Every finding on record at Southern Oaks Nursing & Rehabilitation Center

Based on record review and interview the facility failed to maintain, store, prepare, distribute, and serve food under sanitary conditions. The facility failed to monitor and maintain freezer temperatures. This had the potential to affect the 55 residents who were served trays out of the kitchen according to S3 Dietary Manager. Findings:Review of policy titled Storage of Frozen Food (revised 10/18) revealed:POLICY:The facility ensures the quality and safety of frozen through accepted storage practices.PROCEDURE: .1. Frozen food is stored in a freezer to keep the food solidly frozen (<20F [Fahrenheit].) .10. Food temperatures are regularly monitored and recorded. Corrective action is taken as indicated. Review of freezer temperature monitoring logs failed to reveal a log had been completed for the ice cream freezer. During an interview on 08/05/2026 at 8:37 a.m. S3 Dietary Manager reported she did not have any completed logs for the ice cream freezer as they were not being done.

Based on record reviews, observation, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of infection for 1 (#2) of 1 resident reviewed for perineal care. The facility failed to provide perineal care to Resident #2 in accordance with infection control standards. Findings:Review of facility's Incontinent Care: Bladder Policy (undated) in part revealed:Policy: Perineal management is the cleaning of the perineal area that includes the genitalia and rectal areas. It promotes cleanliness and comfort and prevents infection by removing irritating secretions or excretions, microrganisms, and offensive odors. The care should be administered daily during bathing, and more frequently following urinary and/or fecal incontinence or if excessive secretions are present.Equipment: basin of warm water, mild soap or personal cleanser, towels, washcloth, gloves, waterproof protective pad, lotion. Procedure:9. for female perineal care:e. turn to a side lying position and wash perineum and anus from front to back, rinse and pat or gently dry. 11. remove and discard gloves.12. perform handwashing or use alcohol gel.Review of Resident #2's diagnoses revealed the following, but not limited to pressure ulcer (sacral area), reduced mobility, T (thoracic) 11-T12 compression fracture, left femur fracture, and cognitive communication deficit. Review of Resident #2's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15 indicating severely impaired cognition and required assistance with toileting, bathing, and personal hygiene. Further review of Quarterly MDS revealed Resident #2 was incontinent of bowel and bladder. Observation on 08/04/2026 at 11:40 a.m. revealed S4 CNA (Certified Nurse Assistant) and S5 CNA performing perineal care on Resident #2. During perineal care S4 CNA wiped Resident #2's from anus to vagina. After completing perineal care S4 CNA gathered Resident #2's dirty linens and used PPE (personal protective equipment) gowns and placed the items in same plastic bag. S4 CNA adjusted Resident #2's bed with bed remote with same soiled gloved hands. During an interview on 08/04/2026 at 11:40 a.m. S4 CNA confirmed Resident #2 perineal care was not performed by wiping front to back. S4 CNA confirmed when removing Resident #2's dirty linens and used PPE from Resident #2's room S4 CNA should have brought two plastic bags; one for waste and one for linens and did not. S4 CNA confirmed used soiled gloves should have been removed and hands sanitized after completing Resident #2's perineal care before touching Resident #2's bed's remote and personal items. During an interview on 08/04/2026 at 2:00 p.m. S2 DON (Director of Nursing) reported perineal care should have been performed from front to back and gloves should have been removed after completing perineal care before touching residents' personal items.

Based on record reviews, observations, and interviews, the facility failed to provide the resident who is unable to carry out activities of daily living (ADL), the necessary services to maintain good grooming and personal hygiene for 2 (#27, #36) of 2 residents investigated for ADL care. The facility failed to ensure Resident #27 and Resident #36's fingernails were trimmed and cleaned. Findings:Resident #27Review of Resident #27's medical record revealed an admit date of 07/23/2025 with diagnoses that include in part; need for assistance with personal care, muscle weakness (generalized), muscle spasm, and myalgia of auxiliary muscles, head and neck. Review of Resident #27's physician orders revealed an order dated 07/18/2026 Treatment nurse to check, clean, and trim fingernails and toenails every other Saturday. Every day shift every 2 weeks on Saturday. Review of Resident #27's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 07 indicating severe cognitive impairment. Further review of Resident #27's medical record revealed Resident #27 was care planned for self-care ADL deficit with interventions that included fingernails needed to be cleaned and trimmed. Observation on 08/03/2026 at 8:40 a.m. revealed Resident #27 had long fingernails past the end of the fingertips and black substance underneath. During an interview on 08/03/2026 at 8:40 a.m. Resident #27 reported his fingernails are longer than he likes, need to be cut and cleaned and he was not able to by himself. Observation on 08/03/2026 at 4:20 p.m. revealed Resident #27 with long fingernails past the end of the fingertips and black substance underneath. Resident #36Review of Resident #36's medical record revealed an admit date of 06/01/2026 with diagnoses that include in part hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #36's physician orders revealed an order dated 7/18/2026 Treatment nurse to check, clean and trim fingernails and toenails every other Saturday every day shift every 2 weeks on Saturday.Review of Resident #36's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had a BIMS score of 11 indicating moderate cognitive impairment. Further review of Resident #36's medical record reveal Resident #36 was care planned for self-care ADL deficit with interventions that included fingernails needed to be cleaned and trimmed. Observation on 08/03/2026 at 08:40 a.m. revealed Resident #36 with fingernails long past the end of fingertips with black substance underneath. During an interview on 08/03/2026 at 08:40 a.m. Resident #36 reported his nails are longer than he likes, needed to be cut and cleaned and he was not able to by himself. Resident #36 reported he got a bath this morning but it has been a while since he got his fingernails cleaned and cut. Observation on 08/03/2026 at 4:20 p.m. revealed Resident #36 with fingernails long past the end of his fingertips with black substance underneath. Resident #36 reported his fingernails are too long have not been cut or cleaned. During an interview on 08/03/2026 at 4:45 p.m. S1 CNA (Certified Nurse Assistant) observed Resident #27 and Resident #36's fingernails. S1 CNA confirmed Resident #27 and Resident #36's fingernails were long past the ends of their fingertips and should have been cut and cleaned and were not. During an interview on 08/05/2026 at 12:30 p.m. S2 DON (Director of Nursing) confirmed Resident #27 and #36's fingernails were long past the end of the fingertips, had black substance underneath and should not have.

Based on record reviews and interviews the facility failed to ensure 1 (#7) of 4 residents reviewed for accidents was offered or administered PRN (as needed) pain medication when Resident #7 verbally complained of pain. Findings:Review of Resident #7's face sheet revealed an admission date of 07/17/2024 with the following diagnoses but not limited to inflammatory polyneuropathy, history of falling, and cognitive communication deficit. Review of Resident #7's Quarterly MDS (Minimum Data Sets) dated 04/23/2026 assessment revealed a BIMS (Brief Interview of Mental Status) score of 9 out of 15 indicating moderately impaired cognition. Review of Resident #7's August 2026 Physician Orders revealed an order dated 07/27/2024 for Acetaminophen oral tablet 325 mg (milligram); Give 650 mg by mouth every 4 hours as needed for mild to moderate pain related to inflammatory polyneuropathy, give 2 tablets by mouth every 6 hours as needed for pain.Review of Resident #7's June 2026 EMAR (Electronic Medication Administration Record) and nurse progress notes failed to reveal Acetaminophen 650 mg by mouth was offered or administered on 06/27/2026 at 5:15 p.m., 06/28/2026 at 5:06 a.m., and 06/28/2026 at 7:15 p.m. when Resident #7 verbally expressed pain and/or soreness. Further review of Resident #7's Nursing Progress Notes: 06/27/2026 at 5:15 p.m.: notified by resident that she is still experiencing pain to left arm. and is beginning to have a hard time lifting it.06/28/2026 at 5:06 a.m.: . complaint of soreness to left arm, some bruising noted to left upper arm.06/28/2026 at 7:15 p.m.:. resident is complaining of pain to left arm writer asked resident how did she fall resident stated I was trying to get in my chair from commode I'm hurting honey my arm is hurting .During an interview on 08/04/2026 at 2:30 p.m. S2 DON (Director of Nursing) reviewed Resident #7's EMAR and nurse progress notes and reported PRN (as needed) pain medication (Acetaminophen 650 mg) was not offered or administered when Resident #7 complained of pain and soreness to left arm on 06/27/2026 at 5:15 p.m., 06/28/2026 at 5:06 a.m., and 06/28/2026 at 7:15 p.m.

Based on record review and interviews the facility failed to implement the care plan for 1 (#28) of 22 sampled residents. The facility failed to ensure Nepro supplement consumption and dialysis access site presence or absence of infection was monitored as ordered for Resident #28. Findings: Review of Resident #28's medical record revealed an initial admitted [DATE] with diagnoses which included, in part, end stage renal disease, dependence on renal dialysis, peripheral vascular disease unspecified, and chronic systolic (congestive) heart failure. Review of physician orders revealed: -10/13/2023 Dialysis schedule: resident to have dialysis 3 times a week on Monday/Wednesday/Friday at 06:30 a.m. -07/25/2023 Monitor dialysis access site to right chest wall for signs/symptoms (s/s) of infection. 0=no signs or symptoms of infection noted, 1=signs or symptoms of infection noted. Document in nurses' notes and notify MD (Medical Doctor) every shift every day. -06/24/2024 Nepro with meals Document % of intake, 1=1-25%, 2=26-50%, 3=51-75%, 4=76-100%, 5=refused. Review of May 2025 MAR (Medication Administration Record) failed to reveal evidence that Resident #28's dialysis access site had been monitored for s/s of infection. Further review of May 2025 MAR failed to reveal evidence that Nepro consumption had been monitored. Review of Resident #28's May 2025 progress notes failed to reveal any documentation of Nepro consumption percentage or dialysis access site s/s of infection monitoring. Review of Resident #28's care plan revealed: -Dialysis with interventions that included, in part, requires renal dialysis related to diagnosis of ESRD (End Stage Renal Disease), dialysis port in right chest wall, monitor dialysis access site for signs and symptoms of infection and notify MD if indicated. -Nutrition with interventions that included, in part, potential for altered nutrition and dehydration, resident often refuses renal diet, weight fluctuations over last year, receiving hemodialysis 3 times a week, resident is on a regular texture diet and Nepro supplement. During an interview on 05/21/2025 at 12:40 p.m. S1 DON (Director of Nursing) reviewed Resident #28's medical record and confirmed monitoring for s/s of dialysis site infection and consumption of Nepro supplement should have been entered as per the physician order and was not. During an interview on 05/21/2025 at 12:53 p.m. S3 LPN (Licensed Practical Nurse) reviewed Resident #28's MAR and confirmed 0 or 1 had not been entered to indicate whether Resident #28's dialysis access site had s/s of infection and confirmed no number was present to indicate how much Nepro supplement Resident #28 had consumed and there should have been per the physician order.

