said the resident was fighting her during transfer and she had to set the resident on floor. NA #2 and NA #3 went into Resident #34's room and found the resident sitting on the floor with her back against the bed. NA #3 stated she and NA #2 picked up the resident from the floor and placed her in the wheelchair. Resident #34 was rubbing her right arm while in the chair and then they removed the resident's night gown that revealed a large skin tear to the resident's right forearm. NA #2 then left the room to get Nurse #3 to assess and treat the skin tear. Nurse #3 was unavailable for interview.On 2/18/26 at 4:11 PM the Unit Coordinator was interviewed. She stated Resident #34's incident happened around 6:45 AM on 2/18/26. The Unit Coordinator was informed by Nurse #3, that Resident #34 had a skin tear after NA #1 had to set her on the floor during a transfer. The Unit Coordinator went to Resident #34's room and measured the skin tear. It measured approximately 6.5 centimeters in length.The Administrator was interviewed on 2/19/26 at 2:24 PM. She stated when Resident #34 was lowered to the floor, it was considered a fall. The NAs should have notified the nurse to assess the resident for any injuries before the resident was moved.

Based on record review and staff interviews, the facility failed to administer a pneumococcal vaccine to a resident who had consented to receive the vaccine for 1 of 5 residents reviewed for pneumococcal vaccines (Resident #72).Findings included:Resident #72 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #72 had severe cognitive impairment.Review of Resident #72's medical record revealed no documentation that staff had administered a pneumococcal vaccine. The prior pneumococcal immunization history documented revealed a history of Prevnar 13 (pneumococcal 13-valent conjugate) dated 2/11/16.Review of Resident #72's medical record revealed a form titled 'Vaccine Consent Form 2025'. The pneumonia vaccine was marked under the section titled Individual Requests the Following Vaccination(s). The vaccine consent signature section showed that Resident #72's Responsible Party signed the consent for the pneumococcal vaccine on 9/03/25. An interview on 2/17/26 at 11:16 AM with the Director of Nursing (DON) who also served as the Infection Preventionist for the facility. She stated she assessed and administered immunizations for all new admissions and ensured all residents received vaccines and were up to date per Centers for Disease Control and Prevention (CDC) Guidelines. She stated that the current CDC guidelines recommend pneumococcal conjugate vaccine 20 (PCV20) for residents to be up to date. She explained that she used a CDC algorithm with the resident's prior vaccines to help her determine when a resident needed a vaccine to stay up to date. She entered Resident #72's prior vaccines and stated that the resident should have had the PCV20 to be up to date. She was unable to say why this had not been done. An interview on 2/91/26 at 10:06 AM with the Administrator stated she expected resident vaccines to be kept up to date, and she did not know why staff had not administered the PCV20 vaccine Resident #72.

Based on observations, record review, and resident, family, and staff interviews, the facility failed to protect a resident's right to be free from abuse when a family member (Family Member #1) hit Resident #1 on the leg, covered her mouth with her hand, and told her to shut up. This affected 1 of 3 residents reviewed for abuse (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Her diagnoses included: hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stoke) affecting left non-dominant side. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. She was not documented on the MDS as having behaviors or rejection of care. The MDS indicated she used a wheelchair, had function limitations in range of motion to her upper and lower extremities on one side, and was dependent on staff for toileting, dressing, personal hygiene, transfers, and mobility. Review of a facility submitted investigation report specified an allegation of abuse for Resident #1 was reported to the facility Administrator on 2/19/25. The report indicated a Nurse Aide (NA #1) observed Family Member #1 hitting her [Resident #1] on the leg, covering her mouth and nose with her hand, and telling her to shut up. The investigation reported that NA #1 immediately intervened and reported the incident to the Unit Coordinator (UC #1). The investigation report further revealed that UC #1 removed Family Member #1 from Resident #1's room, interviewed Family Member #1 regarding the incident, and informed Family Member #1 of the investigation process for when an abuse allegation was made. Family Member #1 was informed she could not visit Resident #1 until the investigation was completed. UC #2 escorted Family Member #1 to obtain her belongings from Resident #1's room and then escorted Family Member #1 out of the facility. The allegation of abuse involving Resident #1 was immediately reported to the Administrator by UC #1. The investigation report revealed the facility reported the incident to the local law enforcement agency, the local department of social services, and to the department of health and human services. The facility investigation revealed the facility substantiated the abuse allegation due to NA #1 witnessing the alleged abuse incident. The investigation indicated the perpetrating Family Member #1 was contacted by the Administrator on 2/21/25 and a care plan meeting was arranged for 2/24/25 to establish a supervised visitation schedule for Resident #1's Family Member #1 to visit. An interview was conducted with NA #1 on 4/29/25 at 12:50 PM. NA #1 recalled the incident from 2/19/25 with Resident #1 and Family Member #1. NA #1 said she had been standing in Resident #1's doorway to pass drinks for lunch. NA #1 reported Resident #1 had been talking to someone on the phone. She remembered Family Member #1 kept telling Resident #1 to hush and stop talking to whoever was on the phone. She reported she heard Resident #1 say have you talked to [Family Member #1] about letting me come stay with you. NA #1 reported that was when Family Member #1 became upset and hit Resident #1 with an open hand on her right thigh. NA #1 stated she was able to hear the noise from the smack when Family Member #1 hit Resident #1 on the leg. NA #1 reported she then saw Family Member #1 put her hand over Resident #1's mouth and nose with enough force to push Resident #1's head back and told her to shut up. NA #1 said she walked into the room and told Family Member #1 to stop. NA #1 reported Family Member #1 stopped and immediately started crying. NA #1 said Family Member #1 told her to mind her business, it's okay. NA #1 reported she immediately stuck her head out of the room door and called for NA #2 and asked her to go get the supervisor. NA #1 stated she stayed in the room with Resident #1 and Family Member #1 until the supervisor came to the room. NA #1 said Family Member #1 did not say anything else to Resident #1. She reported that UC #1 and UC #2 came to Resident #1's room and removed the family from the room. NA #1 recalled Resident #1 had been calm and then when she asked the question about going and staying with the other person that was when Family Member #1 burst out. NA #1 said she had not heard or seen Family Member #1 do anything like that before. An interview was conducted with Resident #1 on 4/29/25 at 9:40 AM. Resident #1 recalled the incident with Family Member #1. She said Family Member #1 was upset that day. Resident #1 explained she had called Family Member #3 to ask them to come and take her to see a friend so they could pray for her. She explained Family Member #1 had been upset because she had called Family Member #3 asking them to come and get her. She said Family Member #1 got emotional and was crying. Resident #1 said the staff had thought it was upsetting her but that Family Member #1 was not physically hurting her. Resident #1 explained she and Family Member #1 were talking loudly that day. Resident #1 recalled Family Member #1 had said, Mother you know you can't go out of here unless they take you in the van. Resident #1 did not remember Family Member #1 yelling at her loudly. She said Family Member #1 was fussing at her because she had called Family Member #3. Resident #1 said Family Member #1 loves me and wants what is best for me. Resident #1 stated Family Member #1 put her hand over my mouth because she just wanted me to stop talking about it I guess but she was not trying to smother me. She put her hand over my mouth like saying hush Mom, but she did not do it to hurt me. Resident #1 did not recall Family Member #1 hitting her on her leg. Resident #1 reported she did not remember if Family Member #1 had told her to shut up. Resident #1 said Family Member #1 had never physically hurt her. She reported it did not bother her how Family Member #1 talked to her or when she fussed at her. Resident #1 stated they just don't know what a loving child is. An interview was conducted with UC #1 on 4/29/25 at 11:35 AM. UC #1 recalled the incident from 2/19/25 with Resident #1 and Family Member #1. UC #1 explained it was reported NA #1 had witnessed Family Member #1 hit Resident #1 on the leg, cover her mouth and nose, and tell her to shut up. UC #1 stated she had been with UC #2 when the incident was reported to her and UC #2 went with her to Resident #1's room. UC #1 reported when she and UC #2 entered Resident #1's room she asked Family Member #1 to leave Resident #1's room to go talk. She remembered Family Member #1 started arguing. She said Family Member #1 was not yelling but was loud and aggressive in tone and stated Resident #1 needed to hear this too. UC #1 reported she told Family Member #1 they needed to discuss it outside of the room. UC #1 stated she and UC #2 took Family Member #1 to her office to talk. UC #1 explained Family Member #1 and Resident #1 had been arguing because the night before Resident #1 had called Family Member #3 wanting them to come and pick her up and take her to go see a friend to pray over her. She recalled Family Member #1 expressed she was frustrated because she felt Resident #1 knew not to call people to come get her because they could not come get her and it had been the middle of the night when Resident #1 had called them. UC #1 said Family Member #1 was upset Resident #1 had called them. UC #1 reported Family Member #1 denied hitting Resident #1. UC #1 stated Family Member #1 said she had grabbed Resident #1 by the shoulders but had denied covering her mouth with her hand. UC #1 recalled Family Member #1 said she did not remember if she had told Resident #1 to shut up. UC #1 said she explained to Family Member #1 she could not touch Resident #1 in an aggressive and negative way. UC #1 stated she told Family Member #1 she needed to leave the facility until further instruction was received by the Administrator. UC #1 recalled UC #2 accompanied Family Member #1 to obtain her belongings from Resident #1's room and escorted her out of the facility. UC #1 stated she called the Administrator immediately and reported the incident while UC #2 escorted Family Member #1 out of the facility. UC #1 stated after the incident she completed a skin assessment on Resident #1 and did not find any marks. UC #1 recalled she interviewed Resident #1 after the incident. She reported Resident #1 denied Family Member #1 hit her but did say Family Member #1 had told her to shut up. UC #1 stated Resident #1 said she could not remember if Family Member #1 covered her mouth. UC #1 stated after the incident Resident #1 seemed upset and said, I know better than to call others and ask for things, I know [Family Member #1] takes care of things. UC #1 reported Family Member #1 now had scheduled supervised visits with Resident #1. She voiced there had not been any further issues since the supervised visits were put into place. An interview was conducted with UC #2 on 4/29/25 at 12:00 PM. UC #2 said she had been with UC #1 when it was reported NA #1 had witnessed Family Member #1 slap Resident #1 on the leg and covered her mouth. UC #2 explained she had gone to Resident #1's room with UC #1 after the incident was reported. She recalled when they went to the room Family Member #1 was upset and seemed to know there was an issue. She said Family Member #2 was also visiting and present in the room but did not say much. UC #1 said Resident #1's Family Member #1 was frustrated because Resident #1 called people and asked them to take her places and Resident #1 did not understand she could not get in or out of a car and they could not come get her. She said Family Member #1 was frustrated because Resident #1 kept doing this. UC #2 reported she and UC #1 removed Family Member #1 from Resident #1's room and took her to UC #1's office to ask her what happened. She recalled Family Member #1 said she did not hit Resident #1 and denied covering her mouth. UC #2 reported after talking to Family Member #1 they told her the incident would be investigated but that she needed to leave the facility. UC #1 explained she took Family Member #1 back to get her things from Resident #1's room and then escorted her out of the building. An interview was conducted with Family Member #1 and Family Member #2 on 4/29/25 at 2:00 PM. Family Member #1 explained Resident # 1 had been sitting with her head hanging down. Family Member #1 said she picked up Resident #1's head at her chin and tilted her head up, but not violently to get Resident #1 to look at her. She stated Resident #1 would have screamed if it had hurt her. She reported Resident #1 was talking on the phone and she had not been responding to the person on the phone. Family Member #1 said she did not slap or hit Resident #1 on her leg. She explained in the past she had patted Resident #1 on the leg to get her to lift her leg to get her feet back on the footrest of her wheelchair. Family Member #1 explained she did that often but did not remember specifically if she did it that day. Family Member #1 said she did not remember putting her hand over Resident #1's mouth. When asked if she remembered telling Resident #1 to shut up, Family Member #1 said, I don't know. Family Member #1 stated she did not have a habit of telling Resident #1 to shut up and did not recall telling her to shut up. Family Member #1 reported when NA #1 came into Resident #1's room NA #1 said that is not acceptable get your hands off her. Family Member #1 stated she told NA #1 it was none of her business because she had not perceived the situation as her doing something that was harmful to Resident #1. Family Member #1 reported she had not been arguing with Resident #1 that she had just been trying to get her to pay attention. She stated UC #1 and UC #2 came and talked to her and asked her to leave that day. Family Member #1 reported that the Administrator called and talked to her after the incident and set up a care plan meeting for 2/24/25 to set up supervised visits. Family Member #2 was present during the interview and said Family Member #1 had been trying to get Resident #1 to pay attention that day. Family Member #2 said Family Member #1 would never hurt Resident #1. Family Member #2 did not provide any additional details from the incident. An interview was conducted with the Director of Nursing (DON) on 4/29/25 at 5:05 PM. The DON recalled the incident with Resident #1 and Family Member #1 that occurred on 2/19/25. She reported the Administrator had completed most of the abuse investigation. The DON stated Resident #1 had said it did not happen when they talked to her. The DON reported she thought Resident #1 said it did not happen because Resident #1 was trying to protect Family Member #1. The DON explained the facility substantiated the abuse allegation because the incident had been witnessed by NA #1. She reported NA #1 had witnessed Family Member #1 hit Resident #1 on the leg, cover her mouth, and tell her to shut up. She said Family Member #1 had denied all allegations when they spoke with her. The DON stated Resident #1 did not act afraid of Family Member #1 and wanted her to visit. She reported after the incident a care plan meeting was held with Family Member #1 to set up scheduled supervised visits. The DON reported there had not been any further issues since supervised visits had been implemented. An interview was conducted with the Administrator on 4/30/25 at 11:54 AM. The Administrator said on 2/19/24 she received a phone call from UC #1 reporting the allegation of abuse to Resident #1 by Family Member #1. She stated it was reported that NA #1 was at Resident #1's door looking into the room and saw Family Member #1 put her hand over Resident #1's mouth, pushed her head back while covering her nose and mouth, and saying shut up stop talking. The Administrator said it was also reported that Family Member #1 hit Resident #1 on the leg, she was not sure if it was with an open hand or how hard the hit was. The Administrator stated NA #1 intervened, and the incident was reported to UC #1. The Administrator said Family Member #1 was escorted out of the building after the incident. She reported UC #1 had immediately called her after the incident happened to report it. The Administrator stated she called Family Member #1 the same day on 2/19/25. She reported Family Member #1 said she would never hurt Resident #1 and denied it happened. The Administrator stated they had substantiated the abuse allegation due to the incident being witnessed by NA #1. The Administrator said a care plan meeting was set up with Family Member #1 to establish a supervised visitation schedule to preserve Resident #1's visitation rights.

Based on record review, observations, and resident, staff, Physician, Nurse Practitioner (NP), Physician Assistant (PA) and neurology office Scheduler interviews the facility failed to ensure a neurology appointment was scheduled for a resident (Resident #14). The Physician ordered a neurology referral for Resident #14 first on 8/23/24 for evaluation of her tremors. A second neurology consult was ordered by the NP on 11/5/24 again for evaluation of her tremors. Resident #14 had tremors to her upper and lower extremities, including her hands and feet. Resident #14 reported her tremors had worsened, were unmanageable, made her feel awful, and like she could not do anything. Resident #14 reported the tremors made her not want to leave her room because she did not want people to see her in that state. She stated she felt isolated every day and felt down, depressed, and hopeless all the time because nothing was getting better. This occurred for 1 of 1 resident reviewed for medically related social services (Resident #14). Findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety, mood disorder (depression/ mania), essential tremor (involuntary shaking typically in arms/ hands), drug induced secondary Parkinson's disease (a movement disorder that is caused by medications and causes Parkinson's disease symptoms). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. She was not documented as having behaviors or rejection of care. A history and physical dated 8/23/24 by the Medical Director (MD) read in part: Patient today is complaining of significant ongoing worsened tremors. She reports she has been evaluated by multiple neurologists in the past however no significant improvement has been made. She reports primidone (a medication used to treat tremors) has been helpful. She was previously on a higher dose. She has trialed Sinemet (a medication used to treat symptoms of Parkinson's such as tremors) with no relief of the symptoms. Reports the tremors are giving her some difficulty completing activity of daily living (ADL) including self-feeding. She does report some ongoing increased mood symptoms. Will refer back to neurology services for further recommendations. Resident #14's active physician orders revealed an order dated 8/23/24 entered by the Medical Director (MD) that read: Please refer back to neurology for tremor. Review of Resident #14's electronic medical record revealed there were no records of a neurology appointment being scheduled. A telephone interview was conducted with the MD on 12/5/24 at 1:21 PM. The MD said Resident #14's neurology appointment should have been scheduled by the facility when she had ordered the referral in August. The MD stated she was not aware a neurology appointment had not been scheduled for Resident #14 after she had given the order for the referral in August. She explained she was not surprised Resident #14 had not been seen yet by neurology because a new patient referral with neurology could take a long time. The MD indicated it was hard to say 100% if there were any negative effects from Resident #14 being seen later by neurology. She explained she did not know if neurology would make a huge difference but that it was good to get a specialist's opinion because they knew more about it. The MD said she was not sure if neurology would be able to help improve Resident #14's tremors but having a neurologist input was an important part of the puzzle. A progress note dated 8/27/24 by NP #1 read in part: She [Resident #14] reports her tremors are interfering with her desire to be around others. Patient is anxious and becoming upset as she discusses her tremors. A psychiatric progress note dated 8/29/24 by PA #1 read in part: She is taking Primidone which interacts with Latuda (antipsychotic medication) and causing extrapyramidal symptoms (EPS) (movement disorders that can occur as a side effect of certain medications), involving significant generalized tremor and muscle twitching. Changes included stopping Latuda, starting Risperidone (antipsychotic medication) 1 milligram (mg) every morning and 2 mg every night for schizoaffective disorder (mental health condition), and starting Benztropine (a medication used to treat movement problems) 0.5 mg every 8 hours as needed (PRN) for tremors/ EPS. A psychiatric progress note dated 9/5/24 by PA #1 indicated Resident #14 had seen an improvement in EPS since Latuda was switched to Risperidone and PRN Benztropine was added. A progress note dated 9/13/24 by NP #1 said Resident #14 reported shaking in her knees and she had tremors to her bilateral upper extremities and jaw that were tardive dyskinesia (TD) (a movement disorder typically caused by taking certain medications, such as antipsychotic medications) or essential tremors. The note stated, it is wondered if the shaking in her knee is part of these known tremors. A progress note dated 9/24/24 by NP #1 read in part: Today her chief complaint is her anxiety and her tremors. She states her tremors are worse today than yesterday. Yesterday her Benztropine was discontinued as her tremors had escalated with the three times daily dosing. She is asking to be placed back on her regimen where it was dosed twice daily, and her tremors were better managed. Today her anxiety seems to be driven by her tremors. A psychiatric progress note dated 9/26/24 by PA #1 indicated Resident #14 reported her tremors were worse on Benztropine. The note stated she had tremors present primarily to her bilateral upper extremities. The Benztropine was stopped and Artane (a medication used to treat tremors) 1 mg twice daily was added for EPS. A psychiatric progress note dated 10/11/24 by PA #1 indicated Resident #14 reported some benefit from the Artane but the effects waned midday. Artane orders were changed to 1 mg three times daily for EPS. A psychiatric progress note dated 10/31/24 by PA #1 indicated the Artane three times daily dosing was reported to have caused an increase in Resident #14's tremors. The note said Resident #14 had been refusing the medication because she felt it was causing her tremors to increase. She had also refused her antipsychotic medication. The note revealed Resident #14 denied any return of psychosis symptoms and reported she had only had a single episode of psychosis in her lifetime in the context of grief related to a significant death and questions the validity of the diagnosis. The note revealed Resident #14 no longer wanted to take an antipsychotic medication at all but agreed with allowing the medication to be tapered. Artane was stopped and Risperidone was decreased to 1mg nightly. A progress note dated 11/5/24 by NP #1 read in part: She is very discouraged today and frustrated by her tremors. She reports she has been evaluated by neurology in the past regarding her tremors and that she was told there was nothing that could done about them. When asking if she would like to have a second opinion regarding her tremors she responded to the affirmative. Review of Resident #14's active physician orders revealed an order dated 11/5/24 entered by NP #1 read: neurology consult for tremor, make appointment with a [local] neurologist. A psychiatric progress note dated 11/14/24 by PA #1 read in part: Resident #14 EPS seems worse since stopping both the Artane and Risperidone. She is in some distress over this, feeling frustrated and pessimistic about the future. She is experiencing marked tremulousness in her upper extremities and has been confining herself to her bed most of the time. We discussed treatment options for tardive dyskinesia, and she is receptive to trial of Ingrezza (a medication used to treat tardive dyskinesia). Ingrezza 40 mg daily was added for TD. A psychiatric progress note dated 11/21/24 by PA #1 read in part: Resident #14 presented in a markedly irritable manner today, raising her voice in anger, as she has continued to have symptoms of TD. She has been markedly shaking in her upper extremities, essentially unchanged from when she was last seen and has been spending time in her room much of the time as a result. We discussed the etiology of this, but she was not receptive, and it is not clear to what degree she understood due to her angry state. Changes were made to her medications. Carbidopa-levodopa (a medication used to treat Parkinson's symptoms) 25-100 mg twice daily was added for EPS and Trazodone (a medication used to treat anxiety) 25 mg twice daily was added for anxiety. An interview was conducted with NP #1 on 12/5/24 at 12:40 PM. She explained the psychiatric PA followed Resident #14 for monitoring and management of her tremors. NP #1 stated she had recently seen Resident #14 and had asked her if she had ever been seen by a neurologist. She recalled Resident #14 told her she had been seen by a neurologist in Waynesville and had been told there was not anything else they could do for her tremors. NP #1 explained Resident #14 had preferred to go see a neurologist in Asheville for a second opinion. NP #1 stated she had made the referral for neurology for Resident #14 because her tremors had not gotten better. She explained several different medications had been trialed for Resident #14 to help with her tremors. NP #1 further explained, some of the medications that were trialed may have made the tremors worse, so those had been stopped and now Resident #14's tremors were back to baseline but not getting better. NP #1 said Resident #14's tremors bothered her and affected her quality of life. She said Resident #14 had told her she does like to go to activities much because of her tremors. NP #1 explained Resident #14's tremors did not impact her ability to perform task such as eating but that it was more of a self-image issue and caused her not to want to socialize. She said Resident #14 tremors affects her depression symptoms because of how they affect her life, she explained Resident #14 was followed by psychiatry services to address her psychiatric diagnoses and symptoms. NP #1 stated Resident #1's tremors were not basic essential tremors. She explained there was a psychiatric component to her tremors that needed to be managed by psychiatry and neurology. NP #1 was not aware a neurology referral had previously been made for Resident #14 in August, she said I just knew she needed to go. NP #1 explained she did not think there was physical harm from Resident #14 being seen later by neurology but that maybe there was emotional harm related to anxiety/ depression being worse. NP #1 stated emotionally it would have been better if Resident #14 would have been seen sooner by neurology for her to have some answers. A telephone interview was conducted with PA #1 on 12/5/24 at 12:14 PM. He said he followed Resident #14 for psychiatric services. He explained he provided monitoring and management for her tremors. He explained that had been the focus since Resident #14 had been admitted to the facility. PA #1 further explained Resident #14 had been admitted with a diagnosis of schizoaffective disorder. He said her Latuda and Primidone interacted and caused an increase in EPS. PA #1 stated he had tried different medications for Resident #14 to manage her tremors but that they did not work. He said Resident #14's tremors had waxed and waned since she had been admitted to the facility. PA #1 said the tremors made Resident #14 anxious and when she was anxious it caused them to worsen. He recalled the last time he had seen Resident #14 she had yelled at him and that was new. He said he had stopped her antipsychotic entirely and she had not had new psychosis. PA #1 said Resident #14's was irritable due to not sleeping well and shaking all the time. He said her tremors sometimes interfered with her sleep and that affected her concentration and mood too. PA #1 explained there were times Resident #14's tremors seemed to get a litter better and then they would get worse again. He said he was unaware of how long or to what degree she was shaking prior to coming to the facility. He said he was aware of the neurology referral and had asked a nurse a couple of weeks ago if there had been a neurology referral put in for Resident #14. He explained at first, he had thought he could manage Resident #14's tremors but when they did not get better, he had thought she would need a neurology referral. He stated he could not remember which nurse he had asked about the neurology referral. PA #1 stated he had not been aware a neurology referral had been made previously for Resident #14 in August. PA #1 said he was not sure if Resident #14's tremors could ever go away but was hopeful they could get to a manageable level where she would be able to hold a cup of coffee. PA #1 explained he thought Resident #14 had drug induced parkinsonian symptoms and a neurologist would be appropriate and beneficial for her. He said Resident #14 had feelings of hopelessness, was irritable, and anxious because the tremors were not getting any better. An interview and observation were conducted with Resident #14 on 12/5/24 at 2:30 PM. Resident #14 was observed in her room, laying on her bed, with the lights off. She was observed to have significant shaking of both her hands and arms at rest and with movement. Shaking was also noted in her legs and feet. Resident #14 said she had tremors before she had been admitted to the facility but not like this. She explained she now had shaking in her legs and feet. She said her tremors had gotten worse since being at the facility and over the last 3-4 weeks they had become unmanageable. Resident #14 explained different medications had been tried since she had been at the facility to help with her tremors. She said every time her medications were changed it makes me worse and that makes me feel anxious. Resident #14 stated her tremors made her feel awful and like she could not do anything. She explained they made her not want to leave her room and stated, I just don't want people to see me in that state. Resident #14 said she felt isolated every day and felt down, depressed, and hopeless all the time because nothing was getting better. Resident #14 was not aware a neurology referral had been ordered for her in August and that no one had come to talk to her about it. She explained she had been seen by a neurologist but that it had been several years since she had been seen. Resident #14 said she would have been okay going to an appointment with same neurologist office if she could have been seen sooner. An interview was conducted with the facility Scheduler on 12/5/24 at 11:00 AM. The facility Scheduler stated if there was an order written for a referral she would fax the appointment referral to the medical office. She explained she would give the office a week or two to call her to schedule the appointment and then if she did not hear from the office, she would call the office to schedule the appointment. The facility Scheduler stated she saved the referrals and 1 to 2 times a month she would sit down and go through the referrals. She explained she would discard the referral if the appointment had been made and would call the office for the ones that had not been scheduled. She stated she did not remember if she had called the neurology office or followed up on the neurology appointment ordered in August for Resident #14 specifically. The facility Scheduler explained she had been working on the floor, helping stock supplies, and had not been at her desk as much to give appointments attention. The facility Scheduler stated she had gotten behind on appointments and had not kept up with them as good as she should have. She explained that the Director of Nursing (DON) and Administrator had talked to her about the appointment process and how it was not working in October. The facility Scheduler stated she needed a new process to keep track of appointments, and she was now using a spread sheet to keep up with appointments. She explained she had faxed the referral for Resident #14 to the neurology office on 8/30/24 and had not heard back from the office to schedule the appointment. She said she did not receive any missed calls or messages from the neurology office regarding scheduling the appointment. The facility Scheduler stated she did not remember if she had called the neurology office to follow up on scheduling the appointment for Resident #14. She said she had faxed the neurology referral ordered on 11/5/24 for Resident #14 to the neurologist's office on 11/6/24. She explained she called them on 11/27/24 to follow up on the referral and the office stated they had not received the referral. She stated she had faxed the referral to the office again on 11/27/24. The facility Scheduler said she had called the office this morning and they had scheduled Resident #14 for an appointment on 2/20/25. A telephone interview was conducted with the neurology office Scheduler at the neurology office on 12/5/24 at 11:00 AM. She stated the neurology referral had been faxed to the office on 8/30/24 by the facility and the office had made multiple attempts to contact the facility to schedule a neurology appointment for Resident #14. She explained the office had called the facility's Scheduler at the number provided on the faxed referral. She provided the number the neurology office had called to attempt to schedule the appointment. The phone number had matched the number present on the faxed referral sheet by the facility that had been confirmed as the correct number by the facility's Scheduler. The neurology office stated they had called and left messages on 9/4/24, 9/11/24, 9/12/24, and 9/16/24 for the facility's Scheduler to call back to schedule an appointment for Resident #14. She stated she knew the dates the office had called and left messages on the phone number provided by the facility, because there were notes about the phone calls, dates, and messages in their system. She explained after the fourth attempt on 9/16/24 the office had closed the referral because they had been unable to reach anyone to schedule the appointment. The neurology office scheduler stated Resident #14 had been an established patient with the office but had not been seen since February of 2022. She explained if the office had called the facility, it was because they had an appointment and could get Resident #14 in to be seen. She said the neurology office booked appointments for about 3-4 months out and that most likely Resident #14 would have been seen in November or December if the facility had followed up on the referral sent on 8/30/24. An interview was conducted with the DON on 12/5/24 at 3:25 PM. The DON stated Resident #14 should have had a neurology appointment scheduled after the first order had been given in August. She stated the Appointment Scheduler should have talked with Resident #14 to see if she already had a neurologist she had seen previously or what Neurologist she wanted to go to see. The DON said she was not sure what happened and why the appointment was not made. The DON stated the Appointment Scheduler should have followed up with the neurology office if she had not heard back from them in a week. She explained an issue had been noticed in October with appointments not being followed up on and tracked. The DON stated before October there was not a process in place for following up on appointments, tracking appointments/ referrals, or accountability. She stated there had not been a schedule book and appointments had been logged in the Appointment Scheduler's phone. The DON explained the process the facility now had for referrals/ appointments. She said when an order was entered by a provider for a referral the order was pending and had to be confirmed by a nurse. She further, explained when a referral order was confirmed, the order was printed, and given to facility Scheduler either by placing it on her desk or putting it in her box. The DON said the referral should be faxed to the office when the facility Scheduler received the referral order. She stated if the facility Scheduler had not heard back from the office within a week about a referral, she should call the office to follow up. She stated the facility Scheduler made a list of appointments for the week and she reviewed them on Fridays and checked them against referral orders on the computer. The DON was not aware the neurology appointment ordered on 11/5/24 had not been scheduled until today. She was not sure why there had been a delay in scheduling the 11/5/24 neurology appointment or why the referral had not been followed up on for 3 weeks. The DON explained Resident #14 needed to go to neurology to have their input on the tremors and hopefully give her some improvement in her quality of life. She said even if going to neurology eased Resident #14's mind then it was worth it. An interview was conducted with the Administrator on 12/5/24 at 5:01 PM. The Administrator stated she was not sure about what happened with the neurology appointment that had been ordered in August or how it had been missed being scheduled. She did not say who had been responsible for appointments when the facility Scheduler had been out. She stated she would expect that if the facility Scheduler had not heard back from the office in a week that she would call the office to see why. The Administrator said there had not been a process for appointments, follow up, or accountability before October 2024.