Based on record review, observation and interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (#17) out of 1 (#17) resident reviewed for respiratory services. The facility failed to ensure a physician's order was in place for Oxygen (O2) therapy and the nasal cannula and tubing were stored properly for Resident #17. Findings: Review of the facility's Oxygen Administration Policy (Concentration or Tank) undated policy revealed in part: Policy: Oxygen shall only be administered by a physician order, except in an emergency. In an emergency situation, oxygen can be administered without a physician's order, but the order must be obtained immediately after the crisis is under control . Humidifier bottles, cannula and O2 tubing will be changed at least once weekly and dated. When not in use, cannula or mask should be placed in a plastic bag. Review of Resident #17's medical record revealed an initial admitted [DATE] with diagnoses including but not limited to quadriplegia, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Review of Resident #17's comprehensive care plan revealed in part, Resident #17 had a potential for impaired gas exchange and shortness of breath with an intervention of O2 as ordered. Review of Resident #17's medical record failed to reveal a physician's order for O2 therapy. An observation on 05/19/2025 at 1:25 p.m. revealed Resident #17's O2 nasal cannula and tubing was hung on a picture on the wall, uncovered and not in protective bag. During an interview on 05/19/2025 at 1:40 p.m., S4LPN (Licensed Practical Nurse) acknowledged Resident #17's nasal cannula and tubing was hung on a picture on the wall and was not stored in a bag. S4LPN reported Resident #17's O2 nasal cannula and tubing should be stored in a bag when not in use and was not. During an interview on 05/21/2025 at 9:52 a.m., S2Corporate Nurse reported the facility will follow a resident's specific O2 order. During an interview on 05/21/2025 at 10:00 a.m., S4LPN reported Resident #17 had been on continuous O2 at 2L (Liter) per minute as long as she can remember. S4LPN reviewed Resident #17's current physician orders and acknowledged an order for oxygen therapy was not in place to administer oxygen and should be. During an interview on 05/21/2025 at 10:15 a.m., S1DON (Director of Nursing) acknowledged Resident #17 did not have a physician's order in place for oxygen therapy and should.

Based on record review and interviews, the facility failed to administer a medication as ordered for 1 (#25) of 5 (#10, #22, #25, #27, #49) sampled residents reviewed for unnecessary medications. Findings: Review of Resident #25's medical record revealed in part an initial admitted [DATE]. Further review of Resident #25's medical record revealed diagnoses including, but not limited to bipolar disorder and paranoid schizophrenia. Review of Resident #25's physician orders revealed, in part, an order dated 05/02/2025 to increase Risperdal 1 milligram (mg) to twice a day (BID). Review of Resident #25's May 2025 medication administration record (MAR) from 05/03/2025 to 05/20/2025 revealed in part, Resident #25 received Risperdal 1mg one tablet by mouth (po) at bedtime (HS). During an interview on 05/21/2025 at 9:49 a.m., S3 Licensed Practical Nurse (LPN) reviewed Resident #25's May 2025 MAR and reported Resident #25 received Risperdal 1mg po at HS. During an interview on 05/21/2025 at 11:27 a.m., S1 Director of Nursing (DON) confirmed Resident #25 had an order dated 05/02/2025 to increase Risperdal 1mg po to BID. S1DON reviewed Resident #25's May 2025 MAR and confirmed Resident #25 had not received Risperdal 1mg 1 po BID as ordered on 05/02/2025.

Based on record review, observation, and interview, the facility failed to ensure proper infection control techniques were practiced to prevent cross contamination during incontinence care for 1 (#41) of 22 sampled residents. Findings: Review of undated Policy titled Incontinent Care: Bladder revealed: Policy: Perineal management is the cleansing of the perineal area that includes the genitalia and rectal areas. It promotes cleanliness and comfort and prevents infection by removing irritating secretions or excretions, microorganisms, and offensive odors. The care should be administered daily during bathing, and more frequently following urinary and/or fecal incontinence or if excessive secretions are present. Procedure: . 8. Put on disposable gloves. 9. For female perineal care: . b. Using the washcloth and soap or personal cleaner, wash the [NAME] pubis, rinse and dry. c. Moisten the washcloth with water and soap or personal cleanser, and separate the labia with the thumb and finger of the nondominant hand. Wash down the center of the genitalia from the front to back, then down each side of genitalia from front to back using a different part of the washcloth with each wipe. Review of Resident #41's medical record revealed an admitted [DATE] with diagnoses that included, in part, morbid (severe) obesity due to excess calories, UTI (urinary tract infection) on 04/25/2024, and need for assistance with personal care. Review of Resident #41's physician orders revealed a 01/12/2023 order for Incontinence Care: Check for incontinence at least Q (every) 2 hours, cleanse periarea/buttocks with perifresh. Pat Dry. Apply periguard as a preventive measure. Review of Resident #41's Care Plan revealed Resident #41 had a toileting deficit and needed assistance related to impaired mobility and obesity and was incontinent of bowel and bladder and wore adult briefs with interventions that included, in part, assist with peri-care as needed. During observation of peri-care on 05/21/2025 at 9:10 a.m. S5 CNA (Certified Nursing Assistant) performed peri-care with assistance of S6 CNA for Resident #41. During the course of peri-care: -S5 CNA degloved, put on hand sanitizer and new gloves, dipped a clean washcloth in water with soap, wrung it out, and was observed wiping up left groin area, across and under abdominal fold and down the right groin area and proceeded with the same washcloth and wiped between labia starting in the back and wiped toward the front. During an interview on 05/21/2025 at 11:15 a.m. S1 DON (Director of Nursing) confirmed during peri-care female residents should be cleaned from front to back.

Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from a staff member for 1 (Resident #1) of 3 (Resident #1, #2, #3) sampled residents. The facility failed to ensure S3 CNA (Certified Nursing Assistant), Resident #1's primary CNA and caregiver, did not commit abuse of power when she engaged in sexual relations with Resident #1 in his bed. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. Resident #1 with a diagnosis of aphasia, had limited speech, could make his needs known and his cognition was intact. Resident #1 reported he had sex with S3 CNA which was consensual. Nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse or power. Even though there was no significant decline in Resident #1's mental functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be abused in this manner in his own home or a health care facility. S1 Administrator, S2 DON (Director of Nursing), and S5 Corporate Nurse were notified of the Immediate Jeopardy on 03/14/2025 at 6:42 p.m. The Immediate Jeopardy was removed on 03/17/2025 at 12:50 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Review of Abuse/Neglect Prevention Program (Revised on 09/08/2021) revealed: ABUSE/NEGLECT POLICY STATEMENT The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. Resident #1 was initially admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, bipolar disorder, other recurrent depressive disorders, and aphasia following cerebral infarction. Review of Brief Interview for Mental Status (BIMS) conducted on 3/5/2025 after the incident revealed Resident #1 had a BIMS score of 13, which indicated Resident #1 was cognitively intact. Review of Resident #1's 12/05/2024 Quarterly MDS (Minimum Date Set) revealed Resident #1 required extensive assistance with 1 person physical assist with bed mobility, transfers, and toilet use. Review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for: Depression with interventions that included, in part, monitor for behaviors and side effects of psychotropic medication and notify MD (Medical Doctor) with noted side effects and takes Zoloft and Lexapro for depression. Verbal communication impaired related to aphasia - resident #1 is aware of what is being said to Resident #1, he uses one or two word answers yeah and no. He grunts and shakes head appropriately to asked questions by staff, uses hand motions to make his point known. Interventions included, in part, ask questions that require yes or no answers, allow resident plenty of time to respond, use simple direct communication and speak directly in front of resident. Attempts to contact S3 CNA by phone on 03/12/2025 at 4:49 p.m., 03/13/2025 at 9:03 a.m., and 03/17/2025 at 10:51 a.m. were unsuccessful. During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she went in to Resident #1's room to speak with S3 CNA and upon entering the room S3 CNA had the right side of S3 CNA's pants, underwear and shoes off and was on top of and straddling Resident #1 having intercourse. S4 CNA further reported Resident #1 and S3 CNA looked up at S4 CNA and continued having intercourse. S4 CNA also reported she left out of Resident #1's room to report what she saw to the nurse. During a phone interview on 03/13/2025 at 9:36 a.m. S6 LPN (Licensed Practical Nurse) reported S4 CNA had reported that S3 CNA was observed on top of Resident #1 in Resident #1's bed having sex with Resident #1. S6 LPN further reported she immediately reported the incident to S7 RN (Registered Nurse) and S7 RN told S3 CNA to leave the facility now. During an interview on 03/13/2025 at 1:05 p.m. Resident #1 was asked if Resident #1 had sex with S3 CNA and Resident #1 responded yes. During an interview on 03/13/2025 at 1:16 p.m. S2 DON reported she became aware of the incident between Resident #1 and S3 CNA after S6 RN called to report it. Further reported, by the time she arrived at the facility, S3 CNA had already left the facility. S2 DON and S9 ADON (Assistant Director of Nursing) conducted a full body audit on Resident #1 with no injuries noted. During an interview on 03/13/2025 at 8:10 a.m. S1 Administrator reported he had received a call around 6:25 a.m. the morning of the incident between Resident #1 and S3 CNA and was notified S3 CNA was found having sex with Resident #1. Further reported he arrived at the facility around 7:00 a.m. Also reported he had spoken with S3 CNA by phone and S3 CNA had reported 3 CNA was doing peri care and Resident #1 pulled S3 CNA toward Resident #1 and nothing happened. S1 Administrator further reported the facility did not report the incident between Resident #1 and S3 CNA because he did not recognize it was abuse because it was consensual. During an interview on 03/17/2025 at 2:15 p.m. S1 Administrator and S5 Corporate Nurse confirmed the incident that occurred between Resident #1 and S3 CNA on 03/01/2025 was sexual abuse and that a sexual relationship of staff with a resident was not consistent with the staff member's role as a caregiver and was considered an abuse of power. During an interview on 03/17/2025 at 2:35 p.m. S2 DON confirmed the incident that occurred between Resident #1 and S3 CNA on 03/01/2025 was sexual abuse and that a sexual relationship of staff with a resident was not consistent with the staff member's role as a caregiver and was considered an abuse of power. The facility's Plan of Removal: Resident # 1 was the resident identified as the recipient involved in the noncompliance. All residents have the potential to be affected by this noncompliance. No other residents at the facility were noted to have been affected by this noncompliance Specific changes to the facility's abuse and neglect policy were reviewed and updated on 03-14-2025 to include the following statements: Nursing facility staff are entrusted with the responsibility to protect and care for the residents of the facility. Nursing facility staff are expected to recognize that engaging in a sexual relationship with a resident, even a willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. Changes to this policy were in-serviced to the nursing facility staff beginning the evening of 03-14-2025 and will continue until all staff of the facility have been in-serviced and have had a baseline competency interview. Date and time action taken: 03-14-2025 Prior to survey entrance on 03-12-2025 and prior to the Immediate Jeopardy being called on 03-14-2025 the facility completed the following tasks: 03-01-2025: The accused employee clocked out at 6:17 a.m., immediately after nurse informed of event, pending the investigation. Nursing administration and Administrator came to the facility and took the following steps: The resident was examined for injury (none noted), he was then interviewed by the administrator. Resident #1 did not exhibit any signs of fear, sadness, nor was he emotionally upset The witness to the event was interviewed by administration, and the accused was interviewed, via telephone. Inservices were started for all staff on 03-01-2025 regarding abuse and neglect, including sexual abuse. These inservices continued on until 03-03-2025 attempting to reach all staff members, using a employee roster. Nursing administration began interviewing all interviewable residents to see if they had witnessed or had a sexual encounter with a staff member. None were reported. Also on 03-01-2025 all non-interviewable staff were physically examined for any evidence of a sexual encounter. None of the assessments indicated a sexual encounter had occurred. In addition, staff interviews were conducted to see if they had witnessed or had knowledge of any staff sexual encounters, none were witnessed or had knowledge of any staff to resident sexual encounters. Resident #1 was assigned to have 2 employees care for him on 03-01-2025 and continuing thereafter. Resident #1's RP (Responsible Party) and NP (Nurse Practitioner) were made aware of the situation. 03-03-2025: the administrator met with the resident council and offered to discuss any concerns the residents had regarding the questions asked over the weekend and told them to please come to him or nursing staff if they had any issues they wanted to discuss. 03-03-2025: Resident #1's NP with a mediation change (increasing his antidepressant). The accused was formally terminated from the facility. 03-04-2025: the facility psych NP visited the resident and the facility's SSD (Social Services Director) reached out to in house counseling services to see if Resident #1 is eligible to have in-house counseling related to this event. Monitoring of residents and staff was implemented using the post event monitor and asking questions to see if any inappropriate staff sexual behavior had been witnessed or suspected. This was happening 3 times a week for 6 weeks and then monthly thereafter until compliance was assured. Also the event and corrective actions were being discussed at the QAPI (Quality Assurance and Performance Improvement) meeting weekly with any corrective actions that were implemented based on the interviews being discussed. Completion Date of these actions was 03-04-2025 Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 03/17/2025

Based on record review and interviews the facility failed to develop and implement written policies and procedures that included immediate response to protect an alleged victim from physical and psychosocial harm during and after an investigation. The facility failed to ensure Resident #1 was provided immediate protections after S4 CNA (Certified Nursing Assistant) witnessed S3 CNA engaging in sexual relations with Resident #1. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. S4 CNA immediately left out of Resident #1's room and did not provide immediate protection to Resident #1. S4 CNA responded to the incident according to the facility's policy which stated to report an incident to the nurse. Resident #1 with a diagnosis of aphasia, had limited speech, could make his needs known and his cognition was intact. Resident #1 reported he had sex with S3 CNA which was consensual. Even though there was no significant decline in Resident #1's mental functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be abused in this manner in his own home or a health care facility. S1 Administrator, S2 DON (Director of Nursing), and S5 Corporate Nurse were notified of the Immediate Jeopardy on 03/14/2025 at 6:42 p.m. The Immediate Jeopardy was removed on 03/17/2025 at 12:50 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Review of Abuse/Neglect Prevention Program (Revised on 09/08/2021) revealed: ABUSE/NEGLECT POLICY STATEMENT The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. INVESTIGATION: ACCIDENTS/INCIDENTS REPORTING OF ACCIDENTS/INCIDENTS: Regardless of how minor an injury may be, all accidents or incidents involving a resident, employee or visitor must be reported. Report all accidents or incidents to your immediate supervisor as soon possible. However, DO NOT leave an accident victim unattended unless it is absolutely necessary to summon assistance. All accidents/incidents must be reported to the RN (Registered Nurse) or LPN (Licensed Practical Nurse) as soon as practical (on that shift). If the accident/incident involves suspected patient abuse/neglect, or if the injury is of unknown origin, the RN or LPN must immediately report it to the Administrator and/or Director of Nursing so that facility abuse/neglect reporting and investigation procedures can be implemented. ABUSE/NEGLECT INVESTIGATION, PROTECTION AND REPORTING In the event of any evidence involving mistreatment, exploitation, neglect or abuse including injuries of an unknown source, an occurrence will be reported immediately to the Administrator or his or her designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. 1. Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his/her supervisor immediately. Further review of the Abuse/Neglect Prevention Program (Revised on 09/08/2021) failed to include immediate response by staff to protect an alleged victim of physical and psychosocial harm during and after the investigation. During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she observed S3 CNA having intercourse with Resident #1. S4 CNA further reported she immediately left out of Resident #1's room to report what she saw to the nurse, while S3 CNA and Resident #1 continued to have intercourse. During an interview on 03/13/2025 at 12:49 p.m. S5 Corporate Nurse reported S4 CNA had done the appropriate thing in immediately notifying a nurse after witnessing the 03/01/2025 incident between S3 CNA and Resident #1. S5 Corporate Nurse further reported CNAs were trained according to the facility's policy that if a CNA witnesses abuse, they are to report the abuse immediately to the nurse and the nurse would be the one to intervene. During an interview on 03/13/2025 at 1:16 p.m. S2 DON confirmed CNAs had been taught according to the facility's policy to immediately notify the nurse when an abuse incident was witnessed and the nurse would intervene. During an interview on 03/17/2025 at 2:15 p.m. S1 Administrator and S5 Corporate Nurse reported, after their review of the regulations, S4 CNA should have stayed with Resident #1 for the protection of the resident and attempt to intervene while calling for help. S1 Administrator and S5 Corporate Nurse further confirmed the facility's abuse policy did not include immediate protection for resident of alleged abuse. The facility's Plan of Removal: Resident # 1 was the resident identified as the recipient involved in the non-compliance act. All residents have the potential to be affected by this noncompliance. No other residents at the facility were noted to have been affected by this alleged non-compliance. Specific changes to the facility's abuse and neglect policy were reviewed and updated on 03-14-2025 to include: All staff are to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation. The victim of the abuse is to be examined for injuries both physical and psychological, and medically treated as indicated. Increased supervision of the alleged victim and residents may be necessary, depending on the circumstances. Room and/or staffing changes may be necessary to protect the resident from the alleged perpetrator. Staff must protect the victim from retaliation and provide emotional support and counseling to the resident during and after the investigation, as needed. Changes to this policy were in-serviced to the nursing facility staff beginning the evening of 03-14-2025 at and will continue until all staff of the facility have been in-serviced and have had a baseline compliance interview. Date and time action taken: 03-14-2025 The evening of 03-14-2025, inservice to all facility staff was initiated by the facility Administrator , DON, or ADON (Assistant Director of Nursing) on the following topic: All staff are to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation. Attempt to intervene by keeping the resident in direct line of sight and attempt to notify other staff members by hollering, pulling an emergency cord, and/or telling others to go get help. Supervisory staff are to take control of the situation once they arrive on the scene and will direct other staff members on other protection measures of the victim, including immediate removal of the accused from the situation. Administrative staff are to be notified of the abuse and neglect situation as soon as possible. The victim of the abuse is to be examined for injuries both physical and psychological, and medically treated as indicated. Increased supervision of the alleged victim and residents may be necessary, depending on the circumstances. Room and/or staffing changes may be necessary to protect the resident from the alleged perpetrator. The same staff members, along with S8 LPN, Charge Nurse, and S7 RN, Weekend Supervisor, have continued with this inservice until all facility staff have been inserviced. If the staff member was unable to be reached in person or by phone, they will be inserviced prior to starting their shift at the facility. A personnel roster has been used to ensure every employee has had the inservice. On 03-15-2025, following each staff member's inservice, a baseline competency interview has also been started. Each staff member has been interviewed by the Administrator, DON, ADON, LPN Charge Nurse, or, Weekend RN Supervisor. The specifics asked in this baseline competency interview are as follows to ensure information was learned and retained from the inservice: 1. Employee Inappropriate Sexual Encounters a. As an employee of this facility, can you have any type of sexual activity or relationship including sexual intercourse with a resident, even if it is consensual with the resident? Yes No (answer should be No) b. Sexual activity includes the following: sexual intercourse, anal intercourse, oral sex and any of other type of sexual engagement. True False (answer should be true) c. As an employee of this facility, if you witness any type of sexual activity including sexual intercourse by a staff member, are you to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation? Yes No (answer should be Yes) d. As an employee of this facility, if you witness any type of sexual activity, you must attempt to intervene by keeping the resident in direct line of sight and attempt to notify other staff members. State several ways you can do this (examples -- yell for the person to stop, yell in an attempt to get others to help, pull the call cord out of the wall for the ER light, yell from the person's doorway down the hall, etc) e. If any of the above questions are answered incorrectly, immediately stop and reinservice the employee. Explain your corrective action below. 2. Do you have any other concerns about sexual encounters at the facility that you would like to talk with administration about? Yes or No These baseline competency interviews will follow staff inservice for each staff member until all have been interviewed. If the staff member is unable to be reached in person or by phone, they will have the baseline competency interview completed prior to starting their next shift at the facility. A personnel roster has been used to ensure every employee has had the baseline competency interview. Completion date of educational inservices and baseline competency completions: 03-17-25. A QAPI (Quality Assurance Performance Improvement) monitor to assure sustained compliance will be implemented and will be completed by the Administrator, DON, ADON, LPN Charge Nurse, or Weekend RN Supervisor, by interviewing random staff members. Questions from the Post Event Sustained Monitoring Interview related to Sexual Abuse definitions and Immediate Protection of the Resident Physically and Psychologically During and After the Investigation plan of this facility will be reviewed. This will occur 3 times a week for the next 6 weeks, and then monthly thereafter until compliance is maintained to be assured that the facility staff are aware of what immediate protection of the resident during and after an abuse investigation is, and how to respond to provide this protection and appropriated interventions. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional inservices and/or corrective actions will be implemented as needed. Date of Compliance: 03-17-2025 Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 03/17/2025.