Based on record review, and resident, staff, and Senior Police Officer interviews, the facility failed to protect the resident's right to be free from misappropriation of resident property. This deficient practice was for 1 of 1 resident reviewed for misappropriation of resident property (Resident #78). The findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses which included gastrointestinal hemorrhage and hypertension. The admission Minimum Data Set, dated dated dated [DATE] revealed Resident #78 was cognitively intact. Review of the initial facility report dated 11/30/24 at 10:30 AM documented that Resident #78 reported her wedding rings and mother's ring were missing. An interview with Resident #78 12/05/24 at 9:56 AM revealed that there were 5 rings missing. She stated that her family had taken her out on Wednesday, 11/27/24, to get a manicure for Thanksgiving. At that time, her family had given her 5 rings to wear for Thanksgiving on 11/28/24. She stated that she wore them out with her family on 11/28/24 and had them in her possession when she returned to the facility. She wore them at the facility on Friday, 11/29/24 and took them off at bedtime. Resident #78 stated she put them in a plastic bag when getting ready for bed on 11/29/24 and put the bag on her bedside table. When she got up the next morning on Saturday, 11/30/24, she got dressed and ready for the day. She got the bag from her bedside table to put her rings on and the rings that were in bag were not her rings. There were 4 cheap replacements rings. She stated she reported to staff about her missing rings. She stated she feels sad that her rings are missing as they were gifts from her husband, and she had bequeathed them to her family. An interview on 12/05/24 at 12:13 PM with Medication Aide (MA) #1 revealed she was assigned to provide medications for Resident #78 on Wednesday, Thursday, and Friday (11/27/28 through 11/29/24) day shift. She stated she saw the resident's nails on Thursday and observed she was wearing rings. She stated she remembered one looked like an engagement or wedding ring and that there was more than one ring, but did not remember specifically what they looked like. An interview on 12/05/24 at 11:41 AM with Nursing Assistant (NA) #5 revealed she was assigned to provide care for Resident #78 on the day shift Wednesday, Thursday, and Friday (11/27/28 through 11/29/24) as well as the evening shift of Friday. She stated she had not observed if the resident was wearing rings or not. She stated she had helped Resident #78 to bed on Friday evening and had not noticed any rings. An interview on 12/05/24 at 5:40 PM with NA #2 revealed she was assigned to provide care for Resident #78 on Friday 11/29/24 from 3 PM until Saturday 11/30/24 at 7 AM. She stated she did not recall any rings. She stated she did not remember that night specifically, if she assisted the resident to bed, or anything about jewelry. An interview on 12/05/24 at 3:27 PM with NA #4 revealed she was assigned to provide care for Resident #78 on Saturday, 11/30/24. She stated as she was assisting resident to get up, the resident was crying and told her that her rings were missing. She notified the nurse. An interview on 12/05/24 at 1:28 PM with Nurse #1 revealed she was assigned to provide care for Resident #78 on Saturday, 11/30/24. She stated NA #4 notified her that resident was missing some jewelry. Nurse #1 stated she talked with the resident and then notified the Weekend Supervisor. Resident #78 showed her the 4 cheap costume jewelry rings and told her that someone had taken her rings and replaced them with the cheap rings. Nurse #1 indicated she called the family to verify what rings the resident had. Nurse #1 stated she had never seen the actual rings and had no other knowledge about the missing jewelry. An interview on 12/05/24 at 1:35 PM with the Weekend Supervisor revealed she was notified of Resident #78's missing rings on 11/30/24. The Weekend Supervisor stated the resident told her that she had taken her rings off the night before and placed them in a plastic bag on her bedside table. The Weekend Supervisor stated Resident #78 told her when she got up the next morning (11/30/24), she washed up and when she went to put her rings on, there were other rings in the bag that weren't hers. The Weekend Supervisor notified the Administrator, the police, and the family. She stated she had no idea what happened to them. The Weekend Supervisor recalled the resident got up around 9:30 AM and she talked to the resident between 10 AM and 11 AM. She also stated the resident told her she went to bed on Friday night right after supper between 6 PM and 7 PM. An interview on 12/05/24 at 4:55 PM with the Senior Police Officer revealed he had talked with the resident, her family, and the facility Administrator. He stated he would file a report which would be reviewed by the detectives but there was not much they could do. He stated the family estimated the cost of the missing rings between $4,000 and $5,000. An interview on 12/05/24 at 10:25 AM with the Administrator revealed she was investigating Resident #78's missing rings and had not yet completed her investigation. Review of the facility investigation report dated 12/06/24 at 3:48 PM documented there were 5 rings missing. These rings were described as white gold bands, one was a diamond cluster, one was a mother's ring with different colored stones across the top, and the others were bands with smaller diamonds. A police report was filed. The allegation was substantiated as the rings were missing but there were no accused employees or individuals.

Based on observations, record review, resident, staff, and wound care center Nurse Practitioner (NP) interviews the facility failed to follow physician orders from the wound care center for the treatment of a stage II pressure ulcer (partial thickness open wound) for 1 of 2 residents reviewed for services to prevent and treat pressure ulcers (Resident #233). The findings included: Resident #233 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (narrowing of peripheral blood vessels that can cause a disruption in blood flow) with chronic bilateral lower extremity wounds and eczema (a condition that causes red, dry, itchy skin). Resident #233 was discharged from the facility on 6/14/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #233 was cognitively intact. She was not coded on the MDS for an unhealed pressure ulcer. She was documented on the MDS as having venous and arterial ulcers present. Resident #233 had a care plan dated as initiated on 10/12/23 and revised last on 5/10/24 for potential and actual impaired skin issues related to groin red and chapped, extensive venous stasis wounds to bilateral lower extremities. The care plan goals were for Resident #233's skin to remain intact without signs of breakdown and for her wounds to remain stable without signs of infection through next review. The care plan interventions included to provide wound care as ordered and noted she was followed by the wound care center. A physician order details page from the wound care center dated 4/12/24 for Resident #233 revealed a pressure ulcer of left lower back, stage II listed under the diagnosis section. Under wound treatment it listed wound #6 to the left posterior back with instructions that read: cleansing: cleanse with normal saline one time daily; dressing: Optifoam gentle SA (silicone adhesive foam dressing that absorbs drainage and helps evenly disperse pressure) one time daily. Review of Resident #233's treatment administration record (TAR) for April 2024 and May 2024 was reviewed and revealed there were no wound care orders for Resident #233's stage II pressure ulcer on her lower left back. A wound care center progress note dated 4/19/24 by the wound care center Nurse Practitioner (NP) noted on 4/12/24 Resident #233 had complained about a sore on her left lower back, and they had discovered a large stage II pressure ulcer. The note indicated on 4/19/24 stage II pressure ulcer to her left lower back was still present and very painful and Resident #233 had told the wound care center the area had not received care until yesterday. The wound care center note specified the wound needed to be cared for regularly according to the wound care directions. The stage II pressure ulcer was identified in the note as wound #6. The wound was described as open and being in treatment for 1 week. The wound care center note identified the wound classification as a category/ stage II wound with etiology of pressure ulcer located on the left, posterior back. The note provided the measurements and a description of the wound stating it measured 4.5-centimeter (cm) length x 4.9 cm width x 0.1 cm depth, the wound margin was distinct with the outline attached to the wound base, there was no granulation (new tissue) within the wound bed, and no necrotic (dead/dying tissue) tissue within the wound bed. The progress note indicated the following wound care instructions for the left posterior back wound: primary dressing-foam dressing, adhesive 7x7 three times per week. A physician orders detail page from the wound care center for Resident #233 dated 5/3/24 was present in the electronic medical record and a pressure ulcer of left lower back, stage II was listed under the diagnosis section. Under wound treatment it listed wound #6 to the left posterior back with instructions for an Aquacel foam dressing adhesive (self-adherent foam dressing that decreases bacteria, absorbs drainage, and improves comfort) three times per week. A progress note dated 5/24/24 from the wound care center by the wound care center NP noted the stage II pressure ulcer to Resident #233's left lower back had resolved. A telephone interview was conducted on 12/6/24 at 8:51 AM with the wound care center NP. The NP stated the Stage II pressure injury to Resident #233's left lower back had been identified at the wound care center during her visit on 4/12/24. The NP stated she had classified the wound as a stage II pressure injury and had given wound care orders for the facility to provide wound care. The NP explained she had given orders for a foam dressing to off load and protect the area. The NP recalled when she had seen Resident #233 on 4/19/24 the wound to her left lower back had been painful and Resident #233 had commented no one at the facility had provided wound care to the area. The NP said she had made it clear in her notes the wound needed to be cared for every day. The NP further recalled, when Resident #233 had come to the wound care center on 5/3/24 she had not had a dressing in place to the pressure ulcer to her left lower back. The wound care center NP said she put it again in her notes that the wound needed care every day. The wound care center NP said she had seen Resident #233 again on 5/24/24 and the wound had resolved. The wound care center NP explained the wound to Resident #233's lower back could not have been a psoriasis plaque area (raised, red, scaly patch of skin). She explained a psoriasis plaque would have looked different. She recalled Resident #233 sometimes had areas to her arms and face that looked like psoriasis but that the wound to her left lower back was a pressure ulcer and the skin was not dry or flaky. The wound care center NP explained the wound care notes and orders had been faxed to the facility after each visit. She said they were usually faxed to the facility with in 24 hours. She did not recall the facility ever calling the wound care center to ask about Resident #233's wounds, notes, or wound care orders. A progress note dated 5/8/24 by the Medical Director (MD) said nursing had requested an evaluation of a new left flank skin lesion. The note indicated Resident #233 was followed by outpatient wound care providers for her wounds and at the last visit they had noted a left flank new skin lesion injury. The note said Resident #233 had areas throughout her trunk and had previous psoriatic plaques that had responded well to triamcinolone (a steroid cream) in the past. The note stated Resident #233 had a new Psoriasis Plaque to the left posterior trunk with some flaking and that it was not over a bony surface. The note said to initiate triamcinolone. A telephone interview was conducted with the Medical Director (MD) on 12/6/24 at 10:09 AM. The MD stated she did not remember specifically looking at Resident #233's wounds. The MD explained Resident #233 was followed by the wound care center and deferred to the wound care center for treatment of Resident #233's wounds. The MD said the facility should have followed wound care orders given by the wound care center for all of Resident #233's wounds. The MD thought Resident #233 may have had a reddened area to her back and there was a question about what it was. She did not remember who had asked her to look at the area. She explained she recalled the wound care center had called the area a stage II pressure ulcer, but it was not in a pressure area over a boney area. The MD stated she had ordered triamcinolone cream to the area to see if it healed. The MD said she had felt the area had looked more like Psoriasis. An interview was conducted with Unit Coordinator #1 on 12/5/24 at 2:49 PM. She explained she had worked as a floor nurse during May 2024. She stated she had cared for Resident #233 during that time and had not recalled Resident #233 having a stage II pressure ulcer to her back. She said she recalled Resident #233 had areas of psoriasis that had been treated with a cream. An interview was conducted with Nurse #2 on 12/5/24 at 4:44 PM. Nurse #2 did not recall Resident #233 having a pressure ulcer to her left lower back. He said he did not remember her having any wounds except for the wounds to her legs. He recalled she had a rash to her body and said he thought it had maybe been psoriasis that had been treated with a cream. He did not remember there ever being any wound care orders for a pressure ulcer to Resident #233's left lower back. An interview was conducted with Nurse #3 on 12/5/24 at 4:45 PM. She explained she had been the wound care nurse but had left that position in February 2024. She stated she now worked at the facility as a floor nurse. Nurse #3 said she had cared for Resident #233, and she did not remember Resident #233 having a stage II pressure ulcer to her left back. She said Resident #233 had eczema and had dry bumpy skin but did not recall her having any wounds other than the wounds to her legs. An interview was conducted with the Director of Nursing (DON) on 12/5/24 at 3:36 PM. The DON had not recalled Resident #233 having a pressure ulcer to her left lower back. She only recalled Resident #233 having wounds to her legs and areas of eczema while she had been at the facility. The DON reviewed the April 2024 and May 2024 TAR for Resident #233 and verified there were no wound care orders present for a pressure ulcer to her left lower back. The DON explained there had been an issue with the notes from appointments being reviewed for new/updated orders. She explained it had been a facility wide problem she had become aware of in October 2024. The DON further explained, appointment notes had been scanned into the electronic records without first being reviewed for orders, changes, or follow up needs by a nurse. The DON said she thought Resident #233's wound care notes/orders had been scanned into the electronic record without first being reviewed for changes or new/ updated orders and that was why the facility had missed the orders and the information about the stage II pressure ulcer to her left lower back. The DON stated the facility had done a complete audit of all appointment notes but had not gone back to look at the notes for residents who had been discharged from the facility. The DON said the orders from the wound care center should have been implemented and followed by the facility, but that facility would not have known what those orders were if no one had reviewed the notes/ orders from the wound care center. An interview was conducted with the Administrator on 12/5/24 at 4:59 PM. The Administrator said the facility had discovered things had been scanned into the electronic chart of residents without being reviewed for orders, follow up needs, or orders being entered not the electronic computer system. The Administrator explained she thought this is what happened and why the wound care orders for Resident #233 had been missed. The Administrator stated the wound care center notes should have been reviewed for orders and the orders should have been implemented and followed by the facility for Resident #233.

Based on observations and staff interviews the facility failed to remove expired nutritional supplement from 1 of 2 nourishment room refrigerators. This practice had the potential to affect residents who received nutritional supplements. Findings included: On [DATE] at 2:12 PM an observation of the north nourishment room refrigerator was conducted with the Dietary Manager. The door shelf of the refrigerator contained one container of nutritional supplement dated with ,d+[DATE] received date and an additional date of ,d+[DATE] open date. The nutritional supplement container was approximately 25% full. The Dietary Manager stated during the observation that opened and stored refrigerator items should be discarded after 7 days. The Dietary Manager immediately discarded the nutritional supplement. The Dietary Manager stated the nourishment room refrigerator was checked two times daily, once in the morning and once in the evening by the dietary staff for expired items, dated and labeled open items, and items to restock. The Dietary Manager stated the nutritional supplement was placed in the refrigerator by a nurse and was unsure of when it was placed in the refrigerator. The Administrator stated on [DATE] at 5:17 PM that open nutritional supplements or opened food items should be disposed of when expired.

Based on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 2 of 7 residents reviewed for unnecessary medications (Residents #24 and Resident #38). The findings included: 1.Resident #24 was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia. Review of the medical record for Resident #24 revealed a lipid panel had not been completed since she was admitted to the facility on [DATE]. Review of the physician orders dated 11/12/21 revealed an order for Resident #24 to receive 1 tablet of atorvastatin 20 milligrams (mg) by mouth once daily at bedtime for hyperlipidemia. A review of medication administration records (MARs) indicated Resident #24 had received atorvastatin as ordered for the past 12 months. Review of Resident #24's vital signs revealed her blood pressure was stable and within the normal limits for the past 6 months. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #24 with intact cognition. A further review of medical records revealed the Consultant Pharmacist had completed medication regimen reviews for Resident #24 on the following dates in the past 12 months: 07/11/22, 08/05/22, 09/11/22, 10/19/22, 11/20/22, 12/17/22, 01/31/23, 02/20/23, 03/19/23, 04/20/23, 05/19/23, and 06/20/23. The Consultant Pharmacist had made several recommendations to the physician in the past 12 months. However, none of the recommendations were related to cholesterol level monitoring. During an interview conducted on 07/13/23 at 9:37 AM, Resident #24 stated she had been taking atorvastatin for more than 2 years in the facility. However, she could not recall the facility had ever checked her cholesterol level so far. She added her blood pressure in the past 6 months was stable and within the normal limits. An interview was conducted with the Medical Record Coordinator on 07/13/23 at 11:11 AM. She confirmed she could not find any records related to lipid panel for Resident #24 since her admission. 2. Resident #38 was admitted to the facility on [DATE] with diagnoses included diabetes mellitus. The diabetic care plan initiated on 06/18/22 for Resident #38 revealed she was diagnosed with diabetes mellitus with risk for complications. The goal was to remain free from signs and symptoms of hypoglycemia through the next review period. Intervention included administering insulin as ordered by the physician. Review of the physician's orders dated 03/27/23 revealed Resident #38 had an order to receive 3 units of Novolog insulin subcutaneously before meals for diabetes. The order specified to hold the insulin when Resident #38's CBG was lower than 150 mg/dL. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #38 with intact cognition. A review of the MARs for June and July 2023 revealed Resident #38 had received 3 units of Novolog insulin subcutaneously outside of the perimeter 34 times in June 2023 and 13 times in July 2023 when her CBGs were less than 150 mg/dL prior to insulin administration on the following occasions: - 06/01/23 in the evening when CBG = 111 mg/dL - 06/02/23 in the evening when CBG = 133 mg/dL - 06/04/23 in the morning when CBG = 137 mg/dL - 06/05/23 in the evening when CBG = 108 mg/dL - 06/06/23 in the morning when CBG = 128 mg/dL - 06/06/23 in the evening when CBG = 145 mg/dL - 06/08/23 in the morning when CBG = 114 mg/dL - 06/09/23 in the morning when CBG = 119 mg/dL - 06/10/23 in the morning when CBG = 133 mg/dL - 06/10/23 in the evening when CBG = 110 mg/dL - 06/11/23 in the morning when CBG = 107 mg/dL - 06/11/23 in the evening when CBG = 123 mg/dL - 06/12/23 in the morning when CBG = 106 mg/dL - 06/12/23 in the evening when CBG = 149 mg/dL - 06/13/23 in the evening when CBG = 139 mg/dL - 06/14/23 in the morning when CBG = 145 mg/dL - 06/15/23 in the morning when CBG = 141 mg/dL - 06/16/23 in the evening when CBG = 113 mg/dL - 06/18/23 in the morning when CBG = 117 mg/dL - 06/19/23 in the evening when CBG = 111 mg/dL - 06/20/23 in the morning when CBG = 137 mg/dL - 06/20/23 in the evening when CBG = 120 mg/dL - 06/21/23 in the morning when CBG = 107 mg/dL - 06/21/23 in the evening when CBG = 129 mg/dL - 06/22/23 in the evening when CBG = 144 mg/dL - 06/24/23 in the morning when CBG = 127 mg/dL - 06/24/23 in the evening when CBG = 106 mg/dL - 06/25/23 in the morning when CBG = 121 mg/dL - 06/25/23 in the evening when CBG = 108 mg/dL - 06/27/23 in the morning when CBG = 122 mg/dL - 06/27/23 in the evening when CBG = 134 mg/dL - 06/28/23 in the morning when CBG = 122 mg/dL - 06/29/23 in the evening when CBG = 117 mg/dL - 06/30/23 in the morning when CBG = 122 mg/dL - 07/01/23 in the morning when CBG = 99 mg/dL - 07/03/23 in the morning when CBG = 116 mg/dL - 07/03/23 in the evening when CBG = 117 mg/dL - 07/04/23 in the morning when CBG = 129 mg/dL - 07/05/23 in the morning when CBG = 124 mg/dL - 07/05/23 in the midday when CBG = 101 mg/dL - 07/06/23 in the morning when CBG = 114 mg/dL - 07/09/23 in the morning when CBG = 119 mg/dL - 07/09/23 in the midday when CBG = 139 mg/dL - 07/10/23 in the morning when CBG = 132 mg/dL - 07/11/23 in the morning when CBG = 94 mg/dL - 07/11/23 in the midday when CBG = 112 mg/dL - 07/12/23 in the morning when CBG = 116 mg/dL Review of medical records revealed the Consultant Pharmacist had completed medication regimen reviews for Resident #38 on the following dates in the past 12 months: 07/13/22, 08/13/22, 09/07/22, 10/20/22, 11/23/22, 12/18/22, 01/31/23, 02/21/23, 03/20/23, 04/23/23, 05/21/23, and 06/22/23. The Consultant Pharmacist had made several recommendations to the physician in the past 12 months. However, none of the recommendations were related to concerns over administering Novolog without following the perimeter. During an interview conducted on 07/13/23 at 1:35 PM, the Consultant Pharmacist explained the facility did not have an electronic lab protocol that would trigger lab orders automatically as indicated at certain time interval on regular basis. She added she had alerted the physician to order lipid panel for other residents as indicated but she did not know why Resident #24 was excluded. The Consultant Pharmacist stated she did not notice that nurses had been administering Novolog to Resident #38 without following the physician's perimeter repeatedly when she performed the monthly medication regimen reviews. A phone interview was conducted with the MD on 07/13/23 at 2:01 PM. She expected the Consultant Pharmacist to identify and report all drug irregularities related to Novolog and recommend lipid panel when it had not been in place for more than 1 year. During a joint interview conducted on 07/14/23 at 10:59 AM, the Director of Nursing and the Administrator expected the Consultant Pharmacist to identify and report all drug irregularities as indicated and provide recommendations to the physician in timely manner.

Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the facility failed to prevent a significant medication error when nurses failed to follow physician's perimeter setting as ordered during insulin administration. As a result, Resident #24 received 2 doses of unnecessary Novolog insulin within 1 day, and Resident #38 had received 34 doses of unnecessary Novolog insulin in June 2023, 13 doses of unnecessary Novolog insulin in July 2023. This affected 2 of 7 residents reviewed for significant medication errors (Resident #24 and Resident #38). The findings included: 1.Resident #24 was admitted to the facility on [DATE] with diagnoses included diabetes mellitus. The diabetic care plan initiated on 05/24/21 for Resident #24 revealed she was diagnosed with diabetes mellitus. The goal was to remain free of complications related to diabetes through the next review period. Intervention included to administer diabetes medications as ordered by the physician. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #24 with intact cognition. Review of the physician's orders dated 07/10/23 revealed Resident #24 had an order to receive 4 units of Novolog insulin subcutaneously before meals and at bedtime for diabetes. The order specified to hold the insulin when Resident #24's capillary blood glucose (CBG) was lower than 150 milligrams per deciliter (mg/dL). A review of the medication administration records (MARs) for July 2023 revealed Resident #24 had received 4 units of Novolog insulin subcutaneously 2 times outside of the perimeter within 1 day in July 2023 when her CBGs were less than 150 mg/dL prior to insulin administration on the following occasions: - 07/11/23 in the morning when CBG = 130 mg/dL - 07/11/23 at bedtime when CBG = 110 mg/dL 2. Resident #38 was admitted to the facility on [DATE] with diagnoses included diabetes mellitus. The diabetic care plan initiated on 06/18/22 for Resident #38 revealed she was diagnosed with diabetes mellitus with risk for complications. The goal was to remain free from signs and symptoms of hypoglycemia through the next review period. Intervention included administering insulin as ordered by the physician. Review of the physician's orders dated 03/27/23 revealed Resident #38 had an order to receive 3 units of Novolog insulin subcutaneously before meals for diabetes. The order specified to hold the insulin when Resident #38's CBG was lower than 150 mg/dL. The quarterly MDS dated [DATE] assessed Resident #38 with intact cognition. A review of the MARs for June and July 2023 revealed Resident #38 had received 3 units of Novolog insulin subcutaneously outside of the perimeter 34 times in June 2023 and 13 times in July 2023 when her CBGs were less than 150 mg/dL prior to insulin administration on the following occasions: - 06/01/23 in the evening when CBG = 111 mg/dL - 06/02/23 in the evening when CBG = 133 mg/dL - 06/04/23 in the morning when CBG = 137 mg/dL - 06/05/23 in the evening when CBG = 108 mg/dL - 06/06/23 in the morning when CBG = 128 mg/dL - 06/06/23 in the evening when CBG = 145 mg/dL - 06/08/23 in the morning when CBG = 114 mg/dL - 06/09/23 in the morning when CBG = 119 mg/dL - 06/10/23 in the morning when CBG = 133 mg/dL - 06/10/23 in the evening when CBG = 110 mg/dL - 06/11/23 in the morning when CBG = 107 mg/dL - 06/11/23 in the evening when CBG = 123 mg/dL - 06/12/23 in the morning when CBG = 106 mg/dL - 06/12/23 in the evening when CBG = 149 mg/dL - 06/13/23 in the evening when CBG = 139 mg/dL - 06/14/23 in the morning when CBG = 145 mg/dL - 06/15/23 in the morning when CBG = 141 mg/dL - 06/16/23 in the evening when CBG = 113 mg/dL - 06/18/23 in the morning when CBG = 117 mg/dL - 06/19/23 in the evening when CBG = 111 mg/dL - 06/20/23 in the morning when CBG = 137 mg/dL - 06/20/23 in the evening when CBG = 120 mg/dL - 06/21/23 in the morning when CBG = 107 mg/dL - 06/21/23 in the evening when CBG = 129 mg/dL - 06/22/23 in the evening when CBG = 144 mg/dL - 06/24/23 in the morning when CBG = 127 mg/dL - 06/24/23 in the evening when CBG = 106 mg/dL - 06/25/23 in the morning when CBG = 121 mg/dL - 06/25/23 in the evening when CBG = 108 mg/dL - 06/27/23 in the morning when CBG = 122 mg/dL - 06/27/23 in the evening when CBG = 134 mg/dL - 06/28/23 in the morning when CBG = 122 mg/dL - 06/29/23 in the evening when CBG = 117 mg/dL - 06/30/23 in the morning when CBG = 122 mg/dL - 07/01/23 in the morning when CBG = 99 mg/dL - 07/03/23 in the morning when CBG = 116 mg/dL - 07/03/23 in the evening when CBG = 117 mg/dL - 07/04/23 in the morning when CBG = 129 mg/dL - 07/05/23 in the morning when CBG = 124 mg/dL - 07/05/23 in the midday when CBG = 101 mg/dL - 07/06/23 in the morning when CBG = 114 mg/dL - 07/09/23 in the morning when CBG = 119 mg/dL - 07/09/23 in the midday when CBG = 139 mg/dL - 07/10/23 in the morning when CBG = 132 mg/dL - 07/11/23 in the morning when CBG = 94 mg/dL - 07/11/23 in the midday when CBG = 112 mg/dL - 07/12/23 in the morning when CBG = 116 mg/dL During an interview conducted on 07/13/23 at 9:07 AM, Nurse #1 acknowledged that she was working on 06/01/23, 06/05/23, 06/11/23, 06/16/23, 06/19/23, 06/24/23, 06/25/23, 06/29/23, and 07/03/23 and confirmed she had administered Novolog to Resident #38 repeatedly when her CBGs were less than 150 mg/dL. She was aware of the perimeter set by the physician to hold the Novolog if the CBG was less than 150 mg/dL. She explained most of the times when she told Resident #38 her CBG level, she would request to have the Novolog as she planned to have some snacks soon. Nurse #1 stated Resident #38 had the right to have the insulin and added she did not consult the physician prior to administering Novolog outside of the perimeter. An interview was conducted with the Unit Manager on 07/13/23 at 9:34 AM. She expected the nurse to consult the physician to obtain order to administer Novolog outside of the perimeter. It was her expectation all the nurses to follow physician's order and the perimeter all the time. During an interview conducted on 07/13/23 at 9:37 AM, Resident #24 could not recall if she had ever requested to have Novolog from the nurse when her glucose level was less than 150 mg/dL. An interview was conducted with Nurse #2 on 07/13/23 at 10:06 AM. She acknowledged that she worked on 06/06/23. 06/08/23, 06/12/23, 06/21/23, 07/05/23, and 07/11/23 and confirmed she had administered Novolog to Resident #24 and Resident #38 repeatedly when their CBGs were less than 150 mg/dL. She was aware of the perimeter attached to the Novolog order. Nurse #2 explained both Resident #24 and Resident #38 would request to have the Novolog when they were notified of CBG below 150 mg/dL as they planned to have some snacks within a short period of time. She stated she should have consulted the physician before administering the Novolog outside of the perimeter. During an interview conducted on 07/13/23 at 11:29 AM, Resident #38 confirmed she had requested the nurse to give her Novolog frequently when her CBG was below 150 mg/dL as she planned to have some snacks very soon after the CBG checks. During an interview conducted on 07/13/23 at 1:35 PM, the Consultant Pharmacist stated she did not notice that nurses had been administering Novolog to Resident #38 repeatedly without following physician's perimeter when she performed the monthly medication regimen reviews. She added the incident was a significant medication error as it involved insulin. A phone interview was conducted with the MD on 07/13/23 at 2:01 PM. She stated the nurse should not administer the Novolog when the CBGs were less than 150 mg/dL. It was her expectation for all nurses to follow the physician's order and its perimeter all the time. She was not sure if the incident would be considered as a significant medication error. During a joint interview conducted on 07/14/23 at 10:59 AM, the Director of Nursing and the Administrator acknowledged that the incident was a significant medication error as it involved insulin with the potential of triggering low blood glucose level. Both expected all nursing staff to follow physician's order and the set perimeters fully when administering medications.

Based on observations and staff interviews the facility failed to maintain a walk-in refrigerator from an accumulation of thick, clumpy grayish matter on the circulatory fan cover and thick, clumpy darkish buildup on the floor of 1 of 2 walk-in refrigerators. In addition, the facility failed to discard 2 opened loaves of expired bread. This practice had the potential to affect foods served to residents. Findings included: 1.On [DATE] at 9:32 AM an observation of the kitchen prep table revealed 2 opened loaves of bread sitting next to the toaster and ready to be used. The label on the plastic wrap of the white sandwich bread indicated it was expired on [DATE] and the whole wheat bread revealed it was expired on [DATE]. Further observation revealed half of both loaves of bread had been used. During an interview conducted on [DATE] at 9:37 AM, Cook #1 stated she had used one slice of bread from both loaves of bread this morning to make toasts for residents. She explained it was her oversight as she did not pay attention to the expiration dates of the breads prior to using it. She acknowledged that both loaves of bread should be discarded as they were expired. 2. On [DATE] at 10:11 AM an observation of one of the two walk-in refrigerators revealed the entire floor was covered with rubber mat approximately 1 inch in thickness. Further observation revealed the floor had an accumulation of thick, clumpy, darkish matter underneath the rubber mat. In addition, the air vents in the same walk-in refrigerator were observed with a buildup of thick, clumpy grayish matter on the circulatory fan cover, around the light, and electrical cords. During an interview conducted on [DATE] at 10:20 AM, the Kitchen Manager stated she did not know why Cook #1 did not check the expiration date of the breads before using it. It was her expectation for the kitchen staff to check the expiration date of each food items before using it. She was aware of the dirty floor and dirty air vents in one of the walk-in refrigerators and planned to assign a kitchen staff to clean it. She explained she had just started the role as the kitchen manager about 1 month ago and there were a lot of issues to be addressed. It was her expectation for the floor and the air vents in the walk-in refrigerator to remain clean all the time. During a joint interview conducted on [DATE] at 10:59 AM, the Director of Nursing and the Administrator expected the kitchen to remain clean and free of expired foods.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) regarding smoking for 1 of 1 resident reviewed for smoking (Resident #58). Findings included: Resident #58 was admitted to the facility on [DATE]. The smoking care plan initiated on 01/31/23 for Resident #58 revealed she was an unsafe smoker. The goal was to remain free of injury from unsafe smoking practices through the review date. Interventions included instructing Resident #58 about smoking risks and policy of smoking, monitoring for unsafe smoking with oxygen, and providing supervision when while smoking. Review the smoking assessment for Resident #58 on 04/28/23 revealed she was assessed as an unsafe smoker and required direct supervision during smoking. Review of the admission MDS dated [DATE] revealed Resident #58 was coded as a non-tobacco user under Section J 1300. During an interview conducted on 07/11/23 at 3:03 PM, Resident #58 stated she had smoked cigarettes from the day she had been admitted to the facility. During an observation conducted on 07/12/23 at 1:27 PM, Resident #58 was seen smoking in the courtyard with 3 other residents under the supervision of 1 facility staff. During an interview conducted on 07/14/23 at 9:45 AM, the MDS Coordinator stated Resident #58 had been a tobacco user since she admitted to the facility late last year. He confirmed he was responsible for Resident #58's MDS and it was an error to code her as a non-tobacco user due to his oversight. He added the error would be corrected and the MDS re-submitted as soon as possible. During a joint interview conducted on 07/14/23 at 10:59 AM, the Director of Nursing and the Administrator expected all the MDS assessments to be coded accurately.

Based on record reviews and interviews with Resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to monitor cholesterol level for 1 of 7 residents reviewed for unnecessary medications (Resident #24). The findings included: Review of lipid guidelines published in 2019 by American College of Cardiology and American Heart Association indicated a lipid panel should be conducted at baseline, then 4 to 12 weeks after statin therapy was started or when a dosage was adjusted. Afterwards, a lipid panel test should be repeated once every 3 to 12 months or as needed. Resident #24 was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia. Review of medical records for Resident #24 revealed a lipid panel had not been completed since she was admitted to the facility on [DATE]. Review of physician's orders dated 11/12/21 revealed an order for Resident #24 to receive 1 tablet of atorvastatin 20 milligrams (mg) by mouth once daily at bedtime for hyperlipidemia. A review of the medication administration record (MARs) indicated Resident #24 had received atorvastatin as ordered for the past 12 months. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #24 with intact cognition. During an interview conducted on 07/13/23 at 9:37 AM, Resident #24 stated she had been taking atorvastatin for more than 2 years in the facility. However, she could not recall the facility had ever checked her cholesterol level. An interview was conducted with the Medical Record Coordinator on 07/13/23 at 11:11 AM. She confirmed she could not find any records of lipid panel being completed for Resident #24 since her admission. During an interview conducted on 07/13/23 at 1:35 PM, the Consultant Pharmacist explained the facility did not have an electronic lab protocol that would trigger lab orders automatically as indicated at certain time interval on a regular basis. She added she had alerted the physician to order a lipid panel for other residents as indicated but she did not know why Resident #24 was excluded. A phone interview was conducted with the MD on 07/13/23 at 2:01 PM. She stated she expected the facility to conduct a lipid panel for Resident #24 at least once per year or as needed according to the published lipid guidelines. During a joint interview conducted on 07/14/23 at 10:59 AM, the Director of Nursing and the Administrator expected the facility to conduct lipid panels as indicated per the published lipid guidelines for all the residents with statin therapy for cholesterol monitoring.

Based on medical record review, resident and staff interviews, the facility failed to provide 2 staff members when using a sit-to-stand mechanical lift for 1 of 2 residents (Resident #21) as per the care plan which resulted in a fall with fractures of the distal tibia (shin bone) and fibula (calf bone) with displacement. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, charcot's joint of the right ankle and foot (a complication which affects the bones, joints, and soft tissues of the foot and ankle causing the bones to become weak and break, or the joints to dislocate), type 2 diabetes, and lumbago with sciatica (pain that radiates along the sciatic nerve which runs down one or both legs from the lower back). Review of the quarterly Minimum Data Set, dated dated dated [DATE] for Resident #21 revealed he was cognitively intact and required extensive assist of 1 person for transfers. Resident #21 had a care plan dated 12/16/20 in place for falls and activities of daily living where it stated he required a mechanical lift assist with 2 staff members for transfers. Interview on 12/13/21 at 10:14 AM with Resident #21 revealed he had a fall in March 2021 from a nurse aide not using the stand-up lift with 2 people. Resident #21 stated a few days later he thought his sciatica was acting up, he went to the hospital, and found out his left leg was broken. Review of the incident report dated 3/12/21 for Resident #21 revealed the nurse stated she was called into the shower room by the nurse aide and saw Resident #21 had slid down from the sit-to-stand lift. The nurse reported Resident #21 stated he slid down in the sit-to-stand lift during a transfer with his left foot and leg under him. Review of the nurse note dated 3/12/21 for Resident #21 revealed he had experienced leg weakness and slid down in the sit-to-stand lift. Resident #21 was assessed by the nurse, had no apparent injury, and did not complain of any pain or discomfort. Review of the nurse note dated 3/16/21 for Resident #21 revealed the nurse was called to therapy to look at Resident #21's left ankle. Resident #21 told the nurse he had rolled his ankle in the shower a few days prior on Friday when transferring to the wheelchair, but he had no pain, discomfort, or swelling with the ankle over the weekend. Resident #21 told the nurse he had rolled his left ankle again in therapy and the ankle was now painful, bruised, and swollen. Review of the physician orders dated 3/16/21 for Resident #21 revealed and order for x-ray to left ankle/foot due to swelling, bruising, and pain, and an order to transfer to the emergency room for evaluation and treatment of left tibia/fibula fractures. Review of the radiology results report dated 3/16/21 for Resident #21 revealed acute fractures of the distal tibia and fibula with displacement. The hospital discharge summary dated 3/20/21 revealed Resident #21 presented to the emergency department on 3/16/21 after experiencing a fall, resulting in the fracture of his left ankle. In addition, the x-rays noted a displaced left distal tibial fracture with a comminuted (breakage of bone into more than two fragments) distal fibula fracture. Resident #21 had an intramedullary nail fixation ( permanent nail/rod is placed in the center of the bone) on 3/18/21 and due to the amount of bruising and swelling the fibula could not be repaired at that time. It was noted this would be addressed at the outpatient follow-up in approximately two weeks. Review of a progress note dated 3/22/21 revealed Resident #21 was seen by the physician assistant to review overall status upon readmission following surgical fixation of the left distal tibia/fibula fracture. It was documented Resident #21 complained of ankle pain in the facility last week after a fall in the shower room. Interview on 12/15/21 at 5:53 PM with Nurse Aide #1 revealed she had assisted Resident #21 out of the shower and back into his wheelchair on 03/12/21. Nurse Aide #1 stated she had Resident #21 in the sit-to-stand mechanical lift and his right knee gave out on him and she lowered him to the floor. Nurse Aide #1 revealed she asked Resident #21 if he was hurting anywhere and he said no. Nurse Aide #1 stated she went and got the nurse who also asked Resident #21 if he was hurting which he again denied any pain, so they assisted Resident #21 up to his wheelchair. Nurse Aide #1 revealed she was not aware she was to use 2 staff with the sit-to-stand mechanical lift. Interview on 12/15/21 at 4:35 PM with Nurse #4 revealed the nurse aide had came and told me Resident #21 had slid down from the sit-to-stand lift. Nurse #4 stated Resident #21 had said his left leg hurt a little bit but there was no swelling or discoloration. Nurse #4 revealed Resident #21 was his usual self, laughing with her and the nurse aide and they had assisted Resident #21 back to the wheelchair. Nurse #4 stated Resident #21 did not complain of any pain to her after that. Nurse #4 also stated she did not think there was another nursing staff member assisting the nurse aide with the sit-to-stand lift with Resident #21. Interview on 12/16/21 at 1:21 PM with the Director of Nursing (DON) revealed staff should follow the facility's mechanical lift policy and she expected staff would use a 2 person assist with a mechanical lift. Interview on 12/16/21 at 1:45 PM with the Administrator revealed staff should follow the policy for mechanical lift usage and he expected staff would use 2 people with the mechanical lift at all times.

Based on observations and staff interviews the facility failed to implement a Legionella prevention program that could have affected 55 of 55 residents. The facility also failed to have hand sanitizer or a functioning hand washing station available in 1 of 2 laundry rooms that could have affected 43 of 55 residents reviewed for infection control. 1. Review of the Emergency Preparedness workbook with the Administrator on 12/16/21 at 11:27 AM revealed no information on water safety management for Legionella. He explained he would speak with the Director of Maintenance to acquire about the information. The water safety plan workbook for Legionella dated 09/23/2018 was reviewed. There were no updated facility risk assessments or monitoring logs since 2018. An interview with the Director of Maintenance on 12/16/21 at 12:55 PM revealed he was not aware that he was supposed to complete a yearly facility risk assessment or log his checks and procedures for his water safety plan. An interview with the Administrator on 12/16/21 at 1:57 PM revealed his expectation was for the facility to be in compliance with the Legionella policy. 2. An observation of the South hall laundry room on 12/14/21 at 9:10 AM revealed there was no hand sanitizer available. LA #1 was interviewed at the time of the observation and indicated there was no hand sanitizer in the laundry room. He stated he went outside the laundry room door and sanitized his hands in the resident hallway every time he changed gloves. On 12/14/21 at 9:25 AM, LA #1 stated the sink with the hand soap above it did not work and water could not flow through the pipes. He further stated he was hired a year ago never washed his hands in that sink. An interview with the Environmental Services Manager (ESM) on 12/14/21 at 9:21 AM revealed LA #1 usually cleaned his hands at the sink in the laundry room. On 12/14/21 at 10:42 AM, it was observed that no water flowed out of the sink faucet in the South hall laundry room when the sink handles were used. On 12/14/21 at 10:50 AM, the ESM further stated he was unsure how long the sink had been inoperable. The ESM was not aware until it was brought to his attention on 12/14/21. An interview with the Director of Nursing (DON) on 12/15/21 at 7:47 AM revealed the sink with the hand soap should have been working and hand sanitizer should have been available in the laundry rooms.

Based on observation and staff interviews, the facility failed to remove expired medication from 3 of 4 medication carts (South medication cart, South Blue medication cart, South Green medication cart) and 1 of 2 medication storage rooms (North medication storage room). Findings included: 1. a. Observation on 12/15/21 at 10:30 AM with Nurse #2 of the North medication storage room revealed the following expired medications unopened and available for use: - [MEDICATION(S)] Gel 1.5 fluid ounces (oz) expired 10/2021 - Skin Integrity Hydrogel 4 oz expired 2/2021 Interview on 12/15/21 at 10:56 AM with the Unit Manager revealed the nurses were all responsible for making sure wound care supplies were not expired. b. Observation on 12/15/21 at 11:46 AM with Nurse #3 of the South medication cart revealed the following expired medications labeled for a resident and available for administration: - [MEDICATION(S)] (HCL) 2 milligram (mg) capsule medication card expired 10/31/2021 - [MEDICATION(S)] 250 mg tablet medication card expired 11/30/2021 - [MEDICATION(S)] 250 mg tablet medication card expired 11/30/2021 - Liquid [MEDICATION(S)] Acetaminophen 160 mg/ 5 milliliter (ml) 16 fluid oz, stock medication ¾ full, expired 8/2021 Interview on 12/15/21 at 11:46 AM with Nurse #3 revealed the night nurses should be going through the medication cart to remove expired medications monthly. c. Observation on 12/15/21 at 12:46 PM with Medication Aide #1 of the South Blue medication cart revealed the following expired medications were available for administration: - [MEDICATION(S)] HCL 10 mg tablet medication card, labeled for a resident, expired 10/31/2021 - 3 fuchsia-colored tablets in a medication cup with the word cranberry handwritten on the cup, no expiration date present Interview with Medication Aide #1 revealed the fuchsia-colored tablets in the medication cup with the word cranberry handwritten on the cup were the only cranberry tablets she knew of in the facility. Medication Aide #1 stated she did not know who should be checking for expiration dates on medications. d. Observation on 12/15/21 at 12:46 PM with Medication Aide #1 of the South Green medication cart revealed the following expired medications labeled for a resident and available for administration: - [MEDICATION(S)] 100 mg tablet medication card expired 11/30/21 - [MEDICATION(S)] HCL Slow Release 150 mg tablet medication card expired 11/30/21 Interview on 12/15/21 at 3:19 PM with the Unit Manager revealed the nurses should be doing quarterly medication expiration cart audits. The Unit Manager stated the Unit Managers should go through the carts every week or 2 to ensure all expired medications were removed, all narcotics were current, and all medications were ordered. The Unit Manger revealed every nurse on every shift should be looking at the medication cart for expired medications. Interview on 12/16/21 at 1:21 PM with the Director of Nursing (DON) revealed the night shift nurses should check for expired medications every night when they completed their medication cart checks and cleaned the medication carts. The DON stated all nurses were responsible for checking expiration dates of medications. The DON also stated the 3 fuchsia-colored tablets in a medication cup with the word cranberry handwritten on the cup should have not been in the medication cart. The DON revealed she expected the night nurses would check the medication carts for expired medications nightly.

Based on record review and resident, staff, and resident representative (RP) interviews the facility failed to offer 3 of 5 residents (Residents #1, #14, and #41) the COVID-19 vaccine. These failures occurred during a COVID-19 pandemic. Findings included: Review of the facility COVID-19 vaccination policy for residents updated October 2021 indicated all residents of the center should be offered the COVID-19 vaccine unless there was a documented medical contraindication, or the resident had already been fully vaccinated. The center would educate residents or RPs, if applicable, regarding the benefits and potential side effects associated with receiving the COVID-10 vaccine and offer the COVID-19 vaccine, unless it is medically contraindicated, or the resident has already been immunized. The center will maintain proper documentation in the resident's MR to reflect the resident was provided the required COVID-19 vaccine education, and whether the resident received the vaccine. The center will track which residents received the vaccine, as well as those who refused or did not get vaccinated. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a quarterly minimum data set assessment (MDS) for Resident #1 dated 9/8/21 indicated he was cognitively intact. A review of the immunization section of Resident #1's medical record did not indicate any information regarding the offer or refusal of the COVID-19 vaccine since his admission. A review of Resident #1's medical record did not reveal any information indicating he was offered or refused the COVID-19 vaccine since his admission. On 12/13/21 at 12:26 PM an interview with Resident #1 stated he was not offered the COVID-19 vaccine since he was admitted . He further indicated he would have accepted one if it had been offered to him. On 12/15/21 at 7:52 AM an interview with the Infection Preventionist (IP) indicated she could not find any information in Resident #1's medical record regarding the offer or refusal of the COVID-19 vaccine. She stated there should have been documentation in Resident #1's record that he was educated on the risks versus the benefits of this vaccine and either a signed consent form and record of administration or a refusal of the vaccine. The IP stated Resident #1 received the first dose of the Moderna COVID-19 vaccine on 12/14/21, which was after surveyor intervention. On 12/15/21 at 3:01 PM an interview with the Administrator indicated there should have been documentation in Resident #1's record that he was educated on the risks versus the benefits of the COVID-19 vaccine and either a signed consent form and record of administration or a refusal of the vaccine. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a quarterly MDS assessment for Resident #14 dated 10/11/21 indicated she was moderately cognitively impaired. A review of the immunization section of Resident #14's medical record did not indicate any information related to the COVID-19 vaccine. A review of Resident #14's medical record did not reveal any information indicating she was offered or refused the COVID-19 vaccine since her admission. On 12/16/21 at 11:51 AM an interview with Resident #14 stated she was not offered the COVID-19 vaccine since she was admitted . She further indicated she would have accepted one if it had been offered to her. She stated she was unsure why she didn't get it prior to a few days ago. Multiple attempts for a telephone interview with Resident #14's Responsible Party (RP) were made, but he was not able to be reached. On 12/15/21 at 7:52 AM an interview with the Infection Preventionist (IP) indicated she could not find any information in Resident #14's medical record regarding the offer or refusal of the COVID-19 vaccine. She stated there should have been documentation in Resident #14's record that she and her RP were educated on the risks versus the benefits of this vaccine and either a signed consent form and record of administration or a refusal of the vaccine. The IP stated Resident #14 received the one-dose Johnson and Johnson COVID-19 vaccine on 12/14/21, which was after surveyor intervention. On 12/15/21 at 3:01 PM an interview with the Administrator indicated there should have been documentation in Resident #14's record that she and her RP were educated on the risks versus the benefits of the COVID-19 vaccine and either a signed consent form and record of administration or a refusal of the vaccine. 3. Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the significant change MDS assessment for Resident #41 dated 11/17/21 indicated Resident #41 was severely cognitively impaired. A review of the immunization section of Resident #41's medical record indicated no information regarding any education, offer or refusal of the COVID-19 vaccine. On 12/16/21 at 11:26 AM a telephone interview with Resident #41's RP indicated she and Resident #41 requested the COVID-19 vaccine from various nurses (names unknown). She stated she could not recall if the vaccine was discussed during the admission process. Resident #41's RP inquired with a nurse (name unknown) about the vaccine one month ago, they said they would look into it, and no one got back to her. On 12/15/21 at 7:52 AM an interview with the Infection Preventionist (IP) indicated she could not find any information in Resident #41's medical record regarding the offer or refusal of the COVID-19 vaccine. She stated there should have been documentation in Resident #41's record that she and his RP were educated on the risks versus the benefits of this vaccine and either a signed consent form and record of administration or a refusal of the vaccine. The IP stated Resident #41 received the first dose of the Moderna COVID-19 vaccine on 12/14/21, which was after surveyor intervention. On 12/15/21 at 3:01 PM an interview with the Administrator indicated there should have been documentation in Resident #41's record that he and his RP were educated on the risks versus the benefits of the COVID-19 vaccine and either a signed consent form and record of administration or a refusal of the vaccine.