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 3 (Resident #1, #2, and #3) residents reviewed for abuse. The facility failed to have an effective system in place to: 1. Protect Resident #1 from abuse of power by S3 Certified Nursing Assistance (CNA) when S3 CNA sexually abused Resident #1 on 03/01/2025, 2. Provide immediate protection to Resident #1, and 3. Failed to develop and implement policies to protect the resident. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. S4 CNA immediately left out of Resident #1's room and did not provide immediate protection to Resident #1. S4 CNA responded to the incident according to the facility's policy which stated to report an incident to the nurse. Resident #1 with a diagnosis of aphasia, had limited speech and his cognition was intact. Resident #1 reported having sex with S3 CNA which was consensual. Nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. S1 Administrator, S2 DON (Director of Nursing), and S5 Corporate Nurse were notified of the Immediate Jeopardy on 03/14/2025 at 6:42 p.m. The Immediate Jeopardy was removed on 03/17/2025 at 12:50 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Cross Reference F600 and F607 During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she observed S3 CNA having intercourse with Resident #1. S4 CNA further reported she immediately left out of Resident #1's room to report what she saw to the nurse, while S3 CNA and Resident #1 continued to have intercourse. Review of Abuse/Neglect Prevention Program (Revised on 09/08/2021) failed to include immediate response by staff to protect an alleged victim of physical and psychosocial harm during and after the investigation. During an interview on 03/13/2025 at 8:10 a.m. S1 Administrator reported the facility did not report the incident between Resident #1 and S3 CNA because he did not recognize it was abuse because it was consensual. During an interview on 03/13/2025 at 12:49 p.m. S5 Corporate Nurse reported S4 CNA had done the appropriate thing in immediately notifying a nurse after witnessing the 03/01/2025 incident between S3 CNA and Resident #1. S5 Corporate Nurse further reported CNAs were trained according to facility policy that if a CNA witnesses abuse, they are to report the abuse immediately to the nurse and the nurse would be the one to intervene. During an interview on 03/13/2025 at 1:16 p.m. S2 DON confirmed CNAs had been taught according to facility policy to immediately get a nurse when an abuse incident was observed and the nurse would then intervene. During an interview on 03/17/2025 at 2:15 p.m. S1 Administrator and S5 Corporate Nurse reported S1 Administrator was the designated oversight person when deficient practice occurs and was responsible for ensuring deficient practice did not occur. S1 Administrator and S5 Corporate Nurse also reported the Administrator, as the designated oversight person, was responsible for ensuring staff have been educated on the correct policy and procedure. S1 Administrator and S5 Corporate Nurse further confirmed, after their review of regulations, S4 CNA should have stayed with Resident #1 and attempted to intervene while calling for help. S1 Administrator and S5 Corporate Nurse further reported an administrative breakdown had occurred when staff had not been trained to call for help immediately and to stay with residents in an abuse situation to intervene and protect the resident. During an interview on 03/17/2025 at 2:20 p.m. S5 Corporate Nurse reported training oversight for the administrator and the administrative staff was the responsibility of the NHA (Nursing Home Administrator) Supervisor and the Chief Operating Officer. During an interview on 03/17/2025 at 2:35 p.m. S2 DON reported S4 CNA, who witnessed the 03/01/2025 incident between Resident #1 and S3 CNA, left the room while the sexual act was still in progress, and did not respond immediately to intervene and protect Resident #1. The facility's Plan of Removal: Resident # 1 was the resident identified as the recipient involved in the noncompliance. All residents have the potential to be affected by this noncompliance. No other residents at the facility were noted to have been affected by this noncompliance. On the evening of 03-14-2025, an inservice to the Administrator by NHA (Nursing Home Administrator) Supervisor, was completed. This inservice contained the following content: Nursing facility staff are entrusted with the responsibility to protect and care for the residents of the facility. Nursing facility staff are expected to recognize that engaging in a sexual relationship with a resident, even a willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. And: All staff are to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation. The victim of the abuse is to be examined for injuries both physical and psychological, and medically treated as indicated. Increased supervision of the alleged victim and residents may be necessary, depending on the circumstances. Room and/or staffing changes may be necessary to protect the resident from the alleged perpetrator. Staff must protect the victim from retaliation and provide emotional support and counseling to the resident during and after the investigation, as needed. On 03-15-25, following the Administrator's inservice, a baseline competency interview was completed. He was interviewed by the facility DON. The specifics asked in this baseline competency interview are as follows to ensure information was learned and retained from the inservice: 1. Employee Inappropriate Sexual Encounters a. As an employee of this facility, can you have any type of sexual activity or relationship including sexual intercourse with a resident, even if it is consensual with the resident? Yes No (answer should be No) b. Sexual activity includes the following: sexual intercourse, anal intercourse, oral sex and any of other type of sexual engagement. True False (answer should be true) c. As an employee of this facility, if you witness any type of sexual activity including sexual intercourse by a staff member, are you to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation? Yes No (answer should be Yes) d. As an employee of this facility, if you witness any type of sexual activity, you must attempt to intervene by keeping the resident in direct line of sight and attempt to notify other staff members. State several ways you can do this (examples -- yell for the person to stop, yell in an attempt to get others to help, pull the call cord out of the wall for the ER light, yell from the person's doorway down the hall, etc) e. If any of the above questions are answered incorrectly, immediately stop and reinservice the employee. Explain your corrective action below. 2. Do you have any other concerns about sexual encounters at the facility that you would like to talk with administration about? Yes or No Completion dates of the educational inservice and baseline competency completion for S1 Administrator: 03-14-2025 and 03-15-2025 respectively. A QAPI (Quality Assurance and Performance Improvement) monitor to assure sustained compliance of the facility staff will be implemented and will be completed the Administrator, DON, ADON (Assistant Director of Nursing), LPN (Licensed Practical Nurse) Charge Nurse, or Weekend RN (Registered Nurse) Supervisor, by interviewing random staff members. Questions from the Post Event Sustained Monitoring Interview related to Sexual Abuse definitions and Immediate Protection of the Resident Physically and Psychologically During and After the Investigation plan of this facility will be reviewed. This will occur 3 times a week for the next 6 weeks, and then monthly thereafter until compliance is maintained to be assured that the facility staff are aware of what immediate protection of the resident during and after an abuse investigation is, and how to respond to provide this protection and appropriated interventions. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional inservices and/or corrective actions will be implemented as needed. Date of Compliance: 03-17-2025 Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 03/17/2025.

Based on record review and interview the facility failed to ensure residents' assessment accurately reflected the resident's status during the observation period for 1 (#1) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure Resident #1's MDS (Minimum Data Set) accurately reflected Resident #1's cognitive status. Findings: Review of Resident #1's medical record revealed an initial admitted [DATE] with diagnoses that included, in part, cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, other cerebrovascular disease, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; essential (primary) hypertension, Type 2 Diabetes Mellitus, bipolar disorder and other recurrent depressive disorders. Review of Quarterly MDS with 12/05/2024 ARD (assessment reference date) revealed BIMS (Brief Interview Mental Status) was not conducted as resident was rarely/never understood. The MDS further revealed a Staff Assessment for Mental Status had been utilized to determine Resident #1's cognitive status. The Staff Assessment for Mental Status revealed Resident #1 had a short and long-term memory problem and was severely impaired with making decisions regarding tasks of daily life. Review of MDS's revealed Cognitive Patterns had been monitored using Staff Assessment for Mental Status throughout the last year and included the following: Annual MDS with ARD 06/06/2024. Quarterly MDS with ARD 09/06/2024. Quarterly MDS with ARD 12/05/2024 Further review of Quarterly MDS with ARD of 03/05/2025 (currently in progress) revealed Resident #1 had a BIMS score of 13, indicating Resident #1 was cognitively intact. Review of Resident #1's care plan revealed a care plan for Verbal Communication: Impaired related to aphasia status post CVA (cerebrovascular accident) and indicated Resident #1 had a diagnosis of apraxia and is aware of what is being said to him, he uses one or two word answers yeah and no. He grunts and shakes head appropriately to asked questions by staff and uses hand motions to make his point known. During an interview on 03/17/2025 at 8:10 a.m. S9 ADON (Assistant Director of Nursing) reported even though Resident #1 was able to only speak a few words, was able to make his needs known and from time of his admission to the facility, Resident #1 had been cognitively intact. During an interview on 03/17/2025 at 10:20 a.m. S1 Administrator and S5 Corporate Nurse confirmed Resident #1 was able to communicate, make needs known even though he could only speak a few words due to aphasia, and was cognitively intact. During an interview on 03/17/2025 at 11:58 a.m. S11 NP (Nurse Practitioner) reported Resident #1 was cognitively intact and able to communicate his needs or any complaints. During an interview on 03/17/2025 at 3:39 p.m. S10 Social Services reported in the past Resident #1's cognitive status had been conducted utilizing the Staff Assessment for Mental Status, which gave an inaccurate picture of Resident #1's cognitive status. Social Services further reported a BIMS score had been conducted after a recent incident, utilizing words and pictures on paper and Resident #1's BIMS score was 13, indicating Resident #1 was cognitively intact. During an interview on 03/17/2025 at 3:44 p.m. S12 MDS Nurse reported when an incident occurred on 03/01/2025, she had attempted to look up Resident #1's BIMS score and found that a Staff Assessment for Mental Status was being conducted instead and since Resident #1 was cognitively intact, that assessment gave an inaccurate picture of Resident #1's cognitive status.

Based on record reviews and interviews, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to ensure an alleged violation of sexual abuse was reported to local law enforcement for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. Resident #1 was subject to sexual contact by S3 CNA (Certified Nursing Assistant). Findings: Review of Abuse/Neglect Prevention Program (Revised on 09/08/2021) revealed: ABUSE/NEGLECT POLICY STATEMENT The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. ABUSE/NEGLECT INVESTIGATION, PROTECTION AND REPORTING In the event of any evidence involving mistreatment, exploitation, neglect or abuse including injuries of an unknown source, an occurrence will be reported immediately to the Administrator or his or her designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. 1. Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his/her supervisor immediately. 6. The appropriate law enforcement agencies shall be notified as soon after the incident as possible, if appropriate. Review of Resident #1's medical record revealed Resident #1 was initially admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, bipolar disorder, other recurrent depressive disorders, and aphasia following cerebral infarction. During a phone interview on 03/12/2025 at 4:45 p.m. S4 CNA reported on 03/01/2025 around 5:50 a.m. she went in to Resident #1's room to speak with S3 CNA and upon entering the room S3 CNA had the right side of S3 CNA's pants, underwear and shoes off and was on top of and straddling Resident #1 having intercourse. S4 CNA further reported Resident #1 and S3 CNA looked up at S4 CNA and continued having intercourse. S4 CNA also reported she left out of Resident #1's room to report what she saw to the nurse. During an interview on 03/13/2025 at 8:10 a.m. S1 Administrator reported the facility did not notify the police regarding the 03/01/2025 incident between Resident #1 and S3 CNA as it was determined it was consensual. During a phone interview on 03/13/2025 at 9:36 a.m. S6 LPN (Licensed Practical Nurse) reported the police had not been notified of the 03/01/2025 incident between Resident #1 and S3 CNA. During an interview on 3/17/2025 at 2:15 p.m. S1 Administrator and 5 Corporate Nurse reported the incident between Resident #1 and S3 CNA on 03/01/2025 was sexual abuse and it should have been reported to the police.

Based on record reviews and interview the facility failed to ensure the plan of care was followed for 2 (#2, #3) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure physician orders were followed. Findings: Resident #2 Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that include in part: rheumatoid arthritis, chronic venous insufficiency - peripheral, long term use of insulin, and diabetes mellitus due to underlying condition with hyperglycemia. Review of Resident #2's physician orders revealed in part: 07/02/2024 Lantus Subcutaneous (SQ) Solution 100 unit/ml (milliliter) (Insulin Glargine) inject 60 units subcutaneously before meals 07/01/2024 Gabapentin Oral Capsule 300 mg (milligram) Give 1 capsule by mouth before meals 07/01/2024 Humulin R (Regular) Injection Solution, inject as per sliding scale .SQ before meals and at bedtime. Review of Resident #2's July 2024 Medication Administration Record (MAR) failed to reveal evidence the following medications had been provided on the indicated time/dates: 6:00 a.m. dose of Humulin R injection per sliding scale .SQ before meals and at bedtime: 07/01/2024, 07/05/2024, 07/21/2024, 07/23/2024, 07/26/2024, 07/27/2024, and 07/28/2024. 6:00 a.m. dose of Lantus SQ 100 units/ml inject 60 units SQ before meals: 07/01/2024, 07/04/2024, 07/05/2024, 07/21/2024, 07/23/2024, 07/26/2024, 07/27/2024, and 07/28/2024. 6:00 a.m. dose of Gabapentin capsule 300 mg give 1 capsule by mouth before meals: 07/01/2024, 07/21/2024, 07/27/2024, and 07/28/2024. Resident #3 Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses that include in part: type 2 diabetes mellitus, acute and chronic respiratory failure with hypoxia, non-ST elevation (nonstemi) myocardial infarction, metabolic encephalopathy, viral hepatitis C, Progressive Supranuclear Ophthalmoplegia (Steele-[NAME]-[NAME]), dementia, major depressive disorder-recurrent-severe with psychotic symptoms, and epilepsy. Review of Resident #3's physician orders revealed in part: 07/23/2024 Insulin Aspart FlexPen SQ 100 units/ml Inject as per sliding scale . 07/23/2024 Night: change nebulizer tubing, medication chamber and mask on night shift every Saturday 07/23/2024 Levothyroxine Sodium oral tablet 50 mcg (micrograms) give 1 tablet by mouth before meals 07/23/2024 Protonix oral tablet delayed release 40 mg give 1 tablet by mouth before meals 07/23/2024 Check edema status every shift 07/23/2024 Hydralazine HCl (Hydrochloride) oral tablet 50 mg give 1 tablet by mouth three times a day 07/23/2024 Monitor for side effects of psychotropic meds 07/23/2024 Monitor for behaviors of psychotropic meds 07/23/2024 Monitor for abnormal signs or symptoms of bleeding related to anticoagulant therapy 07/25/2024 Listen to resident's lungs with stethoscope for abnormal breath sounds 3 times a day for the diagnosis of acute on chronic respiratory failure. Document any abnormal findings in the nurse's notes and notify MD (medical doctor). Every shift, 0 = Clear lung sounds, 1 = crackles, rales, rhonchi, wheezing or rub *Record minutes of treatment Review of Resident #3's July 2024 MAR failed to reveal evidence the following had been conducted/administered for the indicated times/dates: 6:00 a.m. dose of Insulin Aspart FlexPen SQ 100 units/ml inject as per sliding scale .: 07/27/2024, 07/28/2024, and 07/29/2024. Night shift: Change nebulizer tubing, medication chamber and mask on night shift every Saturday: 07/27/2024. 6:00 a.m. dose of Levothyroxine Sodium oral tablet 50 mcg give 1 tablet by mouth before meals: 07/27/2024, 7/28/2024. 6:00 a.m. dose of Protonix oral tablet delayed release 40 mg give 1 tablet by mouth before meals: 07/27/2024, 07/28/2024. Night shift: Check edema status every shift: 07/26/2024, 07/27/2024. Night shift: Complete vital signs daily x 10 days every shift: 07/26/2024, 07/27/2024, and 07/28/2024. Night shift: Document seizure activity. Document any seizure activity in the nurse's notes and notify the MD. Every shift: 07/25/2024, 07/26/2024, and 07/27/2024. 6:00 a.m. dose of Hydralazine HCl oral tablet 50 MG give 1 tablet by mouth three times a day: 07/27/2024, 07/28/2024. Night shift: Monitor for side effects of psychotropic meds: 07/25/2024, 07/26/2024, and 07/27/2024. Night shift: Monitor for behaviors of psychotropic meds: 07/25/2024, 07/26/2024, and 07/27/2024. Night shift: Monitor for abnormal signs or symptoms of bleeding related to anticoagulant therapy: 07/25/2024, 07/26/2024, and 07/27/2024. Night shift: Listen to resident's lungs with stethoscope for abnormal breath sounds 3 times a day for the diagnosis of acute on chronic respiratory failure. Document any abnormal findings in the nurse's notes and notify MD. Every shift, 0 = Clear lung sounds, 1 = crackles, rales, rhonchi, wheezing or rub *Record minutes of treatment: 07/25/2024, 07/26/2024, and 07/27/2024. During an interview on 07/31/2024 at 10:15 a.m. S1 DON (Director of Nursing) reviewed the July MAR for Resident #2 and #3 and acknowledged the missing documentation. S1 DON further reported the MAR shows the medications were not given and there was not a nursing note for documentation of medication administration. S1 DON further stated if it wasn't documented, it wasn't done and should have been.

Based on record review and interview, the facility failed to protect the resident's right to be free of verbal abuse and psychosocial harm by facility staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for resident #1 who was cognitively impaired with communication deficits on 04/23/2024 when S3CNA (certified nursing assistant) verbally abused resident #1 by telling resident #1, I will hit you in your m__f__ face, during resident #1's whirlpool bath. Resident #1 was agitated during the bath and did not want his hair washed by S3CNA. It can be determined that any reasonable person would have experienced psychosocial harm as a result of the verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. The facility implemented corrective actions which were completed prior to the Stage Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Policy dated March 2016 revealed the following: The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse including corporal punishment. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, facility members or legal guardians, friends or other individuals. Verbal Abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Additionally, threats of corporal punishment to control behavior are considered verbal abuse. Review of resident #1's electronic health record revealed an admitted [DATE] with a diagnosis of but not limited to: cerebral vascular accident with right sided hemiplegia, aphasia, apraxia, dysphasia, diabetes, bipolar disease and hypertension. Review of resident #1's Quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #1 was assessed to have a BIMS (brief mental status interview) score of 00 indicating cognitive deficits and an inability to complete the interview. Review of resident #1's comprehensive care plan revealed: Behavior: socially inappropriate /disruptive behavior, resident is unable to communicate and grunts and makes hand gestures, refuses medications and nasal swabs: do not argue with resident, do not challenge content of behaviors, assist in selection of appropriate coping mechanisms, allow resident the opportunity to make choices, and participate in care. Impaired Cognition related to diagnosis of CVA (cerebral vascular accident): approach in a calm manner, ask simple direct questions, calmly talk with resident and offer reassurance prior to care, provide consistent caregivers, and provide cueing with decision making. Review of the facility's investigative documentation revealed the following: On 04/23/2024 it was reported that S3CNA was assisting resident #1 in the whirlpool. During this time, resident #1 became frustrated and allegedly attempted to get the S3CNA to leave him alone. In response, S3CNA verbally threatened to hit resident #1. S5LPN (licensed practical nurse) on the nearby hall heard the commotion and entered the whirlpool room and told S3CNA to step away from the resident while he was upset. To protect the resident, S3CNA placed on administrative leave pending the determination of the investigative team. During an interview on 05/20/2024 at 8:30 a.m. resident #1 was able to make gestures to communicate about the incident. When asked, has anyone been verbally aggressive with you, resident #1 nodded head indicating yes. When asked if it was a staff member, resident #1 nodded head indicating yes. When asked if this happened while in the whirlpool, resident #1 nodded head indicating yes. Resident #1 became visibly agitated and upset and attempted to verbally explain but only was able to say, Ah man, ah man. When asked if S3CNA verbally threatened to hit him resident #1 again nodded his head indicating yes and was tearful and visibly agitated. During a phone interview on 05/20/2024 at 12:03 p.m. S5LPN reported standing on the hall across from the whirlpool room on 04/23/2024 when S5LPN heard resident #1 yelling and grunting in the whirlpool room. S5LPN reported when she looked inside the whirlpool room resident #1 was flailing his arms and gesturing because resident #1 did not want S3CNA to wash his hair. S5 LPN further reported S3CNA was aggravated and told resident #1, don't try to hit me, I'll hit you in your mo__f__ing face. S5LPN reported S3CNA was immediately told to come out of the whirlpool and leave resident #1 alone. S3CNA left the whirlpool room and did not return. During an interview on 05/16/2024 at 12:21p.m. S6CNA reported, I was near the whirlpool room (on 04/23/2024) and I heard someone in the whirlpool room say, I'll hit you in your mo_f__ing face. S6CNA also reported S5LPN was present and heard the verbal abuse also. S5LPN told S3CNA to come out the whirlpool room because the resident #1 was agitated and S3CNA left the whirlpool room. During an interview on 05/16/2024 at 12:34 p.m. S4LPN reported hearing resident #1 on 04/23/2024 mumbling and trying to talk loudly, S4LPN looked over into the whirlpool room and I saw resident #1 pointing toward the door trying to tell S3CNA to leave out of the whirlpool room. S5LPN told S3CNA to leave out of the whirlpool. S3CNA left the whirlpool room. During an interview on 05/20/2024 at 12:00 p.m. S2 DON (Director of Nurses) reported on 04/24/2024 resident #1 came to her office and tried to tell her something. Resident #1 was very agitated, visibly upset and was gesturing and pointing at the whirlpool room and his head. S2 DON reported she had difficulty understanding what resident #1 was trying to tell her due to his aphasia until S6CNA came and told her that resident #1 was trying to tell S2DON about what had happened in the whirlpool room on the day before. S2 DON reported that S6CNA told her S3CNA had verbally threatened resident #1 while bathing him in the whirlpool on 04/23/2024. S2DON reported she immediately notified S1 Administrator and an investigation into the verbal abuse began on 04/24/2024. S2 DON further reported S3CNA was suspended while the investigation was completed. S2 DON reported two staff members confirmed hearing the alleged verbal abuse and S3CNA was terminated on 4/26/2024. During an interview 05/21/2024 at 10:00 a.m. S1 Administrator confirmed being notified of resident #1's allegation of verbal abuse by S3CNA on 04/24/2024. S1 Administrator further confirmed that the investigation confirmed two staff members reported hearing the verbal abuse directed at resident #1 by S3CNA. S3CNA was terminated on 04/26/2024. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice. 1. On 04/24/2024 at 3:30pm Verbal abuse allegation brought to the S2DONs' attention by resident #1 and S6CNA. S1Administrator notified and investigation begin. S3CNA temporarily suspended during investigation. 2. Statements obtained from staff member present during altercation confirmed S3CNA's verbal abuse of resident #1. S3CNA was terminated on 04/26/2024. S3CNA's last day of work was 04/24/2024. 3. S5LPN's employment was terminated on 04/25/2024 after learning that S5LPN witnessed S3CNA's verbal abuse of resident #1 and failed to report it to the supervisor immediately. 4. On 04/25/2024 S2 DON and S7ADON (assistant director of nurses), interviewed all residents on A hall and Short B hall, (the residents that S3CNA were assigned to). All residents were asked if they had been abused in any way by S3CNA or any other staff member. 5. An all staff in-service was done on 04/25/2024 regarding abuse and neglect, the procedure for reporting abuse allegations upon discovery and the de-escalation of difficult or angry residents. 6. QA (quality assurance) monitoring began on 04/24/2024 by nursing administration. S2DON or her designee will review each incident/grievance for suspected abuse. This monitoring will occur with each incident/grievance for the next 6 weeks, or until compliance is maintained. Any type of suspicious events will be investigated following our Abuse and Neglect procedure. Daily rounds by the administrator, social worker, DON and ADON will be done on all residents in the facility focusing on abuse indefinitely. The results of the daily rounds and the QA monitoring will be discussed in the facility's daily QA and corrective actions implemented weekly if indicated. 7. Date of Compliance 04/26/2024 when S3CNA was terminated.