Based on record review and staff interviews, the facility failed to develop a baseline care plan in all areas within 48 hours of admission for 1 of 1 resident (Resident #59) reviewed for closed record. The findings included: Resident #59 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #59's admission evaluation dated 09/30/21 revealed Resident #59 was dependent with activities of daily living and mobility. An interview with the Director of Nursing (DON) on 12/15/21 at 2:50 PM revealed no baseline care plan was developed for Resident #59. An interview with the Unit Manager on 12/15/21 at 4:00 PM about the baseline care plan for Resident #59 revealed the admission evaluation triggered the baseline care plan and nurses and unit managers were responsible for developing the baseline care plan within three days of admission. She had no knowledge of why a baseline care plan was not developed for Resident #59 or why the admission evaluation did not trigger a baseline care plan. The MDS Coordinator was interviewed on 12/15/21 at 3:34 PM about the baseline care plan for Resident #59. She revealed no baseline care plan was developed for Resident #59. She stated the admission evaluation triggered the baseline care plan and nursing was responsible for completing the baseline care plan. The DON was interviewed on 12/16/21 at 11:54 AM about the process for baseline care plans. She revealed the admission evaluation triggered a baseline care plan for nursing to complete within 48 hours. She was not sure why a baseline care plan would not be completed for a resident or Resident #59. The Administrator was interviewed on 12/16/21 at 11:33 AM about the process for baseline care plans. He knew each resident was supposed to have a baseline care plan within 72 hours and had no knowledge of why a resident would not have a baseline care plan.

Based on record review and staff interviews the facility failed to train 1 of 1 nurse aides on the sit to stand mechanical lift (Nurse Aide #1). The findings included: Interview on 12/15/21 at 5:52 PM with Nurse Aide #1 revealed she knew staff were to use 2 people when using the Hoyer mechanical lift but was not aware staff were to use 2 people when using the Sit-To-Stand mechanical lift. Review of the policy for Lift, Transfer, and Repositioning dated 2010 revealed the facility required 2 staff members to assist when lifting with mechanical lifting devices. Interview on 12/16/21 at 11:27 AM with the District Director of Clinical Services revealed all new employees including agency personal received training on resident safety and lift training upon hire and then quarterly through the year. The District Director of Clinical Services stated she was unable to locate Nurse Aide #1's orientation competency paperwork. Review of the materials covered in the Orientation Competency nurse aide packet revealed there was a competency required for mechanical lift use as well as an acknowledgement stating staff must watch a 2-part video and complete a return demonstration for each mechanical lift of the Hoyer mechanical lift and the Sit-To-Stand mechanical lift. The Orientation Competency paperwork also stated a mechanical lift always required 2 nursing staff members. Interview on 12/16/21 at 1:21 PM with the Director of Nursing (DON) revealed staff should follow the facility's policy for mechanical lift usage. The DON stated she expected staff would use 2 people to assist with any mechanical lift. The DON revealed all nursing staff should possess the competencies and skill sets necessary to provide care to meet the residents' needs. The DON also revealed she was responsible for assuring these competencies were completed for nursing staff. Interview on 12/16/21 at 1:45 PM with the Administrator revealed staff should follow the facility's policy for mechanical lift usage and 2 staff should use the mechanical lift at all times. The Administrator stated he expected all staff to possess the competencies and skill sets necessary to provide care to meet the residents' needs.

Based on record review, staff interview, pharmacy and physician interview the facility failed to obtain intravenous antibiotics (IVABs) from an outside pharmacy provider for 1 of 3 Residents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] at 9:00pm with a [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 9/15/19 and then readmitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #1 was cognitively intact and required extensive assistance with activities of daily living (ADL's). Review of hospital discharge summary dated 9/14/19 revealed Resident #1 had a Urinary tract infection [MEDICAL CONDITIONS]. Resident #1 was discharged with [MEDICATION NAME] 3.375 grams (antibiotic) intravenously every 8 hours for 14 days. Review of admission nurse's note dated 9/14/19 revealed Resident #1 was admitted to the facility via stretcher with a scheduled dose of [MEDICATION NAME] due at 10:00pm. The admission note further stated [MEDICATION NAME] was on hand but it was unable to be titrated for the dose prescribed. The Medication Variance report dated 9/14/19 written by the DON revealed Resident #1 was admitted to the facility after 5:00pm on Saturday 9/14/19 from the hospital with orders for [MEDICATION NAME] 3.375 grams. The scheduled dose at 10:00pm and 6:00am on 9/15/19 did not arrive from the pharmacy until after the 6:00 am dose on 9/15/19. The note continued that a decision was made to send Resident #1 to the emergency room due to a new onset of confusion. The note further stated there was no way to formulate the correct dose [MEDICATION NAME] from the available medication in the facility. Review of Grievance form dated 9/15/19 revealed Resident #1 missed two doses of IV antibiotics ([MEDICATION NAME]) upon return from the hospital. The investigation summary revealed medications were received from pharmacy and nurse education was completed regarding medication availability. Review of (MONTH) 2019 Medication Administration Record [REDACTED]. Nursing note dated 9/20/19 indicated Resident #1's [MEDICATION NAME] was held due to not having the medication on hand. Nursing note dated 9/20/2019 revealed an order was received from the physician to administer Resident #1's missed dose of [MEDICATION NAME] held on 9/20/19 concurrent with Resident #1's next dose of [MEDICATION NAME] on 9/21/19 at 6:00am. Review of (MONTH) 2019 Medication Administration Record [REDACTED]. Nursing note dated 9/24/19 revealed Resident #1's [MEDICATION NAME] was held until the new supply arrived from pharmacy. Interview with pharmacy representative on 10/16/19 at 4:02pm revealed the pharmacy received orders from the facility through fax and telephone and electronic means. She stated in the instance a resident required medication following cut off pharmacy hours of 5:00pm on Saturday the facility should contact the pharmacy. If the facility required a STAT order after hours, it would come from the back up pharmacy. The pharmacy representative further stated the backup pharmacy would not normally have an IV antibiotic medication available. Interview with physician on 10/16/19 at 4:12pm reveled he recalled the incident involving Resident #1's antibiotic not being available upon admission. He indicated the issue was discussed during a facilities Quality Assurance (QA) meeting regarding medication not being available when residents are admitted when certain mediations may not be available for delivery after hours. The physician stated the medication were to be given as prescribed. He further revealed the nursing staff were to receive the medications and in the instance it was an unique medication request, the nurse should request the discharging hospital send the next does with the resident. The physician stated in the instance the hospital would not provide the medication the admission should have been postponed until the next day when the medication could be obtained. A continued interview with the pharmacy representative on 10/17/19 at 10:17am revealed Pharmacy timeline instructions requested orders to be placed 3-5 days before running out. If orders were received after cutoff time the medication would be delivered the following day. Interview with Resident #1 on 10/17/19 at 11:15am revealed she recalled the facility not having her antibiotic the night she was admitted . She further stated she assumed the issue was resolved. Interview with the Director of Nursing (DON) on 10/17/19 at 12:00pm revealed she was aware of the antibiotic Zyson was not available for Resident #1 upon admission. Resident #1 was admitted after the cut of time for deliveries from the outside pharmacy. She stated Resident #1 did not receive 1 dose of the Antibiotic on 9/14/19 and 9/15/19. She further revealed Resident #1 was discharged to the Hospital the morning of 9/15/19 and received her Antibiotics while hospitalized . She stated the facility had discussed the concern in QA meeting with members of management and the facility physician in an attempt to ensure medications were available upon admission. Following a review of Resident #1s (MONTH) MAR indicated [REDACTED]. The DON indicated residents should have medications on hand at the time they are scheduled to be administered.

Based on observations, record review, review of manufacturer's instructions, and staff, resident, Physician, Emergency Medical Technician (EMT), and manufacturer representative interviews, the facility failed to ensure the transport van's S-hooks were properly secured to a wheelchair during a van transport for 1 of 1 resident reviewed for supervision to prevent accidents. Resident #1's wheelchair flipped backwards and she struck her head and landed on the oxygen tank that was strapped to the back of her wheelchair. The Transportation Aide (TA) removed the oxygen tank and wheelchair prior to the resident being assessed by a Nurse or EMT. Resident #1 was transported to the hospital and diagnosed with [REDACTED]. Findings included: Review of the manufacturer's instructions for the FF600 Retractor Systems Track Applications which is the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport specified, place the S-hook securely around a structural member (non-detachable part of the frame) of the wheelchair. Pull on the S-hook to ensure full engagement around the structural member. Push the retractor release lever until loose webbing is retracted. Repeat procedure for other retractors. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included diabetes, muscle wasting and atrophy, and [MEDICAL CONDITION]. The quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #1 with intact cognition, used a wheelchair for mobility and required limited to extensive assistance with activities of daily living. Review of Resident #1's medical record revealed no [DIAGNOSES REDACTED]. The facility's incident/accident report dated 07/10/19 indicated the following: *Location: out of facility during transport. *Description: Resident #1 fell over in her wheelchair during transport. Nurse #1 received phone call and went to van to evaluate Resident #1. Appeared more confused than earlier in the AM. Complained of back pain from the neck down to her hips and in left arm. 911 called and Resident #1 sent to Emergency Department (ED) for evaluation and treatment. *Immediate Action Taken: Assessment was done and Resident #1 sent to the ED due to complaints of back pain from the hip to her neck and left arm. Reported level of pain 6 out of 10. It was noted Resident #1 was lethargic (drowsy) and with tremor and frequent jerking motions. Review of the facility's post fall review dated 07/10/19 read in part, Witnessed fall with possible head injury, back pain, hit head. Resident #1 fell over in the wheelchair during transport. Physician and Responsible Party (RP) both notified. The ED report dated 07/10/19 revealed Resident #1 arrived by ambulance for evaluation after a fall while being transported to an appointment. The report read in part, She was being transported in a wheelchair van. She was not strapped into a wheelchair. When the van made a sharp curved the patient fell from the wheelchair. She hit her buttocks against the bottom of the van and had likely some degree of whiplash injury to her neck. She also may have hit her head. No loss of consciousness. Resident #1 received Computerized [NAME]ography (CT) scans (computer generated images of the bones, blood vessels and soft tissues inside the body) of the head and lumbar spine that were positive for injury. Resident #1 was diagnosed with [REDACTED]. Resident #1 was transferred to another hospital for a higher level of acute care on 07/10/19 and subsequently discharged to a hospice facility. Resident #1 was unable to be interviewed. A telephone interview was conducted with Transportation Aide (TA) #1 on 07/22/19 at 4:29 PM. TA #1 confirmed she was driving the transport van on 07/10/19 when Resident #1 fell over in the wheelchair during transport and has not been back to work since the incident. TA #1 explained prior to departure, she loaded Resident #1 into the facility van, secured the resident's wheelchair to the van using a 4-point S-hook floor straps and a 2-point lap/shoulder belt, ratcheted the floor straps down, and doubled-checked to make sure the safety straps were secure. TA #1 stated she then drove out of the facility's parking lot, stopped at a red light and as she veered the van toward the right, she felt a couple of kicks on the back of her seat and then heard Resident #7 state Resident #1 had fallen. She added she immediately pulled the van over into a parking lot and noticed Resident #1 had fallen backwards in the wheelchair landing on the floor of the van, looking upward toward the ceiling of the van and lying on top of the oxygen tank that was strapped to the back of the wheelchair. TA #1 verified the front 2 S-hook straps were no longer attached to the wheelchair. She added the Administrator and Nurse #1 were immediately notified and came to the scene of the incident. TA #1 stated Resident #1 was able to roll enough that allowed her to pull the oxygen tank and wheelchair out from underneath her. TA #1 stated she always made sure all safety measures were in place and secure prior to departure but was unable to explain how the front 2 S-hook floor straps had come loose. An interview was conducted with Resident #7 on 07/22/19 at 5:41 PM, who was assessed with [REDACTED]. Resident #7 confirmed he was in the facility van with Resident #1 during transport on 07/10/19 and stated the incident occurred just after we pulled out of the parking lot at the red light. Resident #7 added Resident #1 was positioned in her wheelchair, facing the front of the van, about a wheelchair's length in front of his wheelchair. Resident #7 recalled it was cold and he was looking down at the floor when the van was stopped at a red light and when the van started moving again Resident #1 fell backwards in the wheelchair, landing close to him, with her face looking up toward the ceiling of the van and her eyes appeared to be bulging out of the sockets. Resident #7 stated he never noticed Resident #1 shaking prior to the fall or heard her saying anything as she fell backwards but did recall Resident #1 complaining of back pain and her left arm hurting while she was lying on the floor. He added Resident #1 seemed as if she couldn't catch her breath. Resident #7 stated TA #1 immediately pulled the van over, came to the back of the van and called the facility. He added 911 personnel and facility staff both came to the scene. Resident #7 confirmed TA #1 had transported him in the facility van on multiple occasions without incident and felt she was a safe driver. A telephone interview was conducted with Nurse #1 on 07/22/19 at 9:11 PM. Nurse #1 confirmed she was contacted by the TA #1 on 07/10/19 after Resident #1 fell from her wheelchair during transport and immediately went to the scene of the incident. Nurse #1 recalled when she arrived, Resident #1 had already been removed from the wheelchair and was lying flat on her back on the floor of the van. Nurse #1 stated she was unsure who had removed the oxygen tank and wheelchair from underneath Resident #1 and recalled the oxygen tank was positioned next to the Resident #1's right side, her right arm was straight by her side and her left arm was up in the air next to the wall of the van. During assessment, Nurse #1 stated Resident #1 responded to questioning and complained of pain in her back. Nurse #1 added Resident #1 grimaced when her neck was barely touched and she instructed staff to call 911. She added she had stayed with Resident #1 until paramedics arrived to transport her to the hospital. A telephone interview was conducted with the Emergency Medical Technician (EMT) on 07/24/19 at 3:30 PM. The EMT recalled when Emergency Medical Services (EMS) arrived at the scene of the incident, Resident #1 was lying on the floor of the van in a supine position and her oxygen tank and wheelchair had already been moved from underneath her. The EMT reported they were informed by facility staff that Resident #1 had slid out of her wheelchair during transport. He stated Resident #1 was alert and talking with some confusion and complained of back pain. He added she was assessed for injuries and there were several, questionable areas on her head that were raised but Resident #1 stated they were normal. The EMT stated Resident #1 was placed into the EMS vehicle and transported to the ED for evaluation, with no issues during transport. An interview with the Administrator was conducted on 07/22/19 at 11:47 AM. The Administrator confirmed there was an incident on 07/10/19 where Resident #1 fell from her wheelchair while being transported to an appointment on the facility van. She added an investigation was initiated, TA #1 was suspended immediately following the incident and an outside company was utilized for transportation services. Immediately after the interview, the Administrator provided a summary of the investigation and Performance Improvement Plan (PIP) that was put into place following the incident on 07/10/19. A follow-up, joint interview was conducted with the Administrator and Corporate Registered Nurse (CRN) on 07/22/19 at 4:46 PM. The Administrator confirmed she was notified by TA #1 that Resident #1 had fallen in her wheelchair during transport. The Administrator stated she instructed TA #1 to call the nurse on-call to come and assess the resident. She explained when she arrived at the scene of the incident, Resident #1 was lying on her back on the floor of the van with her wheelchair positioned toward the front of the bus. The Administrator recalled the 2 rear S-hook floor straps were removed from the track, so the wheelchair could be pulled from underneath Resident #1, and the front 2 S-hook floor straps were still in the track. She stated Resident #1 complained of back pain when assessed by Nurse #1 and a call was placed to 911 to transport her to the ED for evaluation. The Administrator stated an investigation was immediately initiated and she, along with the CRN and Maintenance Director, spent the day trying to reenact what could have possibly occurred to cause the front van's 2 floor S-hook straps to come loose from Resident #1's wheelchair. As part of the investigation, which included an interview with Resident #7 and TA #1's recollection of feeling kicks to the back of the driver's seat, the Administrator explained she had staff securely strap her into a wheelchair on the facility van and started making jerking and kicking movements which eventually caused the front 2 S-hook floor straps to come loose from the wheelchair. The Administrator stated based on their investigation and reenactments, they determined all straps were functioning properly and the S-hook floor straps had to have been secured prior to departure or Resident #1 would have fallen out of or slid in the wheelchair as soon as the van was leaving the facility parking lot. She added they concluded the only logical explanation to what possibly occurred was that Resident #1 had kicking and/or jerking movements in the wheelchair during transport which caused the front 2 S-hook floor straps to come loose. A follow-up, joint interview was conducted with the Administrator and CRN on 07/22/19 at 4:46 PM. The CRN verified the Administrator's statement of events and added she also had staff securely strap her into a wheelchair while seated on the facility van. The CRN explained she started rocking and kicking while seated in the wheelchair, trying to mimic [MEDICAL CONDITION] activity, and stated the 2 front S-hook floor straps came loose which surprised her. The CRN then had the Maintenance Director drive the van, with her seated in the wheelchair with all safety straps securely in place except for the front 2 S-hook floor straps. She explained as soon as he started driving the van through the parking lot, she started sliding in the wheelchair and had to grab onto the left wall of the van to stabilize. The CRN stated when Resident #7 and the TA #1 were interviewed, neither recalled hearing anything prior to Resident #1's fall. She added Resident #1 had history of [MEDICAL CONDITION] but could not recall her having any type of [MEDICAL CONDITION] activity prior to this event. The CRN explained based on TA #1's recollection of feeling kicks to the back of the driver's seat along with the fact Resident #1 never made any sounds or yelled out prior to her fall, they felt it was possible she could have had a [MEDICAL CONDITION] just prior to the incident and her kicking movements somehow caused the front 2 S-hook floor straps to come loose from the wheelchair. A joint interview was conducted with the Maintenance Director and Administrator on 07/23/19 at 8:25 AM. The Maintenance Director confirmed weekly maintenance was conducted on the facility van that included checking the shoulder and S-hook straps to ensure they were in good working order and not frayed. He added a safety inspection, as documented on the vehicle work history report, was conducted on 07/06/19 that identified no concerns. The Maintenance Director confirmed he also conducted annual training with authorized drivers, including TA #1, that consisted of reviewing the steps for transport safety, demonstration of how to properly secure someone in the wheelchair and had them provide return demonstration. He confirmed the S-hook straps and locks were checked after the incident involving Resident #1 and found to be in good working order. He added reenactments were conducted to try and determine what could have caused the S-hook floor straps to come loose from Resident #1's wheelchair and stated without knowing the exact position of her wheelchair or how the S-hook floor straps were placed they couldn't determine a definite cause. Both the Administrator and Maintenance Director agreed that in all likelihood, when the S-hook floor straps were securely placed they should not have come loose but added based on their reenactments, they determined the only logical explanation was Resident #1 somehow kicked or jerked the straps loose during transport. An observation of the facility van was conducted with the Administrator, Maintenance Director and Director of Nursing on 07/23/19 at 8:25 AM. The Maintenance Director was placed in the exact wheelchair Resident #1 was seated in at the time of her fall on 07/10/19. The Administrator was observed following the manufacturer's instructions when placing the S-hook floor straps onto the wheelchair and once all straps were correctly placed, she double-checked to ensure the straps were all secure. The Maintenance Director rocked the wheelchair back and forth and all 4 of the van's floor S-hooks that were attached to the wheelchair remained secured. A telephone interview was conducted with the Medical Director (MD) on 07/23/19 at 12:12 PM. The MD confirmed he was notified of the incident involving Resident #1 on 07/10/19. He added the Administrator discussed with him the investigation into the incident and subsequent PIP that was put into place by the facility. The MD stated while at the facility, he looked over the facility van and tried placing the S-hook floor straps on the wheelchair several different ways, but the straps seemed secure and never dislodged. The MD added he was not sure how the straps came loose while Resident #1 was being transported in the facility van and felt it was an unfortunate accident. A telephone interview was conducted with a representative of the manufacturer of the wheelchair safety lock system utilized by the facility on 07/23/19 at 3:24 PM. The representative confirmed if the van's floor S-hooks were secured correctly to the wheelchair as instructed in the training video, they should have not come loose from the wheelchair with any type of movement. A follow-up telephone interview with TA #1 was conducted on 07/30/19 at 3:02 PM. TA #1 stated prior to Resident #7 telling her that Resident #1 had fallen, she did not hear any noises or Resident #1 say anything. She stated she only felt something kick the back of the driver's seat as the van moved and veered toward the right from the stop light. She explained it all happened so quickly and once the van was parked, she went to the back of the van where Resident #1 was lying on the floor. TA #1 recalled the back of Resident #1's wheelchair was lying directly on top of the oxygen tank and she had slid slightly up in the wheelchair with one leg up in the air and the other leg resting on the wheelchair. TA #1 could not recall if Resident #1 was having trouble breathing but did appear uncomfortable lying on top of the oxygen tank. TA #1 stated she was trained to never move a resident until they were assessed by a nurse and confirmed she did not move Resident #1 off the oxygen tank. She explained Resident #1 was moving on her own, independently lifted her head and arched her back slightly toward the left, so she could pull the resident's wheelchair and oxygen tank from underneath her. A follow-up telephone interview was conducted with the EMT on 07/30/19 at 1:27 PM. The EMT stated in some life-threatening instances, it would be appropriate to move a resident after a fall to ensure their safety. The EMT added he was not sure how licensed or non-licensed facility staff were trained to respond when a resident fell but would not suggest moving someone without using manual stabilization (holding the head/neck in place) to prevent further injury. A follow-up interview was conducted with the facility MD on 07/30/19 at 2:01 PM. The MD stated when Resident #1 was observed lying on the oxygen tank it would have been difficult to stabilize her neck without moving her and could understand why non-licensed staff would attempt to move the oxygen tank from underneath her to make her more comfortable. The MD added without knowing the extent of Resident #1's injuries at the time of her fall and because she complained of back pain, staff should have made sure Resident #1's head and neck were immobilized prior to her moving to avoid potential spinal cord injury. The facility provided the following Performance Improvement Plan with the plan of correction date of 07/15/19: Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. -The facility has self-identified an opportunity with transportation services related to the staffing and training of transportation attendants regarding safety precautions, utilization of required safety restraints and emergency management following an accident. -On 07/10/19, Resident #1 received immediate assessment and medical attention as required. 911 was called at the time of the incident and Resident #1 was transported to the hospital via EMS. The Physician and Responsible Party were both notified. The Administrator or designee will complete a full investigation. -On 7/10/19, the Administrator suspended the transportation attendant involved and suspended the usage of facility transportation until all transport staff are re-educated and return demonstration has been verified. The facility has made arrangements to meet residents transport needs in the interim. The facility has arranged outside transport to accommodate transport needs. -The Administrator or designee will complete an audit of all employees currently designated as transportation attendants to verify the following and provide re-education as required. Transportation attendants will not provide transportation services prior to completing re-training as follows: *Safe driving record verified *Has received education on safety precautions related to operating a handicapped accessible vehicle *Has received education and has return demonstrated usage of safety restraints and the completion of the Securement checklist prior to engaging the vehicle for transport *Has received education and has return demonstrated appropriate usage of the mechanical lift associated with the vehicle *Verbalizes understanding of emergency management following an accident. *Verbalizes understanding not to move a resident involved in an accident situation until Medical personnel arrive. Re-education of staff began on 07/12/19 and concluded on 07/15/19. The manufacturer guidelines and video were used for re-education and return demonstration. -On 7/10/19, the Administrator or designee will observe residents being transported by facility staff daily for 14 days and then randomly each week for 10 weeks to ensure appropriate safety restraints are in use and the Securement Checklist is completed prior to engaging the vehicle for a transport. Opportunities identified through these audits will be corrected daily as identified. This was started on 07/12/19. -The Performance Improvement Plan was presented to and accepted by the facility Quality Assurance (QA) committee on 07/12/19. -The results of the audits will be reported in the monthly Quality Assurance (QA) committee meeting for 3 months then quarterly. The committee will evaluate and make further recommendations as indicated. -The Administrator is responsible for compliance. The date of compliance is 07/15/19. The Performance Improvement Plan was validated on 07/23/19 and concluded the facility implemented an acceptable corrective action plan on 07/15/19 once all authorized drivers were trained. The validation included observing the Administrator securing the Maintenance Director in the transportation van since the facility was using an outside company for transportation services. The facility provided documentation that included: Transport Drivers training, vehicle driver safety agreements and re-education records, Departmental Managers safety training records, in-service records provided to all staff on abuse and neglect, daily list of residents with outside appointments, and facility audits. The daily monitoring of residents transported by the outside company's transportation driver were reviewed. There were no residents transported using the facility transport van since 07/10/19. The monitoring started on 07/12/19 with the outside transportation company's driver and was ongoing. Residents who were transported to outside appointments were interviewed and reported no concerns. Facility staff were interviewed and confirmed they received training on transportation safety that included how to properly secure a resident in the wheelchair and perform return demonstrations.