Based on record review and interview the facility failed to ensure an allegation of verbal abuse by staff was reported immediately to the facility administrator and to the State Survey Agency no later than 2 hours after the allegation was made, for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. Findings: Review of the facility's Abuse/Neglect Prevention program dated March 2016 revealed, in part, the following: Reporting: Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his or her supervisor immediately. Reporting requirements: Facility must report to State Survey Agency any incidents and allegations of abuse, neglect, exploitation, misappropriation of resident property and/or injuries of unknown source immediately, but no later than 2 hours after the allegation is made, if the event that caused the allegation involves abuse or results in bodily harm. Review of resident #1's electronic health record revealed an admitted [DATE] with a diagnosis of but not limited to: cerebral vascular accident with right sided hemiplegia, aphasia, apraxia, dysphasia, diabetes, bipolar disease and hypertension. Review of resident #1's Quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #1 was assessed to have a BIMS (brief mental status interview) score of 00 indicating cognitive deficits and an inability to complete the interview. Review of the facility's investigative documentation revealed the following: On 04/23/2024 it was reported that S3CNA (certified nursing assistant) was assisting resident #1 in the whirlpool. During this time, resident #1 became frustrated and allegedly attempted to get the S3CNA to leave him alone. In response, S3CNA verbally threatened to hit resident #1. S5LPN (licensed practical nurse) on the nearby hall heard the commotion and entered the whirlpool room and told S3CNA to step away from the resident while he was upset. To protect the resident, S3CNA was placed on administrative leave pending the determination of the investigative team. During a phone interview on 05/20/2024 at 12:03 p.m. S5LPN reported standing on the hall across from the whirlpool room when S5LPN heard resident #1 yelling and grunting in the whirlpool room. S5LPN reported when she looked inside the whirlpool room resident #1 was flailing his arms and gesturing because resident #1 did not want S3CNA to wash his hair. S5 LPN further reported S3CNA was aggravated and told resident #1, don't try to hit me, I'll hit you in your mo__f__ing face. S5LPN reported S3CNA was immediately told to come out of the whirlpool and leave him resident #1 alone. S3CNA left the whirlpool room and did not return. S5LPN confirmed she did not report this incident to S2DON (director of nurses) or S1 Administrator because she did not want to get S3 CNA in any trouble. During an interview on 05/20/2024 at 12:00 p.m. S2DON confirmed S5LPN did not follow the facility policy and notify her supervisor immediately when S3CNA verbally abused resident #1. S2DON also confirmed that she notified S1Administrator of resident #1's allegation of abuse on 04/24/2024 the day after the incident. Review of the Health Standards Incident Report revealed S1Administrator reported the incident to the State Survey Agency on 04/25/2024 at 1:20 p.m. S1Administrator failed to report the allegation of abuse involving resident #1 on 04/24/2024 when he was made aware by S2DON to the State Survey Agency within two hours. During an interview on 05/21/2024 at 10:00 a.m. S1Administrator confirmed he did not report resident #1's allegation of verbal abuse to the State Survey Agency within the 2 hour window.

Based on record review, observations and interviews the facility failed to provide services to prevent further contractures and potential decline in range of motion for 1 (#22) of 2 (#22, #26) residents reviewed for position and mobility out of a total sample of 17 residents. The facility failed to ensure hand rolls were placed for Resident #22 who had bilateral hand contractures. Findings: Review of Resident #22's medical record revealed an admitted [DATE] with diagnoses that included, in part, quadriplegia, contracture of muscle multiple sites, contracture of bilateral hands, contracture of right wrist, contracture of left wrist, muscle wasting and atrophy not elsewhere classified multiple sites. Review of Resident #22's physician orders revealed: -03/13/2023 Apply hand roll to both hands Q (every) AM. Inspect skin. May remove for baths. -03/15/2024 Remove hand rolls from both hands Q afternoon. Inspect skin. Review of Resident #22's 02/08/2024 quarterly MDS (Minimum Data Set) revealed Resident #22 was cognitively intact with a BIMS (Brief Interview Mental Status) score of 15. Review of Resident #22's Care Plan revealed: -Impaired mobility: requires staff assistance related to quadriplegia with interventions that included, in part, hand roll to bilateral hands. On at 8am, off at 2pm, inspect skin, may remove for bathing. Observation on 04/15/2024 at 12:28 p.m. revealed Resident #22 was lying in bed with pillows supporting each arm and contractures were noted to bilateral hands with no hand roll in place in either hand. During an interview on 04/15/2024 at 12:28 p.m. Resident #22 confirmed he did not have any hand rolls in his hands. Resident #22 further reported he had hand rolls in the past but they would get dirty and had been removed. Observation on 04/16/2024 at 2:15 p.m. revealed Resident #22 was lying in bed, positioned using pillows on each side and no hand rolls were in place. Observation on 04/17/2024 at 9:20 a.m. revealed Resident #22 was lying in bed with arms positioned using pillows and no hand rolls were in place. During an interview on 04/17/2024 at 9:20 a.m. Resident #22 reported they had taken his hand rolls to have them cleaned last week and he had not had them since. During an interview on 04/17/2024 at 9:32 a.m. S2 CNA (Certified Nursing Assistant) observed Resident #22 and confirmed Resident #22 did not have hand rolls in place and should have. During an interview on 04/17/2024 at 9:36 a.m. S1 LPN (Licensed Practical Nurse) reported Resident #22's hand rolls were sent to be washed.

Based on record review and interview, the facility failed to properly prevent and/or contain COVID-19 by failing to ensure all staff had obtained an exemption or were fully vaccinated with the COVID-19 vaccine. Findings: Record review of the facility's COVID-19 staff vaccination report completed by S4 DON (Director of Nursing) on 3/22/22 at 9:00 AM revealed S7 CNA (certified nursing assistant) was marked as partially vaccinated. During an interview on 3/22/22 at 9:10 AM, S4 DON verified S7 CNA has not received the second dose of the COVID-19 vaccination and S7 CNA worked at the facility on 3/16/22, 3/17/22, 3/19/22 and 3/20/22. S4 DON further indicated S7 CNA was serving fluids to drink and meal trays to residents at facility.

Based on observations, interviews and record review the facility failed to maintain an effective pest control program to ensure the facility was free from pests as evidenced by crawling insects observed in multiple areas of the facility. This had the potential to affect all the 52 residents residing in the facility according to the facility census. Findings: Review of Facility General Policies: Pest Control: revealed: a. Our facility maintains an ongoing pest control program to ensure that our building is kept free of insects and rodents. Observation by second surveyor on 3/21/2022 at 12:20 pm revealed a live brown insect crawling in the microwave in the breakroom. Further review revealed another live brown insect crawling on the wall above the microwave. S5 floor tech sitting at the table in the breakroom, removed the brown insect from the microwave and the other insect from the wall. Observation on 3/21/22 at 2:30 pm revealed a live brown crawling insect crawling up the wall in the dining room during resident council meeting. Residents were observed eating and participating in activities in the dining room during the survey. Interviews on 3/21/22 at 2:30 pm with residents (# 53-BIMS (Brief Interview of Mental Status)=15-cognitively intact, #44-BIMS=14-cognitively intact, #34-BIMS=15, #7-BIMS=15, #18-BIMS=15, #15-BIMS=15, #9-BIMS=4-Severe cognitive impairment, #12-BIMS=12-moderate cognitive impairment, #48-BIMS=15) attending the resident council meeting, residents all reported a roach problem in the building and in the breakroom microwave used by residents and staff. During an interview on 3/22/22 at 9:45 am S1 Maintenance acknowledged the facility had a pest control problem. During an interview on 3/22/22 at 9:51 am S2 MDS (Minimum Data Set) Nurse acknowledged there are problems with bugs and roaches. Observation by second surveyor on 3/22/2022 at 12:00 pm revealed a live brown insect crawling inside of the microwave in the breakroom. S6 CNA (Certified Nursing Assistant) alerted the housekeeper who then cleaned the microwave. During an interview on 3/23/22 at 10:40 am S3 Administrator acknowledged the presence of pests in the facility. During the interview S3 Administrator was asked if the facility had an effective pest control program, S3 Administrator stated, Getting rid of all the pests is an impossibility. Observation by third surveyor on 3/23/22 at 2:45 pm revealed in Hall A community shower room, three light brown colored insects crawling inside of a wooden cabinet inside the shower room. During an interview on 3/23/22 at 2:47 pm S1 Maintenance indicated the facility does have a roach problem.

Based on record reviews and interviews the facility failed to ensure pharmacist recommendations that were signed and accepted by the physician were acted upon for 2 (#1,3) out of 5 residents reviewed for unnecessary medications. The facility failed to order and obtain lab for Resident #1 and #3. Findings: Review of resident #1's diagnoses included but not limited to [CONDITION(S)], [CONDITION(S)] due to medical condition, cognitive communication deficit, major depressive disorder, generalized anxiety disorder, type 2 diabetes mellitus Review of Pharmaceutical Consultant Report lab request dated 3/22/2021 revealed: FBS (fasting blood sugar) weekly, RP (renal panel) & A1c (Hemoglobin A1c) every 3 month; CBC (complete blood count) every 6 months related to prescribed medications: [MEDICATION(S)], [MEDICATION(S)] Report reviewed by S1DON (Director of Nursing) and physician-recommendations accepted by physician for lab request on 3/28/2021. Review of resident #1's current physician orders failed to reveal orders as recommended by pharmacist and accepted by physician 3/28/21. Review of resident #1's medical record revealed weekly FBS, RP, A1c every 3 months, & CBC every 6 months had not been ordered. Further review revealed weekly FBS had not been done. During an interview on 6/29/2021 at 2:00 PM S2 LPN (Licensed Practical Nurse) reviewed Resident #1's health record and confirmed FBS had not been done and recommended lab had not been ordered. Review on Resident #3's diagnoses included but not limited to pain in right hip, hypertension, [CONDITION(S)], dementia, major depressive disorder Review of Pharmaceutical Consultant Report lab request dated 3/22/2021 revealed: CBC & CMP (comprehensive metabolic panel) every 6 months; FLP (fasting lipid panel) & TSH (thyroid stimulating hormone) annual related to prescribed medications: [MEDICATION(S)], [MEDICATION(S)], FA (folic acid), [MEDICATION(S)] Report reviewed by S1DON and physician- recommendations accepted by physician for lab request on 3/25/2021. Review of resident 3's current physician's orders failed to reveal lab orders as recommended by pharmacist and accepted by physician 3/25/21. During an interview 6/29/21 at 2:30PM S1DON reviewed the process for pharmaceutical review and said once pharmacist recommendation was completed and signed by the physician as accepted, the new orders were given to the nurse to add to resident's current orders. S1DON confirmed lab had not been ordered as recommended by the pharmacist and accepted by the physician for Resident #1 and #3.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 (#23, #66) of 2 (#23, #66) sampled residents reviewed for admission and readmission orders [REDACTED] 1. Have a system in place to ensure nursing staff transcribe and implement orders for wound care when residents are admitted or readmitted to the facility; 2. Ensure that resident #23 received necessary wound care from 04/01/2016 through 04/14/2016; and 3. Ensure that resident #66 received wound care from 04/12/16 through 04/15/2016. The Immediate Jeopardy (IJ) Situation began on 04/01/2016 at 10:30 AM when Resident #23 returned from a LTAC (Long-Term Acute Care) hospital following treatment for [REDACTED]. The hospital discharge instructions indicated to see MED REC (Medication Reconciliation) which indicated sodium hypochlorite 0.25% solution 1-Dakin's half daily for wound care on re-admission to the nursing home. There was no documented evidence that wound care was performed from 4/1/16 through 4/14/16. There was no oversight and supervision by the registered nurse upon return to the nursing home to ensure transcription, clarification if necessary, and implementation of wound care orders. The order for treatment was transcribed to the Treatment Administration Record on 4/15/16 and Resident #23 began receiving the necessary care and treatment on that date. The resident was sent to the hospital again on 5/4/16 with purulent discharge and enlargement of the right groin wound. On 5/20/16 at 12:55 PM, the survey team notified S1ADMN (Administrator) and S14CorpRN (Corporate Registered Nurse) of the IJ situation. The facility provided a Plan of Removal on 5/20/2016 that included the following: Intervention: 1. Review of admission, readmission hospital orders will be completed by a RN after the residents is admitted or readmitted from the hospital. If a RN is not at the facility when the resident returns from the hospital the RN that is due for the next tour of duty will complete the review, including verifying treatment order(s) if skin issues are present. 2. The RN will verify that the hospital discharge orders and/or attending physician's clarification orders have been transcribed and implemented timely by the licensed facility staff in order to assure that the resident is receiving the care and services that have been ordered. 3. The RN will then complete the order review monitor and place it in the DON office for her follow up. 4. The RN staff of the facility was in-serviced about this plan on 05-20-16 at 1:45 PM by the administrator and corporate nurse. Monitoring: 1. Monitoring of this corrective action will be completed by the DON reviewing the admission and readmission orders [REDACTED]. This will occur with each admission or readmission for 6 weeks and then monthly thereafter until compliance maintained. 2. Corrective action will be implemented immediately upon discovery if areas of the review or order transcription are not acceptable. The immediate jeopardy was removed on 5/20/2016 at 3:37 PM. The deficient practice remains at a level of a potential for more than minimal harm. Findings: Resident #23: Review of clinical record and electronic health record revealed Resident # 23 was originally admitted to the facility on [DATE]. Resident #23 was readmitted to the facility on [DATE] when she returned from a Long-Term Acute Care (LTAC) Hospital following treatment for [REDACTED]. Further review Resident #23's record revealed a Resident Transfer Form dated 5/4/16 to send Resident to the emergency room . A greenish discharge was noted from the surgical wound and an abscess was noted to her left buttock. Review of the MDS dated [DATE] reflected a BIMS (Brief Interview for Mental Status) score of 6, which indicated severely impaired cognition. The 4/8/16 MDS reflected the resident ' s hearing was adequate, she had clear speech, She was able to express ideas and wants, She could understand verbal content, and her vision was adequate without correction. There was no documentation of physical or other behavioral symptoms directed toward others, and no verbal behavioral symptoms directed toward others. A review of the LTAC (Long-Term Acute Care) hospital's discharge summary dated 04/01/2016 revealed Resident #23 was treated for [REDACTED]. Resident #23 had a history of [REDACTED]. Resident #23 did well with wound care, finished the course of antibiotics, and was stable on discharge. She was to follow up with primary care doctor and was returning to her nursing home. On 5/18/2016, a review of the nursing facility's copy of the LTAC hospital's discharge instructions dated 04/01/2016 indicated to see MED REC (Medication Reconciliation) for wound care. The MED REC form for Resident #23 read: Na Hypochlorite 0.25 % SOL; 1 Dakins half daily for wound care. Review of the facility's nurse's notes for Resident #23 revealed that on 04/01/2016 at 4:14 PM, S13LPN documented, At 10:30 AM resident readmitted to (Facility) .wound to rt (right) groin area packed with gauze and covered with ABD pad. Dressing dry/intact. No skin tears, pressure ulcers noted .Discharge Orders faxed to healthcare pharmacy. At 12:18 PM, S19MD informed of resident readmit to facility . Discharge orders faxed to S19MD's office . During a telephone interview on 5/23/16 at 1:30 PM, S19MD confirmed he was the medical director and was one of the attending physicians for Resident #23. S19MD confirmed that when Resident #23 was readmitted to the facility on [DATE] following her hospitalization , her hospital discharge orders, including wound care orders and treatments, became the nursing home admit orders. Review of the Wound Assessment Report dated 04/01/2016 electronically signed by S3TN/LPN (Treatment Nurse/Licensed Practical Nurse) revealed Resident #23 was assessed by S3TN/LPN on 04/01/2016. Further review of the Wound Assessment Report revealed: Wound Type: Surgical Incision; Wound Location: Perineal area; Measurements: Length 3.0 cm x Width 1.0 cm x Depth 2.50 cm. Surgical incision to right labia with no bleeding, drainage noted at this time. No complaints of pain or discomfort voiced. The Treatments section of the Wound Assessment Report dated 04/01/2016 for Resident #23 read: Diet: Mechanical Soft NSOT-No Fried Foods. Further review of the treatment nurse's notes revealed there was no documentation of wound care performed or an order for [REDACTED]. Review of Resident #23's Treatment Administration Record (TAR) for the month of April 2016 revealed and order dated 04/15/2016, which read: Cleanse Surgical Site to right labia with wound cleanser. Pat dry with 4 x 4. Loosely pack wound with Dakins 0.25 % soaked gauze and cover with ABD pad daily until healed. The start date of this order was 04/15/2016. Further review of this April 2016 TAR revealed there was no documentation or indication that wound care was performed from 04/01/2016 through 04/14/2016. During an interview on 05/18/2016 at 9:51 AM, S3TN/LPN (Treatment Nurse/Licensed Practical Nurse) reviewed the clinical records for Resident # 23. She confirmed that she was responsible for performing wound care in the facility as the treatment nurse and could measure wounds that were not pressure related. S3TN/LPN confirmed that she was aware that Resident #23 was readmitted to the facility on [DATE] and she assessed her wound to be a surgical incision to the right labia with no bleeding or drainage that measured 3.0 cm x 1.0 cm x 2.5 cm. She confirmed there was no documentation of wound care performed on 04/01/2016. She confirmed that the LTAC hospital's discharge instructions for wound care were not carried forward and transcribed to the nursing home's record, or implemented on 4/1/16. S3TN/LPN reviewed the Treatment Administration Record for April 2016 and confirmed that orders for wound care were not initiated until 04/15/2016. She confirmed Resident #23 did not receive treatment for [REDACTED]. She confirmed she knew the resident had a wound because she assessed Resident #23 when she was readmitted on [DATE]. Review of Resident # 23's April 2016 Physician order [REDACTED]. Review of Resident #23's May 2016 Physician order [REDACTED]. The order date was 4/15/16. The [DIAGNOSES REDACTED]. During an interview on 5/23/2016 at 10:58 AM, S16IDON (Interim Director of Nursing) confirmed there was no order for Resident #23's wound care on the April 2016 Physician order [REDACTED]. She confirmed that the treatment order with a start date of 4/15/2016 to cleanse surgical site to right labia with wound cleanser, pat dry with 4x4, loosely pack wound with Dakin's 0.25% soaked gauze and cover with ABD pad daily until healed was not transcribed as a readmit order as it should have been when she was readmitted on [DATE]. S16IDON confirmed this