Based on resident interviews, responsible party interviews, staff interviews, physican interviews and record reviews, the facility failed to inform the responsible parties and the physician when 2 of 4 sampled residents alleged sexual abuse by a staff member (Residents #3 and #4). Immediate Jeopardy began on 02/26/16 when Resident #3 told Nurse #1 she was raped by Nurse Aide (NA) #1 and neither the physician nor responsible party were notified. Immediate Jeopardy began on 02/28/16 for Resident #4 when she told Nurse #1 and Nurse #2 she was sexually assaulted by NA #1 and neither the physician nor the responsible party were notified. Immediate Jeopardy was removed on 03/24/16 at 8:12 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to notification of a significant change. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded her with having intact cognition. She was coded as understanding others and being understood with clear speech and no communication problems. She was coded as having no behaviors, no signs of [MEDICAL CONDITION], feeling tired 2-6 days over the previous 2 weeks, and requiring supervision of one person physical assistance for most activities of daily living skills including bed mobility, transfers, walking, toileting and hygiene. Nursing notes dated 02/26/16 at 7:20 PM, written by Nurse #1, revealed Resident #3 asked to speak to this nurse privately. During this conversation, Resident #3 told Nurse #1 that Nurse Aide (NA) #1 stuck it in her and her genital area hurt. Resident #3 refused to have the police called or to go to the hospital. The note did not indicate any notification of the physician or the responsible party. Review of an incident report dated 02/26/16 revealed at 7:20 PM Resident #3 made allegations of being sexually assaulted by (NA #1). Initially she indicated that she said no (to pain/hurt) and she was just scared. Then she complained of vaginal pain & said he penetrated her. This incident report was completed by Nurse #1. The incident report noted the physician's name but not the date or time of contact and no indication the responsible party was notified. Interview with Nurse #1 on 03/21/16 at 2:35 PM revealed that when she spoke to Resident #3 on 02/26/16, Resident #3 began crying and pointed to her genital area stating it hurt. She stated NA #1 stuck it in her, which Nurse #1 stated referred to his penis. Nurse #1 called the Director of Nursing (DON) from her office. The DON told Nurse #1 she would take care of the issue and instructed the nurse to have NA #1 call her. Nurse #1 stated she was not given instructions other than making sure NA #1 did not go back into Resident #3's room. Nurse #1 stated she did not call the physician because the DON said she would handle everything. Upon follow up interview on 03/22/16 at 3:59 PM, Nurse #1 stated she asked the DON if she should call anyone else when she spoke to her on 02/26/16 and the DON stated no. Nursing notes dated 02/27/16 at 1:30 PM written by Nurse #2 revealed Resident #3 stated a nurse aide (not identified in the note) helped her to the bathroom, pushed her against the wall and put his penis in her vagina. She stated that she then moved away and the nurse aide kissed her forcefully. The police department was called and Resident #3 was sent to the hospital for a rape kit and exam. The note did not indicate notification of the physician or responsible party. A phone interview was conducted with Nurse #2 on 03/21/16 at 3:21 PM. Nurse #2 stated she arrived for work on 02/27/16 and Resident #3 told her that 2 days prior, NA #1 asked if she needed to go to the bathroom and she walked independently to the bathroom. Resident #3 stated he followed her into the bathroom, closed the door, locked the door, pushed her against the wall, over the toilet where she grabbed the grab bar and he put his penis between her legs, moved around a bit and then actually penetrated her. Nurse #2 stated Resident #3 told her NA #1 had kissed her about 15 times previously and recently bought her perfume. Nurse #2 called the DON about the allegation. The DON stated she would handle it. Nurse #2 stated the DON told her they needed to keep everyone out of the issue and when Nurse #2 told the DON that she was not ok with that, the DON agreed for the police to be called. Once the police arrived, the officer and Nurse #2 agreed it was appropriate to send Resident #3 to the hospital. During an interview with Resident #3 on 03/21/16 at 9:53 AM, Resident #3 stated that she was raped by NA #1. She stated she was lying in bed when NA #1 suggested she go to the bathroom before her roommate returned from a smoke break. NA #1 followed Resident #3 into the bathroom, locked the door, and placed the tip of his penis in her vagina. Resident #3 stated she returned to bed and did not tell anyone until the next day when she told a nurse. Resident #3 cried during this interview. On 03/23/16 at 9:15 AM, Resident #3 stated during a follow up interview, she called her responsible party herself to report what had happened to her. On 03/23/16 at 11:41 AM, the responsible party (RP) was interviewed via phone. She stated that she was the emergency contact for Resident #3. She stated the facility never contacted her about the alleged rape or that Resident #3 was sent to the hospital for a rape test. The RP stated she learned of the incident because Resident #3 called and told her. The RP stated the facility called her asking about a room change after the incident. She further stated she would have wanted to be called. Notes taken by the DON on 02/26/16 and 02/27/16 presented by the Administrator, revealed no notes related to notification of the RP or the physician. Follow up interview with the DON on 03/22/16 at 9:26 AM revealed she spoke to the Detective on the phone on 02/27/16 who informed the DON they were going to transport Resident #3 to the hospital for a rape kit. The DON stated Resident #3 was her own responsible party and the nurses should call the responsible party if the resident requested it. During follow up interview with the DON on 03/22/16 at 3:46 PM, the DON stated she thought Resident #3's physician had been notified since her name was listed on the incident report. The Administrator was interviewed on 03/22/16 at 2:57 PM. The Administrator stated he was unaware if the physician or family were notified of the incident. The Administrator stated the physician should have been notified of the accusation. He further stated since Resident #3 was her own responsible party, the staff should have inquired if Resident #3 wanted her RP notified of the situation. A telephone interview was conducted with Resident #3's physician, who was also the Medical Director of the facility on 03/22/16 at 4:09 PM. The physician stated that she learned of the abuse situation on Sunday 02/28/16. The physician stated she received a call from her office assistant who was in the facility gathering information for the next physician's visit. The office assistant heard about another resident's (Resident #4) allegation of abuse and called the physician to make sure she was aware of what was happening in the facility. The physician stated she then spoke to Nurse #2 who informed her Resident #3 had gone to the hospital for an evaluation. The physician stated at this time, she was not sure the police had been called so she took it upon herself to call the police and adult protective services. 2. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] coded her with intact cognition and being understood and understanding with no communication issues. She was coded as requiring supervision of one staff for most activities of daily living skills (ADL) including bed mobility, toileting and hygiene, and being continent of bowel and bladder. She was coded as feeling bad about herself 2-6 days over the last 2 weeks, having no behaviors and no signs of [MEDICAL CONDITION]. The annual MDS dated [DATE] coded her with intact cognition, having no behaviors, no communication problems, no signs of [MEDICAL CONDITION], feeling bad about herself 2- 6 days over the last 2 weeks, and requiring set up or limited assistance with ADL. A phone interview with Nurse #2 was conducted on 03/21/16 at 3:43 PM. Nurse #2 stated on 02/28/16 she was asked by Resident #8 to talk with Resident #4. Resident #4 stated NA #1 had been kissing her while she slept. It occurred multiple times. Then the resident stated about 2-3 weeks ago, NA #1 was helping her in the bathroom, and as she stood, he turned her around, pushed her into the wheelchair and tried to penetrate her. She reported he had put his fingers inside her vaginal area, and ejaculated on her. Nurse #2 called the physician who agreed not to send her to the hospital for an exam. There were no nursing notes written by Nurse #2 about the allegations made by Resident #4. or any notification to the physician or Resident #4's responsible party. Nursing notes dated 02/28/16 at 11:00 AM, written by Nurse #1 revealed she received a call from Nurse #2 who reported that Resident #4 had made an allegation that Nurse Aide (NA) #1 had taken sexual advantage of her. Nurse #1's note indicated she came into work to get Resident #4's statement. Resident #4 told Nurse #1 this had been going on for 2 weeks. First, Resident #4 woke up to NA #1's tongue being in her mouth. Then 3 to 4 days later she was in the bathroom and he rubbed her breast and genital area. Another time she was in the bathroom, NA #1 returned and as she turned to get into the wheelchair, he put his hand on her back where she was over the chair, her pants had not been pulled up yet, he pulled his pants down but could not get his penis in her vagina so he ejaculated between her inner thighs. This note did not indicate notification to her physician or responsible party. Interview with Nurse #1 on 03/21/16 at 2:38 PM revealed she received a call from Nurse #2 on 02/28/16 at 11:00 AM who stated Resident #4 claimed she was assaulted by NA #1. Nurse #1 stated she told Nurse #2 to complete an incident report and concern form. Nurse #1 stated she went to the facility and got a statement from Resident #4 and then the police arrived. Nurse #1 stated she was not sure exactly what Nurse #2 had done and she told Nurse #2 to make sure everything was in order and she left after the police. There was no incident report or concern form completed related to Resident #4's allegation of sexual assault. An interview with Resident #4 was conducted on 03/21/16 at 10:19 AM. Resident #4 stated she was assaulted by NA #1 3 times. The first time she was sound asleep and woke to his tongue being in her mouth. Crying, she referred to this incident as a violation that took place a month ago. The second time, she was in the bathroom, had gotten up, pulled her pants up, he grabbed hold of her, pulled her to him and started gyrating against her. The third time she was in the bathroom, had not pulled her pants up yet and he came into the bathroom pushed her forward and bent her over and ran his hands between her legs and tried to put his penis inside her. She stated his penis was too floppy to penetrate her so he finished by putting his penis between her thighs and ejaculated. He then brought her wash cloths with soap and water and instructed her to clean up. Follow up interview with Resident #4 on 03/23/16 at 8:24 AM revealed she definitely wanted her responsible party RP called about the incident. Resident #4 stated she asked the DON if her RP was called, was told no, so she called the RP herself. Phone interview with Resident #4's RP on 03/23/16 at 11:34 AM revealed she learned about the abuse from Resident #4 on Monday 02/29/16 as the facility never called her. She further stated she absolutely wanted to be called about the incident. Follow up interview with the DON on 03/22/16 at 9:45 AM revealed on Sunday (02/28/16), Nurse #2 called her and informed her that Resident #4 had called the police because NA #1 got her also. The DON stated she talked to Resident #4 via phone who stated it happened a long time ago. The DON stated the resident was her own responsible party and if she wanted the family to be called the nurse should call the family. The Administrator provided notes written by the DON relating to what she did once she received the allegation about Resident #4 on 02/28/16. The note indicated the DON made phone calls to the Administrator, several corporate staff and Resident #4's physician. The note did not indicate the physician's response or if the responsible party was notified. The Administrator was interviewed on 03/22/16 at 2:57 PM. The Administrator stated he was unaware if the physician or family were notified of the incident. The Administrator stated the physician should have been notified of the accusation. He further stated the staff should have inquired if Resident #4 wanted her RP notified of the situation. A telephone interview was conducted with Resident #4's physician, who was also the Medical Director of the facility on 03/22/16 at 4:09 PM. The physician stated that she learned of the abuse situation on Sunday 02/28/16. The physician stated she received a call from her office assistant who was in the facility gathering information for the next physician's visit. The office assistant heard about Resident #4's allegation of abuse and called the physician to make sure she was aware of what was happening in the facility. The physician stated she then spoke to Nurse #2. The physician stated she felt it was too late and there was no need to send Resident #4 to the hospital. The physician stated at this time, she was not sure the police had been called so she took it upon herself to call the police and adult protective services. On 03/22/16 at 4:46 PM, the Administrator and the DON were informed of Immediate Jeopardy. The Administration provided a credible allegation of compliance on 03/24/16 at 6:32 PM. Brian Center Waynesville respectfully submits the following allegation of compliance for F 157: 1. On 02/29/16 the Director of Nursing notified the Physician of Resident # 3 regarding the allegation of abuse received on 02/26/16. Resident #3 is responsible for her own affairs and she notified her family on 02/29/16. On 02/29/16 the Director of Nursing notified the Physician of Resident #4 regarding the allegation of abuse received on 02/28/16. Resident #4 is responsible for her own affairs and she notified her responsible party on 02/28/16. 2. Current Residents have the potential to be affected by the same alleged deficient practice. By 03/03/16 the Social Services Director completed interviews with residents who were alert, oriented and able to answer questions to verify no other unreported allegations of abuse occurred. On 03/23/16 the Social Services Director completed an audit of families and responsible parties for those resident unable to participate in the prior interviews to verify no other unreported allegations of abuse occurred. On 03/03/16 the Administrator, Social Services Director, District Director of Operations and the District Director of Care Management completed interviews with all facility staff to verify no other unreported allegations of abuse occurred. On 03/23/16 the Administrator completed an audit of all previously reported allegations of abuse or neglect received during the last 6 months to validate Physician and Responsible Party notification was completed. No further Physician notifications were required as a result of these interviews as no new allegations were identified. These audits and interviews were completed on 03/23/16. 3. Measures put in place to ensure the alleged deficient practice does not recur include All Licensed nurses were re-educated by the Area Staff Development Coordinator and the Director of Nursing on 03/22/16 regarding the facility's policy for Physician and Responsible Party Notification as it relates to: *A Change in Resident Condition *When an Incident or Accident occurs *When an allegation of abuse or neglect occurs. On 03/24/16 All Resident Care Specialists (CNAs) were re-educated by the Area Staff Development Coordinator and the Unit Manger regarding notification of Licensed nurses of any concerns, incidents or accidents, significant change of condition, or when an allegation of abuse or neglect occurs. Resident Care Specialists shall not be allowed to work before receiving this re-education. All new Resident Care Specialists will be educated on notification of Licensed Nurses of any concerns, incidents or accidents, significant change of condition, or when an allegation of abuse or neglect occurs This education will be completed by the Area Staff Development Nurse or the Director of Nursing during orientation. Immediate Jeopardy was removed on 03/24/16 at 8:12 PM when interviews with nursing staff and administrative staff confirmed they had received in-service training on notification of the RP and physician related to allegations of abuse or any change in condition.

Based on resident interviews, record review and staff interviews, the facility failed to maintain 2 of 4 sampled residents' right to be free of sexual abuse (Residents #3 and #4). Immediate Jeopardy began on 02/25/16 when Resident #3 was raped by Nurse Aide (NA) #1. Immediate Jeopardy began for Resident #4 on 02/28/16 when she told Nurse #2 she was sexually assaulted by NA #1. Immediate Jeopardy was removed on 03/24/16 at 8:12 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to resident rights to be free from abuse. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded her with having intact cognition, scoring a 15 out of 15 on the Brief Interview for Mental Status, which measures long and short term memory and temporal orientation. She was coded as understanding others and being understood with clear speech and no communication problems. She was coded as having no behaviors, no [MEDICAL CONDITION], feeling tired 2-6 days over the previous 2 weeks, and requiring supervision of one person physical assistance for most activities of daily living skills including bed mobility, transfers, walking, toileting and hygiene. She was coded as always being continent of bowel and bladder. Nursing notes dated 02/26/16 at 7:20 PM, written by Nurse #1, revealed Resident #3 asked to speak to this nurse privately. During this conversation, Resident #3 told Nurse #1 that Nurse Aide (NA) #1 stuck it in her and her genital area hurt. Review of an incident report dated 02/26/16 revealed at 7:20 PM Resident #3 made allegations of being sexually assaulted by CNA (named NA #1). Initially she indicated that she said no (pain/hurt) and she was just scared. Then she complained of vaginal pain & said he penetrated her. This was completed by Nurse #1. Interview with Nurse #1 on 03/21/16 at 2:35 PM revealed that when she spoke to Resident #3 on 02/26/16, Resident #3 began crying and pointed to her genital area stating it hurt. She stated NA #1 stuck it in her, which Nurse #1 stated referred to his penis. Nurse #1 told NA #1 to not return to Resident #3's room and called the Director of Nursing. Nurse #1 asked the resident if she could call the police or send her to the hospital but Resident #3 stated she only wanted Nurse #1 to call the DON or the Administrator. Nurse #1 stated that Resident #3 had never made any allegations against this nurse aide or others related to treatment or other types of abuse. Nurse #1 described the resident as not always stable and further explained that she would have outbursts verbally over very simple things. She stated she took the allegation Resident #3 made about NA #1 very seriously. Nursing notes dated 02/27/16 at 1:30 PM written by Nurse #2 revealed Resident #3 stated a nurse aide helped her to the bathroom, pushed her against the wall and put his penis in her vagina. She stated that she then moved away and the nurse aide kissed her forcefully. The police were called and Resident #3 was sent to the hospital for a rape kit and exam. Review of the hospital records revealed Resident #3 was seen in the emergency roiagnom on [DATE] at 3:13 PM for reported sexual assault and assault by bodily force. Laboratory tests were drawn and post exposure [MEDICATION NAME] were ordered. A phone interview was conducted with Nurse #2 on 03/21/16 at 3:21 PM. Nurse #2 stated she arrived for work on 02/27/16 and Resident #3 asked who her nurse aide was for the day, around 10:00 AM. When told NA #1 was scheduled, Resident #3 started crying. When asked what was wrong, Nurse #2 stated Resident #3 told her that 2 days prior NA #1 asked if she needed to go to the bathroom and she walked independently to the bathroom. Resident #3 stated he followed her into the bathroom, closed the door, locked the door, pushed her against the wall, over the toilet where she grabbed the grab bar and he put his penis between her legs, moved around a bit and then actually penetrated her. Nurse #2 stated Resident #3 told her NA #1 had kissed her about 15 times and recently bought her perfume. Nurse #2 called the Director of Nursing who reluctantly agreed for the police to be called. During an interview with Resident #3 on 03/21/16 at 9:53 AM, Resident #3 stated that she was raped and stated it occurred the day before she told the nurse (02/25/16). She stated she was lying in bed when NA #1 suggested she go to the bathroom before her roommate returned from a smoke break. NA #1 followed Resident #3 into the bathroom, locked the door, and placed the tip of his penis in her vagina. Resident #3 stated she returned to bed and did not tell anyone until the next day when she told a nurse. Resident #3 cried during this interview. Follow up interview with Resident #3 on 03/23/16 at 9:15 AM, revealed in the past, NA #1 had kissed her and touched her breast. She stated she liked his friendliness. He then bought her perfume she really liked. She stated she did not report the sexual assault because she was afraid he would not buy her more perfume which she really liked. Crying, Resident #3 stated she had to make a decision about getting perfume and being raped and she decided she did not want to be raped again so she reported it. During an interview with Nurse #3 on 03/23/16 at 9:48 AM, she described Resident #3 as alert and oriented. Her mental stability was less steady as she would have sudden outburst saying the world was coming to an end. One minute she would be happy and the next she would be mad. Nurse #3 described her as having manic episodes. She continued saying that Resident #3 never reported staff for mistreatment, or being ugly to her. She would say I hate her referring to staff but give no specific complaints. Nurse #3 stated there was no indication she had problems with NA#1, no previous complaints about him and she never said she did not like him. Interview with NA #4 on 03/23/16 at 1:18 PM revealed Resident #3 can be very cognitive intact and then confused at other times. She never complained about staff and NA #4 could not recall her ever having problems with certain staff members. She described her as demanding, wanting what she wanted immediately, and complaining if she had to wait too long. Resident #3 did not complain of any staff treatment issues. Interview with the Social Worker (SW) on 03/23/16 at 1:48 PM revealed Resident #3 always scored high on the cognitive issues but scored lower related to depression scores. SW stated she has been improving over the last 2 months. SW stated she would take things from others and claim them as her own. She stated she had never known Resident #3 to complain about staff treatment. Nurse #4 was interviewed on 03/24/16 at 10:25 PM. He stated that Resident #3 sometimes got fuzzy about issues but she had no complaints about particular staff or staff treatment. He further explained that Resident #3 would let little things balloon in her head. The Administrator stated during interview on 03/24/16 at 9:20 AM that although Resident #3 had some psychiatric issues, there was no documentation, complaints or indications that she fabricated stories about staff to get them in trouble. Interview with the Detective on 03/22/16 at 10:21 AM revealed this was an ongoing investigation. The Detective stated they attempted to interview NA #1 who refused to talk to the detective. She stated NA #1 had secured legal counsel and the police were trying to arrange for an interview with NA #1 and his attorney this week. The Detective stated the hospital completed a rape kit but it could be months before the results would be available. The Detective stated she preferred the surveyors not interview NA #1 prior to her being able to interview him. NA #1 had not been arrested or charged at this time but the Detective stated he most likely would be charged and arrested. NA #1 was not interviewed. Review of the interview notes conducted by the Administrator with NA #1 dated 03/04/16 revealed NA #1 knew he was suspended as there was an accusation from Resident #3. NA #1 stated that on 02/26/16 he made Resident #3's bed. He stated she was independent and he did not help her with a shower or toileting. NA #1 denied Resident #3's accusation and denied ever making contact with her genital area or breasts. When asked about their relationship, NA #1 stated he did not joke with her and was real serious. NA #1 stated that she would sometimes get upset with him if he could not do what she requested immediately such as wanting coffee but he could not recall anything that had occurred recently. 2. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] coded her with intact cognition, scoring a 14 out of 15 on the Brief Interview for Mental Status (BIMS) (a system for measuring short and long term memory and temporal orientation), and being understood and understanding with no communication issues. She was coded as requiring supervision of one staff for most activities of daily living skills (ADL) including bed mobility, toileting and hygiene, and being continent of bowel and bladder. She was coded as feeling bad about herself 2-6 days over the last 2 weeks, having no behaviors and no signs of [MEDICAL CONDITION]. The annual MDS dated [DATE] coded her with intact cognition, scoring a 13 out of 15 on the BIMS, having no behaviors, no communication problems, feeling bad about herself 2- 6 days over the last 2 weeks, and requiring set up or limited assistance with ADLs. Nursing notes dated 02/28/16 at 11:00 AM, written by Nurse #1 revealed she received a call from Nurse #2 who reported that Resident #4 had made an allegation that Nurse Aide (NA) #1 had taken sexual advantage of her. Nurse #1's note indicated she came into work to get Resident #4's statement. Resident #4 told Nurse #1 this had been going on for 2 weeks. First, Resident #4 woke up to NA #1's tongue being in her mouth. Then she stated 3 to 4 days later she was in the bathroom and he rubbed her breast and genital area. Another time she was in the bathroom, NA #1 returned and as she turned to get into the wheelchair, he put his hand on her back where she was over the chair, her pants had not been pulled up yet, he pulled his pants down but could not get his penis in her vagina so he ejaculated between her inner thighs. Interview with Nurse #1 on 03/21/16 at 2:38 PM revealed she received a call from Nurse #2 on 02/28/16 who stated Resident #4 claimed she was also assaulted by NA #1. Nurse #2 came into the facility and spoke with Resident #4 on 02/28/16 and wrote the resident's detailed account in the nursing notes. who stated NA #1 had been taking sexual advantage of her for two weeks. There was no incident report or concern form completed related to Resident #4's allegation of sexual assault. A phone interview with Nurse #2 was conducted on 03/21/16 at 3:43 PM. Nurse #2 stated on 02/28/16 she was asked by Resident #8 (who was friends with Resident #4) to talk with Resident #4. Nurse #2 stated Resident #4 felt comfortable talking since Resident #3 had come forward with allegations of abuse. Resident #4 stated NA #1 had been kissing her while she slept. It occurred multiple times then about 2-3 weeks ago, he was helping her in the bathroom, and as she stood, he turned her around, pushed her into the wheelchair and tried to penetrate her. She reported he had put his fingers inside her vaginal area, and ejaculated on her. Nurse #2 then stated after talking to the Director of Nursing via phone, Nurse #2 told Resident #4 to call the police. Nurse #2 stated because the incident happened a couple of weeks prior to the report, there was no need to send her to the hospital as evidence would be gone. Nurse #2 called the physician who agreed not to send her to the hospital for an exam. An interview with Resident #4 was conducted on 03/21/16 at 10:19 AM. Resident #4 stated she was assaulted by NA #1 3 times. The first time she was sound asleep and woke to his tongue being in her mouth. Crying, she referred to this incident as a violation that took place a month ago. The second time, she was in the bathroom, had gotten up, pulled her pants up, he grabbed hold of her, pulled her to him and started gyrating against her. The third time she was in the bathroom, had not pulled her pants up yet and he came into the bathroom pushed her forward and bent her over and ran his hands between her legs and tried to put his penis inside her. She stated his penis was too floppy to penetrate her so he finished by putting his penis between her thighs and ejaculated. He then brought her wash cloths with soap and water and instructed her to clean up. Follow up interview with Resident #4 on 03/23/16 at 8:24 AM revealed she did not tell anyone for fear and that it happened often. She stated she finally felt comfortable when she told Resident #8 what NA #1 did to her and Resident #8 told her either she had to tell someone about it or he would tell someone about NA #1. Nurse #3 was interviewed on 03/23/16 at 9:52 AM. Nurse #3 described Resident #4 as being alert and oriented with some lethargy with pain medication. She stated Resident #4 has never complained about any staff including NA #1. NA #3 was interviewed on 03/23/16 at 1:15 PM. NA #3 stated sometimes Resident #4 had some confusion. She did not recall any time Resident #4 complained about staff or staff treatment. In addition, Resident #4 never said she disliked any staff member. NA #4 was interviewed on 03/23/16 at 1:18 PM. NA #4 described Resident #4 as being mentally together and never complained about any staff. The Social Worker (SW) was interviewed on 03/23/16 at 1:48 PM. SW stated Resident #4 was highly cognitively intact and her psychiatric issues involved self harm. Her emotional well being has improved since coming to this facility. SW stated she may fabricate in order to get something accomplished medically. SW attributed this as needing some control. Nurse #4 was interviewed on 03/24/16 at 10:25 AM. Per Nurse #4 Resident #4 has never complained or made allegations against any staff member. The Administrator stated during interview on 03/24/16 at 9:20 AM that although Resident #4 had some psychiatric issues, there was no documentation, complaints or indications that she fabricated stories about staff to get them in trouble. Interview with the Detective on 03/22/16 at 10:21 AM revealed Resident #4 called the police herself. The Detective stated this was an ongoing investigation, NA #1 had secured legal counsel and the police were hoping to arrange for an interview with NA #1 this week. The Detective stated she preferred the surveyors not interview NA #1 prior to her being able to interview him. NA #1 had not been arrested or charged at this time but the Detective stated he most likely would be charged and arrested. NA #1 was not interviewed. Review of the information gathered by the Administrator when he interviewed NA #1 (no date specified) revealed he denied ever putting his tongue in her mouth or kissing or hugging her. He stated he had not taken her to the bathroom as she took herself. He denied ever helping her dress and denied making contact with her body when asked about rubbing her breasts and groin area. He denied trying to put his penis in her vagina and ejaculating on her stating she was lying. On 03/24/16 at 9:20 AM, the Administrator and the District Director of Clinical Services were informed of Immediate Jeopardy. The Administration provided an acceptable credible allegation of compliance on 03/24/16 at 6:32 PM. Brian Center Waynesville respectfully submits the following allegation of compliance for F223: 1. Nurse #1 notified the DON of an allegation of abuse related to Resident #3 on 02/26/16. Resident #3 alleged that NA#1 raped her Thursday 02/25/2016. On 02/26/16, immediately following the notification from Nurse #1 the Director of Nursing removed NA #1 from the Resident Care Areas. The accused did not return to the facility and was terminated on 03/15/2016. The Director of Nursing took statements over the phone from Nurse #1 and NA #1 and Resident #3 on 02/26/2016. On 02/27/2016 Resident #3 contacted the Police, who came into the Facility, and Resident #3 was transferred to the hospital for medical evaluation. Resident #3 received STD testing and [MEDICATION NAME] treatment with [MEDICATION NAME] and Raltegravir for 30 days. Resident #3 received Psych services on 02/29/16 for ongoing emotional support. The Director of Nursing called the Administrator on 02/27/2016 at approximately 1:30 PM to inform him of Resident #3's allegation. A 24 hour report for Resident #3 was submitted by the Director of Nursing on 02/29/2016 and the 5 Day report was submitted by the Administrator on 03/4/2016. Nurse #1 was re-educated by the Director of Nursing on the Facility's Policy for Abuse Prohibition including the Elder Justice Act. 2. On 02/28/2016 Resident #4 called the Police to report an allegation of abuse. Resident #4 notified Nurse #2 of same allegation. Resident #4 alleged that NA #1 came into the bathroom and sexually abused her and was unable to remember the date or time. Nurse #2 then immediately notified the Director of Nursing on 02/28/16. NA #1 was previously suspended on 02/26/26 and continued to remain out of the facility. The Police came into the Facility and Resident #4 declined to go to the hospital for medical evaluation and STD testing. Resident #4 received Psych Services on 03/9/16 and 03/23/16 for ongoing emotional support. A 24 Hour Report was submitted on 02/29/2016, by the Director Nursing for Resident #4's allegation of abuse. The 5 Day Report was submitted for Resident #4 on 03/04/2016 by the Administrator. Nurse #1 was re-educated on 03/22/2016 by the Director of Nursing on the Facility's Policy for Abuse Prohibition including the Elder Justice Act. Nurse # 2's last day worked in facility was February 28, 2016. Current Residents have the potential to be affected by the same alleged deficient. By 03/03/2016 the Social Services Director completed interviews with residents who were alert, oriented and able to answer questions to verify no other unreported allegations of abuse occurred. On 03/23/16 the Social Services Director completed an audit of families and responsible parties for those resident unable to participate in the prior interviews to verify no other unreported allegations of abuse occurred. On 03/03/2016 the Administrator, Social Services Director, District Director of Operations and the District Director of Care Management completed interviews with all facility staff to verify no other unreported allegations of abuse occurred No new allegations were identified as a result of these interviews. These audits and interviews were completed on 03/23/16. The Facility's Abuse Prohibition Policy was reviewed the District Director of Operations, the District Director of Clinical Services, the Director of Nursing and the Administrator and all required components related to F226 were present. 3. Measures put in place to ensure the alleged deficient practice does not recur include: The Director of Nursing was suspended by the Administrator on February 29, 2016 pending investigation related to delayed reporting of abuse allegation to the Administrator and timely completion of investigation. The Administrator provided the Director of Nursing with disciplinary action as a final warning and was placed on a Performance Improvement Plan that included reporting allegations of abuse/neglect to the appropriate parties in a timely manner and initiate the investigation immediately upon returning to work on 03/08/2016. The Director of Nursing was terminated on 03/24/16 and replaced with an Interim Director of Nursing who was immediately re-educated by the District Director of Clinical Services regarding Abuse Prohibition to include timely completion of 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect. On 03/23/16 all facility staff, the Nursing Department including Resident Care Specialists (CNAs), Business Office Staff, Housekeeping, Dietary and Therapy were re-educated by the Director of Nursing, Unit Manager, and Area Staff Development Coordinator regarding: *The definition of Abuse meaning the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Injuries of unknown origin may occur as a result of abuse. *Immediately intervene to stop. *A schedule has been developed by the Administrator, to begin 03/24/16, for the next 7 days to include daily supervision during all 3 shifts. All staff involved have reviewed and agreed to the schedule. The Administrator, Director of Nursing (DON), Unit Manager (UM), District Director of Clinical Services (DDCS) or District Director of Operations (DDO) will participate in this weekly schedule. A member of this leadership team will be available and rounding within the facility each day assessing the ongoing performance of the facility staff to ensure there is no tolerance for abuse. *No tolerance for abuse. No staff shall work prior to receiving this education. All new employees will be educated on the above prior to working in resident care area. This education will be completed by the Area Human Resource Officer or the Director of Nursing during orientation. Immediate jeopardy was removed on 03/24/16 at 8:12 PM when interviews with nursing staff and administrative staff and non-nursing staff confirmed they had received in-service training and knew the different types of abuse and the appropriate boundaries to maintain when caring for residents in order to maintain a professional yet caring relationship with residents.

Based on resident interviews, staff interviews, and record reviews the facility failed to report allegations of abuse to the Administrator, report suspicion of a crime to law enforcement and complete and send the 24 hour report to the Health Care Personnel Registry (HCPR) as required. This affected 2 of 4 residents sampled for abuse (Residents #3 and #4). Immediate Jeopardy began on [DATE] when after Resident #3 alleged rape to Nurse #1, neither Nurse #1 nor the DON informed the Administrator of the abuse allegation or called the police. The DON did not fax the 24 hour initial report to the HCPR until [DATE]. Immediate Jeopardy began on [DATE] for Resident #4 when she told Nurse #1 and Nurse #2 she was sexually abused by NA #1, neither Nurse #1 nor Nurse #2 called the police and neither nurse nor the Director of Nursing (DON) called the Administrator. Immediate Jeopardy was removed on [DATE] at 8:12 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to informing the Administrator of allegations of abuse, informing law enforcement of the suspicion of a crime and making reports to the HCPR within 24 hours of an allegation of abuse. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded her with having intact cognition, as understanding others and being understood with clear speech and no communication problems. She was coded as having no behaviors, no signs of [MEDICAL CONDITION], feeling tired ,[DATE] days over the previous 2 weeks, and requiring supervision of one person physical assistance for most activities of daily living skills. Nursing notes dated [DATE] at 7:20 PM, written by Nurse #1, revealed Resident #3 asked to speak to this nurse privately. During this conversation, Resident #3 told Nurse #1 that Nurse Aide (NA) #1 stuck it in her and her genital area hurt. The nurse noted she asked Resident #3 if she wanted the police called or to be sent out (for evaluation) and the resident stated she only wanted the nurse to call the DON or the Administrator. Nurse #1 wrote that she immediately instructed NA #1 not to go back into Resident #3's room and then went to her office and called the DON. The note stated the DON instructed Nurse #1 to make sure NA #1 did not go back into the room and to have NA #1 call the DON immediately which she did. Review of an incident report dated [DATE] revealed at 7:20 PM Resident #3 made allegations of being sexually assaulted by NA #1. Initially she indicated that she said no (to pain/hurt) and she was just scared. Then she complained of vaginal pain & said he penetrated her. This incident report was completed by Nurse #1. Interview with Nurse #1 on [DATE] at 2:35 PM revealed that when she spoke to Resident #3 on [DATE], Resident #3 began crying and pointed to her genital area stating it hurt. She stated NA #1 stuck it in her, which Nurse #1 stated referred to his penis. Nurse #1 told NA #1 to not return to Resident #3's room and called the DON from her office. The DON told Nurse #1 she would take care of the issue and instructed the nurse to have NA #1 call her. After talking to the DON, Nurse #1 instructed NA #1 to call the DON and said she did not talk to the DON again that evening. Nurse #1 stated she was not given instructions other than making sure NA #1 did not go back into Resident #3's room. Nurse #1 stated she assigned Resident #3 and her roommate to another nurse aide and did not see NA #1 again. She stated she did not think NA #1 was on the hall but could not guarantee it. She saw him at the end of the shift when he left the facility with his girlfriend NA #2. Nurse #1 stated DON said she would take care of everything and so she did not call the police or address it again during her shift. Nurse #1 stated that she understood her responsibility was to call her supervisor (DON) regarding abuse and the DON was to give instructions and handle the situation. Nurse #1 stated she did not call the police or send her to the hospital because Resident #3 was crying and very upset and adamant she call the DON or Administrator. Neither the DON nor the Administrator came to the facility. Upon follow up interview on [DATE] at 3:59 PM, Nurse #1 stated she asked the DON if she should call anyone else when she spoke to her on [DATE] and the DON stated no. She stated she assumed the DON would take the lead in handling the allegation and investigation. Nurse #1 further stated she did not reassign the rest of NA #1's residents because she was not aware of what the DON told NA #1 and she did not talk to the DON after the initial phone call. The DON gave no instructions to call the police or the Administrator so Nurse #1 just held and comforted Resident #3. Nurse #1 kept saying she thought the DON was handling the situation. Nursing notes dated [DATE] at 1:30 PM written by Nurse #2 revealed Resident #3 stated a nurse aide (not identified in the note) helped her to the bathroom, pushed her against the wall and put his penis in her vagina. She stated that she then moved away and the nurse aide kissed her forcefully. The police were called and Resident #3 was sent to the hospital for a rape kit and exam. Review of the hospital records revealed Resident #3 was seen in the emergency roiagnom on [DATE] at 3:13 PM for reported sexual assault and assault by bodily force. Laboratory tests were drawn and post exposure [MEDICATION NAME] were ordered. A phone interview was conducted with Nurse #2 on [DATE] at 3:21 PM. Nurse #2 stated she arrived for work on [DATE] and Resident #3 asked who her nurse aide was for the day, around 10:00 AM. When told NA #1 was scheduled, Resident #3 started crying. Nurse #2 stated she was unaware of the allegations Resident #3 made to Nurse #1 the previous day. When asked what was wrong, Nurse #2 stated Resident #3 told her that 2 days prior, NA #1 asked if she needed to go to the bathroom and she walked independently to the bathroom. Resident #3 stated he followed her into the bathroom, closed the door, locked the door, pushed her against the wall, over the toilet where she grabbed the grab bar and he put his penis between her legs, moved around a bit and then actually penetrated her. Nurse #2 stated Resident #3 told her NA #1 had kissed her about 15 times previously and recently bought her perfume. Nurse #2 called the DON about the allegation. The DON stated she would handle it. Then Nurse #2 told the DON that Resident #3 was told to call the police (Nurse #2 stated she told Resident #3 to call the police). Nurse #2 stated the DON told her they needed to keep everyone out of the issue and when Nurse #2 told the DON that she was not ok with that, the DON agreed for the police to be called. Once the police arrived, the officer and Nurse #2 agreed it was appropriate to send Resident #3 to the hospital. Nurse #2 stated neither the DON or the Administrator came to the facility over the weekend. During an interview with Resident #3 on [DATE] at 9:53 AM, Resident #3 stated that she was raped by NA #1. She stated she was lying in bed when NA #1 suggested she go to the bathroom before her roommate returned from a smoke break. NA #1 followed Resident #3 into the bathroom, locked the door, and placed the tip of his penis in her vagina. Resident #3 stated she returned to bed and did not tell anyone until the next day when she told a nurse. Resident #3 cried during this interview. Review of the Health Care Personnel Registry (HCPR) 24 hour report revealed it was completed by the DON who signed it on [DATE]. The report noted there was a reasonable suspicion of a crime for resident abuse as Resident #3 alleged NA #1 put his penis in her vagina. The report noted the police were called and she was taken to the emergency room . This form was noted to be faxed to the HCPR on [DATE] at 9:43 AM. Interview with the DON on [DATE] at 12:03 PM revealed NA #1 was suspended at 8:04 PM on [DATE] but he had no ride home so he stayed in the residents' television room until 11:00 PM. She presented his time clock report for [DATE] which showed he clocked out for supper at 8:04 PM, clocked back in at 8:32 PM and out again at 11:06 PM. Notes taken by the DON, presented by the Administrator, revealed: *on [DATE] at 8:00 PM, Nurse #1 called her and told her NA #1 had raped Resident #3. The DON spoke to Resident #3 on the phone, she was crying and upset, and told the DON NA #1 bent her over the toilet and put his penis in her. DON told her she would call the police and Resident #3 stated no. *on [DATE] at 8:20 PM, the DON spoke to NA #1 on the phone and told him he was suspended due to a pending investigation of an allegation of sexual assault which he denied. When told to leave the facility, NA #1 stated he did not have a ride and needed to wait for his friend so the DON told him to go to the television room and wait and do not enter any resident room. *on [DATE] at 8:30 PM, the DON wrote she called Resident #3 again and she still did not want the police called and asked if the DON would take care of it. *(still noted as [DATE]) at 2:45 PM, the DON called the Administrator to inform him Resident #3 wanted the police called because she was raped by NA #1 on [DATE]. Per this note, Resident #3 called the police. *(still noted as [DATE]) at 2:50 PM the Detective came to the facility and took Resident #3's statement. She had emergency medical services (EMS) coming to the facility to transport the resident to the hospital for evaluation and rape test. DON noted she agreed Resident #3 needed to go. Follow up interview with the DON on [DATE] at 9:26 AM revealed she told Nurse #1 to call the police when she was informed of the allegation of rape on [DATE] but Resident #3 did not want the police called. She spoke to NA #1 on the phone on [DATE] and told him he was suspended and told to wait in the television room when informed he did not have a ride home. She did not recall telling him to clock out and did not instruct anyone to make sure he was supervised as he waited for his ride. She stated she did not come into the facility at all during the weekend. On Saturday ([DATE]) Nurse #2 called her to report Resident #3 called the police and they were on their way. The DON spoke to the Detective on the phone who informed the DON they were going to transport Resident #3 to the hospital for a rape kit. The DON called the Administrator on [DATE]. The DON stated she started the HCPR 24 hour report after being informed of the resident going to the hospital, but had trouble getting the fax to go through until she arrived at the facility Monday morning. The DON stated she had no reason for not calling the police, stated she handled the situation wrong and on Monday [DATE] she was told she should have called NA #1 a cab and she was suspended for 5 days and did not have anything more to do with the investigation. The DON stated on [DATE] at 3:36 PM that she tried to fax the 24 hour report to HCPR from her home fax/scan machine but couldn't get it to go through, so when she came to work on Monday [DATE] she faxed the report to HCPR then called and verified they had received the report. The DON stated she didn't have a reason for not coming into the facility over the weekend to fax the report. She then stated she thought the 24 hour report was 24 hours of business days not hours. The Administrator was interviewed on [DATE] at 2:57 PM. The Administrator stated he was informed by the DON in the afternoon ([DATE]) that Resident #3 accused NA #1 of sexually assaulting her, that the DON suspended NA #1, the police came to the facility and arranged for a forensic examination. At the time of the call, Resident #1 was at the hospital and he was told she was ok and cooperating with the police. The Administrator stated he did not come to the facility as the police were involved and the DON stated she had completed the HCPR 24 hour report. The Administrator stated he was not aware Resident #3 made the initial allegation on Friday night ([DATE]) and the actual abuse occurred on Thursday ([DATE]) until he arrived at work Monday [DATE]. The Administrator further stated that he should have been called on [DATE] and the interviews started immediately but that everyone was interviewed, NA #1 was not in the facility, and the police had been called (he suspected by Resident #3). He stated he found out on [DATE] that the DON did not come into the facility over the weekend. He stated the DON should have called the police and made sure NA #1 left the facility. They since talked about calling a cab to remove the alleged perpetrator. He stated he was unaware if the physician or family were notified and unaware if a physical assessment had been done prior to the hospital visit. In addition, the Administrator stated that NA #1's second language was English and he did not understand he was suspended until the next day. NA #1 was just told to sit in the television room on [DATE]. He gave no reason why he did not come to the facility when he was alerted to the abuse allegations. The Administrator stated NA #1 was terminated on [DATE] for the pattern of allegations made against him as there was no definitive hard core proof of guilt. Review of the investigative notes taken by the Administrator revealed he did not begin interviewing staff, including NA #1, or Resident #3, until [DATE] and completed interviews on [DATE]. The HCPR 5 day investigation report faxed [DATE] at 8:54 PM marked that the allegation was unsubstantiated at this time and there was an ongoing police investigation. Interview with the Detective on [DATE] at 10:21 AM revealed this was an ongoing investigation, NA #1 had secured legal counsel and the police were hoping to arrange for an interview with NA #1 this week. The Detective was unable to say who initiated the report to the police. The Detective stated it could be months before the results of the rape kit collected at the hospital would be available. The Detective stated she preferred the surveyors not interview NA #1 prior to her being able to interview him. 2. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] coded her with intact cognition, being understood and understanding, having no communication problems, no behaviors and no signs of [MEDICAL CONDITION]. She was coded as requiring supervision of one staff for most activities of daily living skills. The annual MDS dated [DATE] coded her with intact cognition, having no behaviors, no communication problems, no signs of [MEDICAL CONDITION], and requiring set up or limited assistance with ADL. A phone interview with Nurse #2 was conducted on [DATE] at 3:43 PM. Nurse #2 stated on [DATE] she was asked by Resident #8 to talk with Resident #4. Nurse #2 stated Resident #4 felt comfortable talking since Resident #3 had come forward with allegations of abuse. Resident #4 stated NA #1 had been kissing her while she slept. It occurred multiple times. Then the resident stated about ,[DATE] weeks ago, NA #1 was helping her in the bathroom, and as she stood, he turned her around, pushed her into the wheelchair and tried to penetrate her. She reported he had put his fingers inside her vaginal area, and ejaculated on her. Nurse #2 called the DON who told her that Resident #4 just heard about the incident with Resdient #3 and got on the band wagon. The DON told Nurse #2 she and the Administrator would be in on Monday to talk to her. Nurse #2 then stated after talking to the Director of Nursing via phone, Nurse #2 told Resident #4 to call the police. Resident #4 stated she used Resident #8's phone to call the police. There were no nursing notes written by Nurse #2 about the allegations made by Resident #4. Nursing notes dated [DATE] at 11:00 AM, written by Nurse #1 revealed she received a call from Nurse #2 who reported that Resident #4 had made an allegation that Nurse Aide (NA) #1 had taken sexual advantage of her. Nurse #1's note indicated she came into work to get Resident #4's statement. Resident #4 told Nurse #1 this had been going on for 2 weeks. First, Resident #4 woke up to NA #1's tongue being in her mouth. Then 3 to 4 days later she was in the bathroom and he rubbed her breast and genital area. Another time she was in the bathroom, NA #1 returned and as she turned to get into the wheelchair, he put his hand on her back where she was over the chair, her pants had not been pulled up yet, he pulled his pants down but could not get his penis in her vagina so he ejaculated between her inner thighs. Inteview with Nurse #1 on [DATE] at 2:38 PM revealed she received a call from Nurse #2 on [DATE] at 11:00 AM who stated Resident #4 claimed she was assaulted by NA #1. Nurse #2 stated she told Nurse #2 to complete an incident report and concern form. Nurse #1 stated she went to the facility and got a statement from Resident #4 and then the police arrived. Nurse #1 stated she never spoke to the DON on [DATE] and the DON did not come to the facility. She assumed the DON was handling the situation. There was no incident report or concern form completed related to Resident #4's allegation of sexual assault. An interview with Resident #4 was conducted on [DATE] at 10:19 AM. Resident #4 stated she was assaulted by NA #1 3 times. The first time she was sound asleep and woke to his tongue being in her mouth. Crying, she referred to this incident as a violation that took place a month ago. The second time, she was in the bathroom, had gotten up, pulled her pants up, he grabbed hold of her, pulled her to him and started gyrating against her. The third time she was in the bathroom, had not pulled her pants up yet and he came into the bathroom pushed her forward and bent her over and ran his hands between her legs and tried to put his penis inside her. She stated his penis was too floppy to penetrate her so he finished by putting his penis between her thighs and ejaculated. He then brought her wash cloths with soap and water and instructed her to clean up. Follow up interview with Resident #4 on [DATE] at 8:24 AM revealed she did not tell anyone for fear and that it happened often. She stated she finally felt comfortable when she told Resident #8 about what NA #1 did to her and Resident #8 told her either Resident #4 had to tell someone about it or he would tell someone about NA #1. Review of the Health Care Personnel Registry (HCPR) 24 hour report signed and faxed by the DON on [DATE] at 12:24 PM marked there was no reasonable suspicion of a crime. The DON was interviewed on [DATE] at 12:03 PM who stated NA #1 had been suspended on [DATE] for a previous allegation of sexual assault made by Resident #3. Follow up interview with the DON on [DATE] at 9:45 AM revealed on Sunday ([DATE]), Nurse #2 called her and informed her that Resident #4 had called the police because NA #1 got her also. The DON stated she talked to Resident #4 via phone who stated it happened a long time ago. When asked why she waited to report it, Resident #4 stated she just didn't want to. The DON stated the resident asked her if she (Resident #4) should not have called the police but the DON said she told the resident it was ok to call the police. Resident #4 refused to go to the hospital. The DON did not come to the facility and stated the police had already been called, NA #1 had been suspended and the resident did not want to go to the hospital. The DON stated she talked with the Administrator via phone on [DATE]. She stated neither she nor the Administrator came in on Sunday. The Administrator provided notes written by the DON relating to what she did once she received the allegation about Resident #4: *on [DATE] at about 11:00 AM, the DON received a phone call from Nurse #2 who informed her that Resident #4 was accusing NA #1 of raping her too. This occurred a long time ago and that the resident called the police. Per the notes, the DON spoke to Resident #4 on the phone and was told NA #1 ejaculated between her legs while she was in the bathroom. Resident #4 told her about another time waking up with NA #1's tongue in her mouth. The DON told Resident #4 it was ok that she called the police and that the resident would probably go to the hospital. Resident #4 declined to go to the hospital. The DON called and texted the Administrator. When he returned her call, the Administrator instructed the DON to call the District Director of Operations. She noted the District Director of Operation told her to call the corporate attorney, who she spoke with twice. The DON then called other corporate staff and the physician per these notes. Another interview with the DON on [DATE] at 3:46 PM revealed she was suspended on Monday [DATE] and had no more involvement in the investigation. She further stated she felt the resident was safe since NA #1 was already suspended. The Administrator was interviewed on [DATE] at 2:57 PM. The Administrator stated the DON was suspended on Monday [DATE] for not following the policy for allegations of abuse. He stated he found out on [DATE] that the DON did not come into the facility over the weekend. He stated his understanding was the resident had called the police before he was informed of the allegation. The Administrator stated the District Director of Operations came at his request to conduct interviews. He gave no reason why he did not come to the facility when he was alerted to the abuse allegations. The Administrator stated NA #1 was terminated on [DATE] for the pattern of allegations made against him as there was no definitive hard core proof of guilt. Review of the investigative notes taken by the Administrator revealed he did not begin interviewing staff, including NA #1, until [DATE] and completed interviews on [DATE]. Resident #3 refused to be interviewed explaining her family secured an attorney. The HCPR 5 day investigation report faxed [DATE] at 8:58 PM marked that there was no reasonable suspicion of a crime related to resident abuse and the allegation was unsubstantiated at this time and there was an ongoing police investigation. Interview with the Detective on [DATE] at 10:21 AM revealed Resident #4 called the police herself. The Detective stated this was an ongoing investigation, NA #1 had secured legal counsel and the police were hoping to arrange for an interview with NA #1 this week. The Detective stated she preferred the surveyors not interview NA #1 prior to her being able to interview him. On [DATE] at 4:46 PM, the Administrator and the DON were informed of Immediate Jeopardy. The Administration provided an acceptable credible allegation of compliance on [DATE] at 6:32 PM. Brian Center Waynesville respectfully submits the following allegation of compliance for F 225. 1. Nurse #1 notified the Director of Nursing (DON) of an allegation of abuse related to Resident #3 on [DATE]. On [DATE], immediately following the notification from Nurse #1 the Director of Nursing removed Nursing Assistant (NA) #1 from the Resident Care Areas, but NA #1 was allowed to stay in the facility while unsupervised in a non resident care area until his shift concluded. The accused NA did not return to the facility and was terminated on [DATE]. The Director of Nursing took statements over the phone from Nurse # 1 and NA #1 and Resident #3 on [DATE]. On [DATE] Resident #3 contacted the Police, who came into the Facility, and Resident #3 was transferred to the hospital for medical evaluation. The Director of Nursing called the Administrator on [DATE] at approximately 1:30 PM to inform him of Resident #3 ' s allegation. On [DATE] Resident #4 called the Police to report an allegation of abuse against NA #1. Resident #4 then notified Nurse #2 of same allegation. Nurse #2 then immediately notified the Director of Nursing on [DATE]. NA #1 was previously suspended on [DATE] and continued to remain out of the facility. The Police came into the facility on [DATE] and Resident #4 declined to go to the hospital for medical evaluation. A 24 Hour Report was submitted on [DATE], by the Director Nursing for Resident #3's allegation of abuse and Resident #4's allegation of abuse. The 5 Day Report was submitted for Resident #3 and Resident #4 on [DATE] by the Administrator. Nurse #1 was re-educated on [DATE] by the Director of Nursing on the Prohibition including the Elder Justice Act to include calling the police for a reasonable suspicion of a crime. Nurse #2's last day worked in facility was [DATE] due to her being a no call no show on [DATE] and has never returned to facility. 2. Current Residents have the potential to be affected by the same alleged deficient. By [DATE] the Social Services Director completed interviews with residents who were alert, oriented and able to answer questions to verify no other unreported allegations of abuse occurred. On [DATE] the Social Services Director completed an audit of families and responsible parties for those resident unable to participate in the prior interviews to verify no other unreported allegations of abuse occurred. On [DATE] the Administrator, Social Services Director, District Director of Operations and the District Director of Care Management completed interviews with all facility staff to verify no other unreported allegations of abuse occurred. No new allegations were identified as a result of these interviews. These audits and interviews were completed on [DATE]. 3. Measures put in place to ensure the alleged deficient practice does not recur include: On [DATE] the District Director of Clinical Services re-educated the Director of Nursing on the following: * Prohibition to include timely completion of 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect. The Director of Nursing was suspended by the Administrator on [DATE] pending investigation related to delayed reporting of abuse allegation to the Administrator and timely completion of investigation. The Administrator provided the Director of Nursing with disciplinary action as a final warning and was placed on a Performance Improvement Plan that included leading by example, maintain professionalism and report allegations of abuse/neglect to the appropriate parties in a timely manner, take each allegation in a serious nature and initiate the investigation immediately with follow through with interviewing witnesses and involved persons upon returning to work on [DATE]. The Director of Nursing was terminated on [DATE] and replaced with an Interim Director of Nursing who was immediately re-educated by the District Director of Clinical Services regarding Abuse Prohibition to include timely completion of 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect. On [DATE] the District Director of Operations re-educated the Administrator on Abuse Prohibition, the Elder Justice Act, reporting guidelines for the 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, and his responsibilities to coordinate an effective investigation by ensuring timely interviews and assessments, reviewing results and findings, and determining interventions according to opportunities identified during the investigation. The Administrator was terminated on [DATE] and replaced with an Interim Administrator who was immediately re-educated by the District Director of Operations regarding Abuse prohibition, the Elder Justice Act, reporting guidelines for the 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, and her responsibilities to coordinate an effective investigation by ensuring timely interviews and assessments, reviewing results and findings, and determining interventions according to opportunities identified during the investigation. On [DATE] all facility staff including housekeeping, dietary, and therapy were re-educated by the Director of Nursing, Unit Manager, and Area Staff Development Coordinator on Abuse Prohibition, the Elder Justice Act to include reporting allegations immediately to the abuse coordinator and calling the police for a reasonable suspicion of a crime. No staff will be allowed to work before receiving this re-education. All new employees will be educated on the facility's Policy for Abuse Prohibition, the Elder Justice Act and their responsibility of calling the police for a reasonable suspicion of a crime. This education will be completed by the Area Human Resource Officer or the Director of Nurse during orientation. On [DATE] the Administrator and Director of Nursing implemented a new system to monitor the management of allegations by reviewing all events with the Division Director of Clinical Services daily to ensure adherence to the Abuse Prohibition and Elder Justice Act and conduct a weekly focus call to further review events occurring throughout the week to ensure completion of investigations and reporting as required. Immediate jeopardy was removed on [DATE] at 8:12 PM when interviews with nursing staff, administrative staff, non-nursing staff, confirmed they had received in-service training and knew the different types of abuse, the need to report allegations of abuse to the Administrator, the need to compete a 24 hour and 5 day HCPR report within required time frames, and the need to call the police to report suspicion of a crime.

Based on resident interviews, staff interviews, and record reviews the faclity failed to implement their abuse policy in the areas of identification, protection, reporting and responding. The facility failed to supervise the alleged perpetrator until he left the facility, call law enforcement to report suspicion of a crime, failed to immediately assess the residents for injuries, failed to immediately notify the Administrator, and failed to file the 24 hour report to the Health Care Personnel Registry as required. This affected 2 of 4 residents sampled for abuse (Residents #3 and #4). Immediate Jeopardy began on [DATE] when Resident #3 told Nurse #1 she had been raped by Nurse Aide (NA) #1 and the Director of Nursing (DON) allowed the perpetrator to remain in the building without supervision for 3 additional hours. Neither Nurse #1 nor the DON informed the Administrator of the abuse allegation, called the police, or sought medical attention for Resident #3. Immediate Jeopardy began on [DATE] for Resident #4 when she told Nurse #1 and Nurse #2 she was sexually abused by NA #1, neither Nurse #1 nor Nurse #2 called the police or medically assessed Resident #4, and neither nurse or the Director of Nursing (DON) called the Administrator. Immediate Jeopardy was removed on [DATE] at 8:12 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to protecting residents from being abused and following the abuse policy. The findings included: The facility's Abuse and Neglect Prohibition policy with a revision date of [DATE] included: *The facility administrator is the Abuse Prevention Coordinator. *Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. *Facility supervisors will immediately correct and intervene in reported situations of abuse. *Any employee alleged to be involved in an instance of abuse will be suspended immediately. *The facility will protect residents from harm during the investigation. *The facility will report all allegations of abuse to the state agency in accordance with the state regulation. *In accordance with the Elder Justice Act, the facility will report to law enforcement agencies any reasonable suspicion of a crime against any individual who is a resident of the facility. 1. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded her with having intact cognition, scoring a 15 out of 15 on the Brief Interview for Mental Status, which measures long and short term memory and temporal orientation. She was coded as understanding others and being understood with clear speech and no communication problems. She was coded as having no behaviors, no signs of [MEDICAL CONDITION], feeling tired ,[DATE] days over the previous 2 weeks, and requiring supervision of one person physical assistance for most activities of daily living skills including bed mobility, transfers, walking, toileting and hygiene. She was coded as always being continent of bowel and bladder. Nursing notes dated [DATE] at 7:20 PM, written by Nurse #1, revealed Resident #3 asked to speak to this nurse privately. During this conversation, Resident #3 told Nurse #1 that Nurse Aide (NA) #1 stuck it in her and her genital area hurt. The nurse noted she asked Resident #3 if she wanted the police called or to be sent out (for evaluation) and the resident stated she only wanted the nurse to call the DON or the Administrator. Nurse #1 wrote that she immediately instructed NA #1 not to go back into Resident #3's room and then went to her office and called the DON. The note stated the DON instructed Nurse #1 to make sure NA #1 did not go back into the room and to have NA #1 call the DON immediately which she did. Review of an incident report dated [DATE] revealed at 7:20 PM Resident #3 made allegations of being sexually assaulted by NA #1. Initially she indicated that she said no (to pain/hurt) and she was just scared. Then she complained of vaginal pain & said he penetrated her. This incident report was completed by Nurse #1. Interview with Nurse #1 on [DATE] at 2:35 PM revealed that when she spoke to Resident #3 on [DATE], Resident #3 began crying and pointed to her genital area stating it hurt. She stated NA #1 stuck it in her, which Nurse #1 stated referred to his penis. Nurse #1 told NA #1 to not return to Resident #3's room and called the DON from her office. The DON told Nurse #1 she would take care of the issue and instructed the nurse to have NA #1 call her. After talking to the DON, Nurse #1 instructed NA #1 to call the DON and said she did not talk to the DON again that evening. Nurse #1 stated she was not given instructions other than making sure NA #1 did not go back into Resident #3's room. Nurse #1 stated she assigned Resident #3 and her roommate to another nurse aide and did not see NA #1 again. She stated she did not think NA #1 was on the hall but could not guarantee it. She saw him at the end of the shift when he left the facility with his girlfriend NA #2. Nurse #1 stated DON said she would take care of everything and so she did not call the police or address it again during her shift. Nurse #1 stated that she understood her responsibility was to call her supervisor (DON) regarding abuse and the DON was to give instructions and handle the situation. Nurse #1 stated she did not call the police or send her to the hospital because Resident #3 was crying and very upset and adamant she call the DON or Administrator. Neither the DON nor the Administrator came to the facility. Upon follow up interview on [DATE] at 3:59 PM, Nurse #1 stated she asked the DON if she should call anyone else when she spoke to her on [DATE] and the DON stated no. She stated she assumed the DON would take the lead in handling the allegation and investigation. Nurse #1 further stated she did not reassign the rest of NA #1's residents because she was not aware of what the DON told NA #1 and she did not talk to the DON after the initial phone call. The DON gave no instructions for a physical assessment of Resident #3, to call the police or the Administrator so Nurse #1 just held and comforted Resident #3. Nurse #1 kept saying she thought the DON was handling the situation. Nursing notes dated [DATE] at 1:30 PM written by Nurse #2 revealed Resident #3 stated a nurse aide (not identified in the note) helped her to the bathroom, pushed her against the wall and put his penis in her vagina. She stated that she then moved away and the nurse aide kissed her forcefully. The police were called and Resident #3 was sent to the hospital for a rape kit and exam. Review of the hospital records revealed Resident #3 was seen in the emergency roiagnom on [DATE] at 3:13 PM for reported sexual assault and assault by bodily force. Laboratory tests were drawn and post exposure [MEDICATION NAME] were ordered. A phone interview was conducted with Nurse #2 on [DATE] at 3:21 PM. Nurse #2 stated she arrived for work on [DATE] and Resident #3 asked who her nurse aide was for the day, around 10:00 AM. When told NA #1 was scheduled, Resident #3 started crying. Nurse #2 stated she was unaware of the allegations Resident #3 made to Nurse #1 the previous day. When asked what was wrong, Nurse #2 stated Resident #3 told her that 2 days prior, NA #1 asked if she needed to go to the bathroom and she walked independently to the bathroom. Resident #3 stated he followed her into the bathroom, closed the door, locked the door, pushed her against the wall, over the toilet where she grabbed the grab bar and he put his penis between her legs, moved around a bit and then actually penetrated her. Nurse #2 stated Resident #3 told her NA #1 had kissed her about 15 times previously and recently bought her perfume. Nurse #2 called the DON about the allegation. The DON stated she would handle it. Then Nurse #2 told the DON that Resident #3 was told to call the police (Nurse #2 stated she told Resident #3 to call the police). Nurse #2 stated the DON told her they needed to keep everyone out of the issue and when Nurse #2 told the DON that she was not ok with that, the DON agreed for the police to be called. Once the police arrived, the officer and Nurse #2 agreed it was appropriate to send Resident #3 to the hospital. Nurse #2 stated neither the DON or the Administrator came to the facility over the weekend. During an interview with Resident #3 on [DATE] at 9:53 AM, Resident #3 stated that she was raped by NA #1. She stated she was lying in bed when NA #1 suggested she go to the bathroom before her roommate returned from a smoke break. NA #1 followed Resident #3 into the bathroom, locked the door, and placed the tip of his penis in her vagina. Resident #3 stated she returned to bed and did not tell anyone until the next day when she told a nurse. Resident #3 cried during this interview. Follow up interview with Resident #3 on [DATE] at 9:15 AM, revealed in the past, NA #1 had kissed her and touched her breast. She stated she liked his friendliness and so never reported the incidents. She stated NA #1 bought her perfume which she really liked. She stated she did not report the sexual assault because she was afraid he would not buy her more perfume which she really liked. Crying, Resident #3 stated she had to make a decision about getting perfume and being raped and she decided she did not want to be raped again so she reported it. Review of the Health Care Personnel Registry (HCPR) 24 hour report revealed it was completed by the DON who signed it on [DATE]. The report noted there was a reasonable suspicion of a crime for resident abuse as Resident #3 alleged NA #1 put his penis in her vagina. The report noted the police were called and she was taken to the emergency room . This form was noted to be faxed to the HCPR on [DATE] at 9:43 AM. Interview with the DON on [DATE] at 12:03 PM revealed NA #1 was suspended at 8:04 PM on [DATE] but he had no ride home so he stayed in the residents' television room until 11:00 PM. She presented his time clock report for [DATE] which showed he clocked out for supper at 8:04 PM, clocked back in at 8:32 PM and out again at 11:06 PM. Notes taken by the DON, presented by the Administrator, revealed: *on [DATE] at 8:00 PM, Nurse #1 called her and told her NA #1 had raped Resident #3. The DON spoke to Resident #3 on the phone, she was crying and upset, and told the DON NA #1 bent her over the toilet and put his penis in her. DON told her she would call the police and Resident #3 stated no. *on [DATE] at 8:20 PM, the DON spoke to NA #1 on the phone and told him he was suspended due to a pending investigation of an allegation of sexual assault which he denied. When told to leave the facility, NA #1 stated he did not have a ride and needed to wait for his friend so the DON told him to go to the television room and wait and do not enter any resident room. *on [DATE] at 8:30 PM, the DON wrote she called Resident #3 again and she still did not want the police called and asked if the DON would take care of it. *(still noted as [DATE]) at 2:45 PM, the DON called the Administrator to inform him Resident #3 wanted the police called because she was raped by NA #1 on [DATE]. Per this note, Resident #3 called the police. *(still noted as [DATE]) at 2:50 PM the Detective came to the facility and took Resident #3's statement. She had emergency medical services (EMS) coming to the facility to transport the resident to the hospital for evaluation and rape test. DON noted she agreed Resident #3 needed to go. Follow up interview with the DON on [DATE] at 9:26 AM revealed she told Nurse #1 to call the police when she was informed of the allegation of rape on [DATE] but Resident #3 did not want the police called. She spoke to NA #1 on the phone on [DATE] and told him he was suspended and told to wait in the television room when informed he did not have a ride home. She did not recall telling him to clock out and did not instruct anyone to make sure he was supervised as he waited for his ride. She stated she did not come into the facility at all during the weekend. On Saturday ([DATE]) Nurse #2 called her to report Resident #3 called the police and they were on their way. The DON spoke to the Detective on the phone who informed the DON they were going to transport Resident #3 to the hospital for a rape kit. The DON called the Administrator on [DATE]. The DON stated she started the HCPR 24 hour report after being informed of the resident going to the hospital, but had trouble getting the fax to go through until she arrived at the facility Monday morning. The DON stated she had no reason for not calling the police, stated she handled the situation wrong and on Monday [DATE] she was suspended for 5 days and did not have anything more to do with the investigation. The Administrator was interviewed on [DATE] at 2:57 PM. The Administrator stated he was informed by the DON in the afternoon ([DATE]) that Resident #3 accused NA #1 of sexually assaulting her, that the DON suspended NA #1, the police came to the facility and arranged for a forensic examination. At the time of the call, Resident #1 was at the hospital and he was told she was ok and cooperating with the police. The Administrator stated he did not come to the facility as the police were involved and the DON stated she had completed the HCPR 24 hour report. The Administrator stated he was not aware Resident #3 made the initial allegation on Friday night ([DATE]) and the actual abuse occurred on Thursday ([DATE]) until he arrived at work Monday [DATE]. The Administrator further stated that he should have been called [DATE] and the interviews started immediately but that everyone was interviewed, NA #1 was not in the facility, and the police had been called(he suspected by Resident #3). He stated he found out on [DATE] that the DON did not come into the facility over the weekend. He stated the DON should have called the police. He stated he was unaware if the physician or family were notified and unaware if a physical assessment had been done prior to the hospital visit. In addition, the Administrator stated that NA #1's second language was English and he did not understand he was suspend until the next day. NA #1 was just told to sit in the television room on [DATE]. The Administrator stated the DON should have called a cab to remove NA #1 from the premises. He gave no reason why he did not come to the facility when he was alerted to the abuse allegations. The Administrator stated NA #1 was terminated on [DATE] for the pattern of allegations made against him as there was no definitive hard core proof of guilt. Review of the investigative notes taken by the Administrator revealed he did not begin interviewing staff, including NA #1, or Resident #3, until [DATE] and completed interviews on [DATE]. The HCPR 5 day investigation report faxed [DATE] at 8:54 PM marked that the allegation was unsubstantiated at this time and there was an ongoing police investigation. Interview with the Detective on [DATE] at 10:21 AM revealed this was an ongoing investigation, NA #1 had secured legal counsel and the police were hoping to arrange for an interview with NA #1 this week. The Detective stated it could be months before the results of the rape kit collected at the hospital would be available. The Detective stated she preferred the surveyors not interview NA #1 prior to her being able to interview him. NA #1 was not interviewed. 2. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] coded her with intact cognition and being understood and understanding with no communication issues. She was coded as requiring supervision of one staff for most activities of daily living skills (ADL) including bed mobility, toileting and hygiene, and being continent of bowel and bladder. She was coded as feeling bad about herself ,[DATE] days over the last 2 weeks, having no behaviors and no signs of [MEDICAL CONDITION]. The annual MDS dated [DATE] coded her with intact cognition, having no behaviors, no communication problems, no signs of [MEDICAL CONDITION], feeling bad about herself 2- 6 days over the last 2 weeks, and requiring set up or limited assistance with ADLs. A phone interview with Nurse #2 was conducted on [DATE] at 3:43 PM. Nurse #2 stated on [DATE] she was asked by Resident #8 to talk with Resident #4. Nurse #2 stated Resident #4 felt comfortable talking since Resident #3 had come forward with allegations of abuse. Resident #4 stated NA #1 had been kissing her while she slept. It occurred multiple times. Then the resident stated about ,[DATE] weeks ago, NA #1 was helping her in the bathroom, and as she stood, he turned her around, pushed her into the wheelchair and tried to penetrate her. She reported he had put his fingers inside her vaginal area, and ejaculated on her. Nurse #2 then stated after talking to the Director of Nursing via phone, Nurse #2 told Resident #4 call the police. Nurse #2 stated that because the incident happened a couple of weeks prior to the report, there was no need to send her to the hospital as evidence would be gone. Nurse #2 called the physican who agreed not to send her to the hospital for an exam. There were no nursing notes written by Nurse #2 about the allegations made by Resident #4. Nursing notes dated [DATE] at 11:00 AM, written by Nurse #1 revealed she received a call from Nurse #2 who reported that Resident #4 had made an allegation that Nurse Aide (NA) #1 had taken sexual advantage of her. Nurse #1's note indicated she came into work to get Resident #4's statement. Resident #4 told Nurse #1 this had been going on for 2 weeks. First, Resident #4 woke up to NA #1's tongue being in her mouth. Then 3 to 4 days later she was in the bathroom and he rubbed her breast and genital area. Another time she was in the bathroom, NA #1 returned and as she turned to get into the wheelchair, he put his hand on her back where she was over the chair, her pants had not been pulled up yet, he pulled his pants down but could not get his penis in her vagina so he ejaculated between her inner thighs. Inteview with Nurse #1 on [DATE] at 2:38 PM revealed she received a call from Nurse #2 on [DATE] at 11:00 AM who stated Resident #4 claimed she was assaulted by NA #1. Nurse #2 stated she told Nurse #2 to complete an incident report and concern form. Nurse #1 stated she went to the facility and got a statement from Resident #4 and then the police arrived. Nurse #1 stated she never spoke to the DON on [DATE] and the DON did not come to the facility. There was no incident report or concern form completed related to Resident #4's allegation of sexual assault. An interview with Resident #4 was conducted on [DATE] at 10:19 AM. Resident #4 stated she was assaulted by NA #1 3 times. The first time she was sound asleep and woke to his tongue being in her mouth. Crying, she referred to this incident as a violation that took place a month ago. The second time, she was in the bathroom, had gotten up, pulled her pants up, he grabbed hold of her, pulled her to him and started gyrating against her. The third time she was in the bathroom, had not pulled her pants up yet and he came into the bathroom pushed her forward and bent her over and ran his hands between her legs and tried to put his penis inside her. She stated his penis was too floppy to penetrate her so he finished by putting his penis between her thighs and ejaculated. He then brought her wash cloths with soap and water and instructed her to clean up. Follow up interview with Resident #4 on [DATE] at 8:24 AM revealed she did not tell anyone for fear and that it happened often. She stated she finally felt comfortable when she told Resident #8 about what NA #1 did to her and Resident #8 told her either Resident #4 had to tell someone about it or he would tell someone about NA #1. Review of the Health Care Personnel Registry (HCPR) 24 hour report signed and faxed by the DON on [DATE] marked there was no reasonable suspicion of a crime. The allegation noted that the incident was a long time ago and described the allegation was that NA #1 came into the bathroom and ejaculated between Resident #4's legs. The allegation on this report also stated another time she was sleeping and he kissed her with his tongue in her mouth. She did not report these incidents to anyone until [DATE]. The DON was interviewed on [DATE] at 12:03 PM who stated NA #1 had been suspended on [DATE] for a previous allegation of sexual assault made by Resident #3. Follow up interview with the DON on [DATE] at 9:45 AM revealed on Sunday ([DATE]), Nurse #2 called her and informed her that Resident #4 had called the police because NA #1 got her also. The DON stated she talked to Resident #4 via phone who stated it happened a long time ago. When asked why she waited to report it, Resident #4 stated she just didn't want to. The DON stated the resident asked her if she (Resident #4) should not have called the police but the DON said she told the resident it was ok to call the police. Resident #4 refused to go to the hospital. The DON stated that if the resident who was her own responsible party wanted the family to be called the nurse should call the family. The DON did not come to the facility and stated the police had already been called, NA #1 had been suspended and the resident did not want to go to the hospital. The DON stated she talked with the Administrator via phone on [DATE]. She stated neither she nor the Administrator came in on Sunday. The Administrator provided notes written by the DON relating to what she did once she received the allegation about Resident #4: *on [DATE] at about 11:00 AM, the DON received a phone call from Nurse #2 who informed her that Resident #4 was accusing NA #1 of raping her too. This occurred a long time ago and that the resident called the police. Per the notes, the DON spoke to Resident #4 on the phone and was told NA #1 ejaculated between her legs while she was in the bathroom. Resident #4 told her about another time waking up with NA #1's tongue in her mouth. The DON told Resident #4 it was ok that she called the police and that the resident would probably go to the hospital. Resident #4 declined to go to the hospital. The DON called and texted the Administrator. When he returned her call, the Administrator instructed the DON to call the District Director of Operations. She noted the District Director of Operation told her to call the corporate attorney, who she spoke with twice. The DON then called other corporate staff and the physician per these notes. Another interview with the DON on [DATE] at 3:46 PM revealed she was suspended on Monday [DATE] and had no more involvement in the investigation. She stated the nurse should have completed a body assessment but she had not looked at the record to see if an assessment was completed. She further stated she felt the resident was safe since NA #1 was already suspended. The Administrator was interviewed on [DATE] at 2:57 PM. The Administrator stated the DON was suspended on Monday [DATE] for not following the policy for allegations of abuse. He stated he found out on [DATE] that the DON did not come into the facility over the weekend. He stated his understanding was the resident had called the police before he was informed of the allegation. He stated he was unaware if the physician or family were notified and unaware if a physical assessment had been done. The Administrator stated the District Director of Operations came at his request to conduct interviews. He gave no reason why he did not come to the facility when he was alerted to the abuse allegations. The Administrator stated NA #1 was terminated on [DATE] for the pattern of allegations made against him as there was no definitive hard core proof of guilt. Review of the investigative notes taken by the Administrator revealed he did not begin interviewing staff, including NA #1, until [DATE] and completed interviews on [DATE]. Resident #3 refused to be interviewed explaining her family secured an attorney. The HCPR 5 day investigation report faxed [DATE] at 8:58 PM marked that there was no reasonable suspicion of a crime related to resident abuse and the allegation was unsubstantiated at this time and there was an ongoing police investigation. Interview with the Detective on [DATE] at 10:21 AM revealed Resident #4 called the police herself. The Detective stated this was an ongoing investigation, NA #1 had secured legal counsel and the police were hoping to arrange for an interview with NA #1 this week. The Detective stated she preferred the surveyors not interview NA #1 prior to her being able to interview him. NA #1 was not interviewed. On [DATE] at 4:46 PM, the Administrator and the DON were informed of Immediate Jeopardy. The Administration provided an acceptable credible allegation of compliance on [DATE] at 6:32 PM. Brian Center Waynesville respectfully submits the following allegation of compliance for F 226. 1. Nurse #1 notified the DON of an allegation of abuse related to Resident #3 on [DATE]. Resident #3 alleged that NA#1 raped her in the shower on Thursday [DATE]. On [DATE], immediately following the notification from Nurse #1 the Director of Nursing removed NA #1 from the Resident Care Areas. The accused did not return to the facility and was terminated on [DATE]. The Director of Nursing took statements over the phone from Nurse # 1 and NA #1 and Resident #3 on [DATE]. On [DATE] Resident #3 contacted the Police, who came into the Facility, and Resident #3 was transferred to the hospital for medical evaluation. Resident #3 received STD testing and [MEDICATION NAME] treatment with [MEDICATION NAME] and Raltegravir for 30 days. Resident #3 received Psych services on [DATE] for ongoing emotional support. The Director of Nursing called the Administrator on [DATE] at approximately 1:30 PM to inform him of Resident #3's allegation. A 24 hour report for Resident #3 was submitted by the Director of Nursing on [DATE] and the 5 Day report was submitted by the Administrator on [DATE]. Nurse #1 was re-educated by the Director of Nursing on the Facility's Policy for Abuse Prohibition including the Elder Justice Act. 2. On [DATE] Resident #4 called the Police to report an allegation of abuse. Resident #4 then notified Nurse #2 of same allegation. Resident #4 alleged that NA #1 came into the bathroom and sexually abused her and was unable to remember the date or time. Nurse #2 then immediately notified the Director of Nursing on [DATE]. NA#1 was previously suspended on [DATE] and continued to remain out of the facility. The Police came into the Facility and Resident #4 declined to go to the hospital for medical evaluation and STD testing. Resident #4 received Psych Services on [DATE] and [DATE] for ongoing emotional support. A 24 Hour Report was submitted on [DATE], by the Director Nursing for Resident #4's allegation of abuse. The 5 Day Report was submitted for Resident #4 on [DATE] by the Administrator. Nurse #1 was re-educated on [DATE] by the Director of Nursing on the Facility's Policy for Abuse Prohibition including the Elder Justice Act. Nurse # 2 last day worked in facility was [DATE]. 3. Current Residents have the potential to be affected by the same alleged deficient. By [DATE] the Social Services Director completed interviews with residents who were alert, oriented and able to answer questions to verify no other unreported allegations of abuse occurred. On [DATE] the Social Services Director completed an audit of families and responsible parties for those resident unable to participate in the prior interviews to verify no other unreported allegations of abuse occurred. On [DATE] the Administrator, Social Services Director, District Director of Operations and the District Director of Care Management completed interviews with all facility staff to verify no other unreported allegations of abuse occurred. No new allegations were identified as a result of these interviews. These audits and interviews were completed on [DATE]. The Facility's Abuse Prohibition Policy was reviewed the District Director of Operations, the District Director of Clinical Services, the Director of Nursing and the Administrator and all required components related to F 226 were present. 4. Measures put in place to ensure the alleged deficient practice does not recur include: On [DATE] the District Director of Clinical Services re-educated the Director of Nursing on the following: *The Facility's Policy for Abuse Prohibition to include timely completion of 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect. The Director of Nursing was suspended by the Administrator on [DATE] pending investigation related to delayed reporting of abuse allegation to the Administrator and timely completion of investigation. The Administrator provided the Director of Nursing with disciplinary action as a final warning and was placed on a Performance Improvement Plan that included reporting allegations of abuse/neglect to the appropriate parties in a timely manner and initiate the investigation immediately upon returning to work on [DATE]. The Director of Nursing was terminated on [DATE] and replaced with an Interim Director of Nursing who was immediately re-educated by the District Director of Clinical Services regarding Abuse Prohibition to include timely completion of 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry ,the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect. On [DATE] the District Director of Operations re-educated the Administrator on the Facility's Policy for Abuse Prohibition , the Elder Justice Act, reporting guidelines for the 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, and his responsibilities to coordinate an effective investigation by ensuring timely interviews and assessments, reviewing results and findings, and determining interventions according to opportunities identified during the investigation. The Administrator was terminated on [DATE] and replaced with an Interim Administrator who was immediately re-educated by the District Director of Operations regarding Abuse prohibition, the Elder Justice Act, reporting guidelines for the 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, and her responsibilities to coordinate an effective investigation by ensuring timely interviews and assessments, reviewing results and findings, and determining interventions according to opportunities identified during the investigation. On [DATE] All facility staff, the Nursing Department including Resident Care Specialists (CNAs), Business Office Staff, Housekeeping, Dietary and Therapy were re-educated by the Director of Nursing, Unit Manager, and Area Staff Development Coordinator regarding the definition of Abuse meaning the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Injuries of unknown origin may occur as a result of abuse. Education also included

Based on resident interviews, staff interviews, record reviews, and police interviews, the administration failed to impose expectations related to immediately removing an alleged perpetrator from resident care areas, failed to impose expectations related to immediately calling law enforcement when a crime is suspected, failed to empower staff to make the call to law enforcement when a crime is suspected, and failed to impose expectations that the Administrator be informed immediately of an allegation of abuse, failed to impose expectations that the Health Care Personnel Registry (HCPR) be notified within 24 hours of an allegation of abuse by a staff member and failed to impose expectations that the physician and responsible parties of the residents involved were notified of allegations of abuse and health status. Immediate Jeopardy began on [DATE] when Resident #3 was sexually assaulted by Nurse Aide (NA) #1. Resident #3 told Nurse #1 she had been raped by NA #1 and the Director of Nursing (DON) allowed the perpetrator to remain in the building without supervision for 3 additional hours. Neither Nurse #1 nor the DON informed the Administrator of the abuse allegation, called the police, called the responsible party, or called the physician. In addition, the 24 hour initial report was not faxed to the HCPR within the required 24 hours. Immediate Jeopardy began on [DATE] for Resident #4 when she told Nurse #1 and Nurse #2 she was sexually abused by NA #1, and neither Nurse #1, Nurse #2, or the DON called the police, the administrator immediately, the responsible party, or called the physician. Immediate Jeopardy was removed on [DATE] at 8:12 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm, that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to protecting residents from being abused, notifying the physician and responsible parties and following the facility's abuse policy and procedure. The findings included: Cross refer to F 157: Based on resident interviews, responsible party interviews, staff interviews, physican interviews and record reviews, the facility failed to inform the responsible parties and the physician when 2 of 4 sampled residents alleged sexual abuse by a staff member (Residents #3 and #4). Cross refer to F 223: Based on resident interviews, record review and staff interviews, the facility failed to maintain 2 of 4 sampled residents' right to be free of sexual abuse (Residents #3 and #4). Cross refer to F 225: Based on resident interviews, staff interviews, and record reviews the facility failed to report allegations of abuse to the Administrator, report suspicion of a crime to law enforcement and complete and send the 24 hour report to the Health Care Personnel Registry (HCPR) as required. This affected 2 of 4 residents sampled for abuse (Residents #3 and #4). Cross refer to F 226: Based on resident interviews, staff interviews, and record reviews the faclity failed to implement their abuse policy in the areas of identification, protection, reporting and responding. The facility failed to supervise the alleged perpetrator until he left the facility, call law enforcement to report suspicion of a crime, failed to immediately assess the residents for injuries, failed to immediately notify the Administrator, and failed to file the 24 hour report to the Health Care Personnel Registry as required. This affected 2 of 4 residents sampled for abuse (Residents #3 and #4). On [DATE] at 4:46 PM, the Administrator and the DON were informed of Immediate Jeopardy. The Administration provided an acceptable credible allegation of compliance on [DATE] at 6:32 PM. Brian Center Waynesville respectfully submits the following allegation of compliance for F 490. 1. Nurse #1 notified the DON of an allegation of abuse related to Resident #3 on [DATE]. On [DATE], immediately following the notification from Nurse #1 the Director of Nursing removed CNA #1 from the Resident Care Areas. The accused did not return to the facility and was terminated on [DATE]. The Director of Nursing took statements over the phone from Nurse # 1 and CNA #1 and Resident #3 on [DATE]. On [DATE] Resident #3 contacted the Police, who came into the Facility, and Resident #3 was transferred to the hospital for medical evaluation. The Director of Nursing called the Administrator on [DATE] at approximately 1:30 PM to inform him of Resident #3's allegation. On [DATE] Resident # 4 called the Police to report an allegation of abuse. Resident #4 then notified Nurse #2 of same allegation. Nurse #2 then immediately notified the Director of Nursing on [DATE]. CAN#1 was previously suspended on [DATE] and continued to remain out of the facility. The Police came into the Facility and Resident #4 declined to go to the hospital for medical evaluation. A 24 Hour Report was submitted on [DATE], by the Director Nursing for Resident #3's allegation of abuse and Resident #4's allegation of abuse. The 5 Day Report was submitted for Resident #3 and Resident #4 on [DATE] by the Administrator. Nurse #1 was re-educated on [DATE] by the Director of Nursing on the Facility's Policy for Abuse Prohibition including the Elder Justice Act, and the policy for notification of Physicians and Responsible Parties when Residents have a change of condition, incident or allegation of abuse or neglect. Nurse # 2 last day worked in facility was [DATE]. On [DATE] the Director of Nursing notified the Physician of Resident #3 regarding the allegation of abuse received on [DATE]. Resident #3 is responsible for her own affairs and she notified her family on [DATE]. On [DATE] the Director of Nursing notified the Physician of Resident #4 regarding the allegation of abuse received on [DATE]. Resident #4 is responsible for her own affairs and she notified her Responsible Party on [DATE]. 2. Current Residents have the potential to be affected by the same alleged deficient. By [DATE] the Social Services Director completed interviews with residents who were alert, oriented and able to answer questions to verify no other unreported allegations of abuse occurred. On [DATE] the Administrator, Social Services Director, District Director of Operations and the District Director of Care Management completed interviews with all facility staff to verify no other unreported allegations of abuse occurred No new allegations were identified as a result of these interviews. These audits and interviews were completed on [DATE]. By [DATE] the Social Services Director completed interviews with residents who were alert, oriented and able to answer questions to verify no other unreported allegations of abuse occurred. On [DATE] the Social Services Director completed an audit of families and responsible parties for those resident unable to participate in the prior interviews to verify no other unreported allegations of abuse occurred. On [DATE] the Administrator, Social Services Director, District Director of Operations and the District Director of Care Management completed interviews with all facility staff to verify no other unreported allegations of abuse occurred. On [DATE] the Administrator completed an audit of all previously reported allegations of abuse or neglect received during the last 6 months to validate Physician and Responsible Party notification was completed. No further Physician notifications were required as a result of these interviews as no new allegations were identified. These audits and interviews were completed on [DATE]. 3. Measures put in place to ensure the alleged deficient practice does not recur include: On [DATE] the District Director of Clinical Services re-educated the Director of Nursing on the following: *The Facility's Policy for Abuse Prohibition to include timely completion of 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, the Elder Justice Act and immediate notification to the Administrator of allegations of abuse or neglect. *The Facility Policy for Notification of Physicians and Responsible Parties when a Resident has a Change of Condition, an Incident or Accident occurs, or when an allegation of abuse or neglect occurs. The Director of Nursing was suspended by the Administrator on [DATE] pending investigation related to delayed reporting of abuse allegation to the Administrator and timely completion of investigation. The Administrator provided the Director of Nursing with disciplinary action as a final warning and was placed on a Performance Improvement Plan that included leading by example, maintain professionalism and report allegations of abuse/neglect to the appropriate parties in a timely manner, take each allegation in a serious nature and initiate the investigation immediately with follow through with interviewing witnesses and involved persons upon returning to work on [DATE]. On [DATE] the District Director of Operations re-educated the Administrator on the Facility's Policy for Abuse Prohibition, the Elder Justice Act, reporting guidelines for the 24 Hour and 5 Day Reports to the NC Health Care Personnel Registry, and his responsibilities to coordinate an effective investigation by ensuring timely interviews and assessments, reviewing results and findings, and determining interventions according to opportunities identified during the investigation. On [DATE] the Administrator was terminated and an Interim Administrator assigned by the District Director of Operations. The Interim Administrator was educated by the District Director of Clinical Services regarding the Facility's Policy for Abuse Prohibition to include the Elder Justice Act. Education also included maintaining a professional relationship with residents, families and the Resident's Right to live in the facility free from abuse and neglect. The facility will not tolerate abuse and will follow the policy for Abuse Prohibition to investigate all allegations of abuse or neglect thoroughly. As the Abuse Coordinator the Administrator is expected to ensure the implementation of Abuse prohibition throughout the facility and maintain an environment for Residents that is free from abuse and neglect. On [DATE] Facility Staff including housekeeping, dietary, and therapy were re-educated by the Director of Nursing, Unit Manager, and Area Staff Development Coordinator on the Facility's Policy for Abuse Prohibition to include the Elder Justice Act. Education also included maintaining a professional relationship with residents and families and the Resident's Right to live in the facility free from abuse and neglect. The facility will not tolerate abuse and will follow the policy for Abuse Prohibition to investigate all allegations of abuse or neglect thoroughly. Facility Staff shall not be allowed to work before receiving this re-education. All new employees will be educated on Abuse Prohibition, the Elder Justice Act and their responsibility of calling the police for a reasonable suspicion of a crime. Education will also include maintaining a professional relationship with residents and families and the Resident's Right to live in the facility free from abuse and neglect. The facility will not tolerate abuse and will follow the policy for Abuse Prohibition to investigate all allegations of abuse or neglect thoroughly. This education will be completed by the Area Human Resource Officer or the Director of Nurse during orientation. On [DATE] the Administrator and Director of Nursing implemented a new system to monitor the management of allegations by reviewing all events with the Division Director of Clinical Services daily to ensure adherence to the Facility Policy on Abuse Prohibition and conduct a weekly focus call to further review events occurring throughout the week to ensure completion on investigations and reporting as required. All Licensed nurses and CNAs were re-educated by the Area Staff Development Coordinator and the Director of Nursing on [DATE] regarding the facility's policy for Physician and Responsible Party Notification as it relates to: *A Change in Resident Condition *When and Incident or Accident occurs *When an allegation of abuse or neglect occurs. Licensed Nurses and CNAs shall not be allowed to work before receiving this re-education. All new employees will be educated by the Area Human Resource Officer or the Director of Nurse during orientation. The Administrator and Director of Nursing will complete a root cause analysis by [DATE] regarding abuse within the facility. The Administrator and Director of Nursing will hold weekly staff meetings to review and re-educate Abuse Prohibition. During these meetings the leadership will reinforce the Resident's right to remain free from abuse and neglect. A schedule has been developed by the Administrator, beginning [DATE], for the next 7 days to include daily supervision during all 3 shifts. All staff involved have reviewed and agreed to the schedule. The Admnistrator, Director of Nursing(DON), Unit Manager (UM), District Director of Clinical Services (DDCS) or District Director of Operations (DDO) will participate in this weekly schedule. A member of this leadership team will be available and rounding within the facility each day assessing the ongoing performance of the facility staff to ensure there is no tolerance for abuse. The Administrator and Director of Nursing will complete Performance Evaluations for current Licensed and Certified Nursing staff by [DATE], then annually. Immediate jeopardy was removed on [DATE] at 8:12 PM when interviews with residents revealed they were aware and felt comfortable reporting abuse incidents immediately. Nursing staff, administrative staff, non-nursing staff, and residents confirmed they had received in-service training and knew the different types of abuse, the need to report allegations of abuse to the Administrator, the need to compete a 24 hour and 5 day HCPR report within required time frames, the need to call the police to report suspicion of a crime, the need to call the responsible party and the physican, and the need to evaluate the resident and obtain appropriate medical interventions for the affected residents.

Based on record review and staff interviews, the facility failed to evaluate and analyze the circumstances and/or trends of falls and modify interventions to reduce the risk of falls and/or injuries. This affected 1 of 3 residents sampled for falls who fell multiple times resulting in a fractured shoulder (Resident #9). The findings included: Resident #9 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A plan of care was originally developed on [DATE] which identified the problem that Resident #9 was at risk for falls related to mental status and the use of sedatives/hypnotics. The goal was for Resident #9 to have a reduction in potential for falls and injury. This generic plan of care had check marks by the following pre-printed interventions: *Falling Star Program *Encourage resident to ask for assist *Ensure that resident has proper footwear as indicated and accepted *Interdisciplinary referral to physical therapy, occupational therapy, restorative nursing and social services *orient resident to room/environment *place call light within reach *offer/assist to toilet frequently and as accepted *observe for potential medication causes. The Care Area Assessment (CAA) dated [DATE] relating to falls stated Resident #9 was a long term resident with advanced dementia. She was described as ambulating around the facility independently, having an unsteady gait at times, needing to be reminded to walk close to the handrails for support. The last fall per this CAA occurred on [DATE] during which she was not injured. An interview with the Director of Nursing (DON) was conducted on [DATE] at 12:18 PM to review Resident #9's falls. She explained that after each fall the Interdisciplinary Team (IDT) committee met and discussed the falls and circumstances known to determine if care plan interventions needed to be added or changed. The DON stated the falling star program listed on Resident #9's care plan just identified the resident as a fall risk and indicated to staff that they should keep an eye on her. Resident #9 had recurring falls as follows: On [DATE] at 7:35 PM, an incident report noted Resident #9 was found on the floor by the side of the bed. She sustained a skin tear to her left hand between her thumb and index finger. The Situation, Background, Assessment, Recommendation (SBAR)/progress note dated [DATE] stated she was continually more confused and agitated and needed more assistance with activity of daily living skills. The SBAR stated she had small emesis. The (IDT) post fall review for the unwitnessed fall on [DATE] stated that staff were instructed to increase visual checks due to resident's severe dementia and that the resident would not leave the bedroom door open. The intervention recommendations included a check for care plan revision and for other with a note for staff education. The care plan noted [DATE] to increase visual checks. The DON stated during interview on [DATE] at 12:18 PM that the intervention to check more often was that staff would check more frequently and try to keep her door open. She stated there was no set time or frequency to check on her and she could not describe what frequently meant. She further stated that if staff noticed her walking and she appeared tired, they would encourage to sit and rest. She stated the unit manager would pass the information to the staff from the IDT meeting and update the care plan to check on her more frequently. On [DATE] at 7:25 PM, an incident report noted Resident #9 was found on the floor vomiting beside the bed. The SBAR/progress note contained no additional note other than nursing thought the problem may be dizziness from vomiting. The IDT post fall review of this unwitnessed fall stated staff were instructed to attempt to leave the bedroom door open and increase visual checks. The intervention recommendations included a check for care plan revision and for other with a note for staff education. The care plan noted [DATE] to continue approach and encourage the resident to leave the door open and continue to increase visual checks. The DON stated during interview on [DATE] at 12:18 PM that staff were instructed to try to keep the bedroom door open to increase visual checks since both Resident #9 and the roommate often closed the door. The quarterly Minimum (MDS) data set [DATE] coded her as being severely cognitively impaired, having wandering behaviors, being unsteady but able to stabilize herself, requiring supervision for most activities of daily living skills, including ambulation, being occasionally incontinent of bladder and having 1 fall with a non-major injury since the previous assessment. She received antidepressant and antianxiety medications daily. There were no new care plan interventions relative to falls at this review. Resident #9 continued to fall as follows: On [DATE] at 2:00 PM, an incident report noted Resident #9 was found lying in another resident's room. She complained about right elbow, right hip and nasal pain. A bruise on the right elbow was noted on the form. The SBAR/progress note stated she complained of nausea post fall and the nurse thought the problem may be confusion and agitation. Physician orders [REDACTED]. Results dated [DATE] revealed elbow, hip and pelvis were negative and the resident was uncooperative for Xrays of the nasal bones. The IDT post fall review for this unwitnessed fall stated staff were to continue visual checks. The intervention recommendations included a check for care plan revision and for other with a note for staff education. The care plan was only updated with the date of the fall. The DON stated during interview on [DATE] at 12:18 PM that she could not say how often staff were expected to visually check on Resident #9. The DON stated because she was ambulatory there was nothing staff could do to try to prevent her from falling. She further stated that during the IDT meetings, the team did not discuss any time frames for visually checking on Resident #9 and identified no trends involved with her falling as she fell at all different times. On [DATE] at 10:00 AM a physician note indicated Resident #9 was seen for increased anxiety. Trazodone (an antidepressant medication) 25 milligrams (mg) was added as needed every 6 hours for anxiety. On [DATE] at 9:00 PM, an incident report noted Resident #9 was found lying on the floor in the bathroom between the toilet and the wall. She stated her right elbow hurt but there was no obvious redness, bruising or edema. The SBAR/progress note stated the resident was falling more frequently and that physical therapy (PT) eval and treatment should be considered. The IDT post fall review for this unwitnessed fall stated staff were advised to remove socks before bed. Also the resident has had frequent falls and physician was aware and a request for a PT eval was made. The intervention recommendations included a check for care plan revision and for other with a note for staff education. The care plan noted [DATE] continue approach, increase visual checks. The care plan was updated with a request for physician to eval for PT for frequent falls on [DATE]. There was nothing added to the care plan regarding socks. The DON stated during interview on [DATE] at 12:18 PM that she could not recall what the significance of having staff remove her socks at night entailed, as there was nothing related to socks in the incident report. The DON stated Resident #9 normally wore shoes and socks when up and dressed. The DON stated they analyzed and talked in IDT committee about what staff could do to keep the resident safe. On [DATE] Resident #9 was seen by the nurse practitioner (NP) due to an increase in falls. The physician note stated there was no clear reason for her frequent falls. The NP's plan was to hold Procardia (a hypertension medication)due to low blood pressure, have PT/occupational therapy (OT) evaluate, and obtain a CT scan to evaluate a brain mass which had not been checked since 2009. PT began working with the resident on [DATE] for therapeutic exercises, neuromuscular re-education, and gait training. On [DATE] at 3:00 AM, an incident report revealed Resident #9 was found on the floor in her room. She hit her head on the floor and sustained 2 small bumps on the back of her head. Neurochecks were initiated. The IDT post fall review for this unwitnessed fall stated the resident was severely cognitively impaired. Her short term memory was absent. The resident could not remember to ask for assistance or ring the call light. Resident #9 was on frequent visual checks and staff was attempting to leave the door open by repeatedly reminding her to not close her door. The intervention recommendations included a check for care plan revision. The DON stated during interview on [DATE] at 12:18 PM that the facility was unable to prevent her from falling as she was ambulatory. On [DATE] at 7:10 PM, an incident report revealed Resident #9 was found sitting beside her bed and denied falling stating she was just resting. The SBAR/progress note for [DATE] noted the resident fell twice this date and was treated with ice to her head. The IDT post fall review for this unwitnessed fall stated the resident has had frequent falls due to severe dementia and has been placed on visual checks. She was noted as non-compliant with any instruction. The care plan was updated on [DATE] noting she had a fall in her room and sustained 2 hematomas to her head. The only other thing noted was to continue the goal through the next review. The DON stated during interview on [DATE] at 12:18 PM that the intervention was for staff to keep an eye on Resident #9. She stated there was nothing the staff could do to stop her from falling. She further stated Resident #9 did get more confused in the afternoons due to sundowning. The resident was seen by the nurse practitioner (NP) on [DATE] for followup. Her blood pressures were noted essentially normal. The NP noted tremors were noted at rest which were worse than previous, she had very poor safety awareness, she was unaware of her surroundings and her falls were generally unwitnessed. An EKG noted supraventricular bradycardia. The NP discontinued medications of Metoprolol (a hypertension medication) and requested a cardiology consult. On [DATE] at 10:01 AM the Medical Records Clerk stated Resident #9 died prior to the cardiology appointment. On [DATE] at 1:15 PM, an incident report noted Resident #9 fell on the floor and was found with a swollen abnormal left upper arm. The IDT note indicated she was found lying in the hall and it was an unwitnessed fall. A physician's orders [REDACTED]. Mobile X-ray results revealed Resident #9 sustained an acute fracture of the surgical neck and greater tuberosity. There was medial displacement of the distal fragment and medial apex angulation. The physican ordered Resident #9 to be sent to the hospital for treatment of [REDACTED].#9 returned to the facility with a sling. The care plan was not changed. During interview on [DATE] at 12:18 PM, the DON stated there was no written plan to increase supervision for Resident #9 and the DON was unable to say how often staff were expected to visually check on the resident. Per physician notes on [DATE], Resident #9 developed a temperature, was lethargic, not eating, diaphoretic and clammy. treatment for [REDACTED]. Resident #9 died in the facility on [DATE]. On [DATE] at 10:25 PM Nurse #4 was interviewed. Nurse #4 stated Resident #9's dementia progressively declined. He described poor short term memory. He stated the resident's ambulation became very shaky before she fractured her shoulder. When asked what interventions were in place to reduce her falls, Nurse #4 stated staff were to check on her frequently. After she fractured her shoulder, Nurse #4 stated she became very lethargic and basically did not ambulate anymore. On [DATE] at 2:06 PM the Administrator stated Resident #9 ambulated independently, was confused and staff were expected to keep their eye on her. He was unable to explain what was meant by frequent visual checks. Nurse #3 was interviewed on [DATE] at 7:14 PM. Nurse #3 stated she thought Resident #9 had a bed alarm and the bed was kept in the lowest position. She stated Resident #9 was up all hours day and night and wandered all around the facility. Nurse Aide (NA) #5 stated during interview on [DATE] at 7:22 PM that she worked second shift. She stated Resident #9 was unsteady and she would walk her back to her room. NA #5 stated she could not recall an alarm being used and could not recall any directions regarding checking on her frequently. NA #6, who worked 7:00 PM to 7:00 AM, stated during interview on [DATE] at 7:28 PM that Resident #9 was progressively becoming more unsteady over the last 3 months. She stated she could not recall receiving any instruction related to visual checks and that she did not recall an alarm used for her. During interview with NA #7, who worked 7:00 PM to 7:00 AM, NA #7 described Resident #9 as very confused. She stated the resident was fairly steady up until the last month and a half and she started falling. She did not recall any alarm in place. She further stated staff keep their eye on her but nothing different than they did for any other resident.

Based on record review and staff interview the facility's Quality Assessment and Assurance (QA and A) Committee failed to maintain implemented procedures and monitor the interventions that the committee put in place December 2015. This was for 5 deficiencies that were cited in December 2015 on a recertification survey. These deficiencies were re-cited on the current complaint survey. The deficiencies were in the areas of Services Meet Professional Standards, Supervision to Prevent Accidents, Labs Only Obtained with a physician's orders [REDACTED]. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F281: Services Meet Professional Standards: Based on record review and staff interview the facility failed to obtain physician's orders [REDACTED].#7. During the recertification survey of December 2015, the facility was cited for F281 for failure to obtain lab tests that were ordered by the physician. On the current survey the facility failed to obtain physician's orders [REDACTED]. F323: Supervision to Prevent Accidents: Based on record review and staff interviews, the facility failed to evaluate the circumstances and/or trends of falls in order to develop interventions to reduce the number of falls or injuries. During the recertification survey of December 2015, the facility was cited for F323 for failure to protect residents from potential environmental hazards by leaving the biohazard waste disposal units on 2 medication carts unlocked. On the current survey the facility failed to evaluate the circumstances or pattern of falls in a resident with recurring falls. F504: Labs only Obtained with a physician's orders [REDACTED]. During the recertification survey of December 2015, the facility was cited for F504 for failure to obtain a physician's orders [REDACTED]. On the current survey the facility failed to obtain a physician's orders [REDACTED]. F514: Lab Reports Filed in Chart: Based on record review and staff interview the facility failed to file results of laboratory tests in the clinical records of three residents. During the recertification survey of December 2015, the facility was cited for F514 for failure to obtain complete and accurate medication orders. On the current survey the facility failed to file the results of laboratory tests in the clinical records of three residents. F520 Quality Assessment and Assurance Program: Based on record review and staff interview the facility's Quality Assessment and Assurance (QA and A) Committee failed to maintain implemented procedures and monitor the interventions that the committee put in place in December 2015. During the recertification survey of December 2015, the facility was cited for F520 for failure to maintain compliance at F253, F312 and F514 since the previous recertification survey of 02/27/15. On the current survey the facility had recurring noncompliance at F 281, F323, F504, F514 and F520. An interview was held on 03/24/16 at 1:00 PM with the Director of Nursing (DON) about her expectation for obtaining orders for treatments including wound care and medicated ointments. The DON stated she expected staff to have an order for [REDACTED]. When asked about her expectation for having a physician's orders [REDACTED].>An interview on 03/24/16 at 2:04 PM with the Administrator about the continued non-compliance at F281, F323, F504 and F514 revealed he thought the problem with lab results not being on the resident's medical record and some of the other issues was because of the Unit Coordinator who quit within the past 2 weeks. The Administrator stated they had continued to monitor all of the areas and could offer no further explanation.