resulted in Resident #23 not receiving wound care from 4/1/16 through 4/14/16. S16IDON confirmed that S3TN/LPN documented on Resident #23's readmit assessment dated [DATE] that the resident complained of mild discomfort during assessment of vaginal area and the packing was not removed at that time. She confirmed there was no documented evidence that any facility staff removed the packing that was present upon admit 4/1/16 and the wound care was not performed until 2 weeks later. S16IDON stated an order was obtained on 4/25/16 for pain medication to be administered prior to wound care, but there was no documentation that staff notified the physician or nurse practitioner of any other wound care concerns until 4/28/16 when the wound care nurse asked the nurse practitioner to evaluate the wound. S16IDON confirmed that S17RN documented clear light green liquid draining around the Foley catheter site on 4/3/16; but S17RN did not notify anyone about the green drainage. S16IDON confirmed that Resident #23's right groin wound continued to deteriorate and she was readmitted to the hospital on [DATE] with an enlarged right groin wound with greenish, purulent drainage and an abscess to her left buttock. S16IDON confirmed Resident #23 has not been readmitted to the facility as of 5/23/2016 and was transferred from the acute care hospital to the LTAC hospital to continue receiving treatment of [REDACTED]. Review of the Hospital Records for Resident #23's acute care hospitalized from [DATE] to 5/13/2016 revealed she was diagnosed with [REDACTED]. She was seen and followed in consultation by Wound Care and Infectious Disease. She was started on IV antibiotics. She was also seen and followed in consultation by GYN Oncology to rule out recurrence of [MEDICAL CONDITION] as the etiology of the groin wound. There was no evidence of recurrence. Continuation of wound care was recommended. She was thought to be in need of future long-term wound care so long-term acute care evaluation was done. Also a diverting [MEDICAL CONDITION] was done to avoid further contamination of the wound. She was transferred to (LTAC) hospital for further care. Review of # 23's Care Plan reflected a problem dated 6/11/13 of at risk for altered skin integrity related to incontinent episodes of bowel and bladder, decreased mobility related to [DIAGNOSES REDACTED]. daily. There was no documented evidence of wound care orders reflected on Resident # 23's care plan prior to 4/15/16. Interview on 5/19/16 at 2:30 p.m. with the Nurse Practitioner (NP) revealed S3 TN/ LPN notified her when she came in on 4/7/16 of Resident # 23's wound. She stated she and S3 TN/LPN looked at the wound assessment, documentation note and picture dated 3/29/16 from the LTAC hospital, and they looked at the discharge packet. She stated they decided to go along with the wound care that was provided at the LTAC hospital. NP stated she did not write the wound care orders because the doctor was at the facility the same time she was. She confirmed she should have written the wound care order, but she did not. The Nurse Practitioner confirmed that an order for [REDACTED]. During further interview with the Nurse Practitioner on 5/19/16 at 3:05 PM, she revealed she did not discuss the wound with the doctor (S26MD) making rounds on 4/7/16. The facility was asked for all progress notes and any other documentation done by the NP regarding Resident #23's care during her readmit to the facility from 4/1/16 through 5/4/16. Progress notes for Resident #23 were completed by NP on 4/14/2016, 4/21/2016, and 4/28/2016. A review of the progress notes dated 4/14/16 and 4/21/16 revealed Resident #23's right groin wound was not addressed or mentioned in NP's notes. A review of the progress notes dated 4/28/16 revealed the wound care nurse asked the nurse practitioner to evaluate the wound today and there was green drainage inside the wound. Her [DIAGNOSES REDACTED]. This resident has a surgical wound that was left open by the surgeon. It now has green drainage. I have ordered a culture of the drainage. I have also instructed the wound care nurse to continue with the packing. There was no progress notes or documentation by NP dated 4/7/2016 or 4/15/2016. During an interview on 5/19/16 at 2:46 PM, the Corporate Registered Nurse revealed a registered nurse should have assessed Resident #23's wound when she was readmitted on [DATE] and they did not. She stated S2DON (Director of Nursing) was out sick and they had a nurse filling in, but there was no documentation of the RN assessment. She stated the weekend RNs performed wound care on the weekends and there was no documentation of wound care being done by the RN on the weekends of 4/2/2016 and 4/9/2016. During an interview on 5/20/16 at 9:50 AM, S17RN confirmed she was the weekend registered nurse and she worked on 04/02/16, 04/03/16, 04/09/16, and 04/10/16 after Resident #23's readmit from the hospital on [DATE]. S17RN stated she was responsible for wound care and treatments on the weekends and would document any treatments she performed on the TAR. She reviewed the TAR for the month of April 2016 and confirmed there was no documented evidence of wound care and the start date of the order for treatment of [REDACTED]. S17RN stated she looked at the wound on 04/02/16 and 04/03/16, but did not document an assessment of it. She stated she remembered noticing some light yellowish-green drainage around Resident #23's Foley insertion site. She stated the wound was like a skin fold and she could barely see it. She stated there was no dressing to the wound when she saw it and there was no packing that she could see. She stated the wound had no redness, bleeding, or drainage. She stated she did not perform any wound care and she did not see any orders for wound care. She stated that the next weekend she was there and she did not perform wound care. She stated she just checked on Resident #23. When asked if she should have ensured there was treatment orders since she knew Resident #23 had a wound, S17RN stated I don't know. A review of the Nurse's Note for Resident #23 dated 04/03/2016 timed 1:34 PM written by S17RN read: Resident assisted to right side with assist of 2 CNA's. Moves all extremities but slowly. Denies pain or discomfort at this time. Voices needs at this time. Checked perineum and small amount of brown stool passed. Cleaned and brief changed. Small amount clear light green liquid draining from around Foley catheter insertion site. Cleaned area gently and placed ABD pad to absorb any drainage at site. GU ([MEDICAL CONDITION]) catheter draining medium yl (yellow) urine, moderate amt (amount). Instructed to use call light for assistance with all needs and transfers. Call light placed (clipped) in reach on pillow case. During a telephone interview on 5/23/16 at 1:30 PM, S19MD confirmed Resident #23 should have received wound care from 04/01/2016 through 04/14/2016 and treatment should have been initiated prior to 04/15/2016. S19MD confirmed that he was not notified that Resident #23 did not receive wound care for 2 weeks and either he or S26MD should have been notified. Review of the Wound Assessment Report dated 4/15/16 for Resident #23's surgical incision wound revealed S3TN/LPN documented the following measurements: Length 3.5 cm x Width 1.0 cm x Depth 2.50 cm. Drainage: Serous, Scant Review of the Wound Assessment Report dated 4/22/16 for Resident #23's surgical incision wound revealed S3TN/LPN documented the following measurements: Length 6.0 cm x Width 1.0 cm x Depth 2.50 cm. Drainage: Serous, Small. The Wound Status was noted to be Deteriorated. Review of the Departmental Notes, Category: General Nurses' Notes for Resident #23 written by S29LPN dated 04/25/2016, timed 6:07 PM revealed: 4:30 PM writer received call from ___ at MD office with a verbal order to give [MEDICATION NAME] 5 mg 1 tablet by mouth 30 minutes prior to wound treatments per S19MD. Review of the Wound Assessment Report dated 4/29/16 for Resident #23's surgical incision wound revealed S3TN/LPN documented the following measurements: Length 6.0 cm x Width 1.0 cm x Depth 2.50 cm. Drainage: Serous, Small. The Wound Status was noted to be Deteriorated. Symptoms of Infection read: Increased pain, Malodorous or purulent drainage. On 5/23/16 at 8:45 AM, S16IDON (Interim Director of Nursing) presented the LTAC Hospital Discharge Care Orders dated 4/1/2016 and stated those orders became the facility's readmission orders [REDACTED]. She confirmed there was no documented evidence of wound care for Resident #23 from 4/1/16 through 4/14/16. She stated she did not provide oversight to ensure that care and services related the transcription and implementation of physician orders [REDACTED]. She revealed that there were only 2 residents that were a readmission or a new admission from the hospital to the facility with wound care orders from 4/1/16 - 5/16/16. During an interview on 5/23/16 at 4:09 PM, S16 Interim DON(S16IDON) stated she was not aware that she was responsible for the oversight of care and services until Friday, 5/20/16. She confirmed that she was responsible for reviewing and clarifying the orders for all admits and readmits while she was the interim DON and for ensuring that the staff implemented the orders but she did not fully realize this until 5/20/16. S16IDON stated she should have ensured that Resident # 23 had wound care orders and received wound care upon readmission to the facility on [DATE]. S16IDON confirmed Resident #23 missed treatment from 04/01/2016 through 4/14/2016. She reported she was not fully aware that it was her responsibility to review admit and readmit orders, to clarify orders when necessary, and to ensure the implementation of orders. S16IDON revealed that the CN (Corporate Nurse) reviewed the Wound Assessment Module for the facility and identified there was a problem with skin assessments and residents not receiving wound care in April. She stated there was no QA for wound care or assessments put in place after the CN identified these problems. On 05/23/2016 at 4:40 PM, S16IDON presented documentation of correspondence sent to her and S1ADMN (Administrator) dated 4/11/2016. She confirmed this correspondence was when the CN (Corporate Nurse) first identified a problem specific to Resident #23 regarding lack of documentation of the perineal area since 04/01/2016. She confirmed the correspondence dated 4/11/2016 indicated there were issues with S3TN/LPN not updating wounds timely for other residents. S16IDON also reviewed correspondence dated 4/18/16 from the CN and reported the CN reviewed Wound Reports for the week ending 04/15/16 and indicated to share the information with S3TN/LPN for her review and correction. She reported the information regarding Resident #23 read: Resident #23's surgical incision has not been updated in the WAM (Wound Assessment Module) since 04/01/16. S16IDON stated that the CN indicated, This must be updated weekly . She reported that the CN indicated she was very concerned about skin in this building because of inconsistent documentation by S3TN/LPN when a resident admits or readmits with head to toe skin assessments not being completed. S16IDON revealed that the CN wanted her and S1ADMN to take a serious look at the issues and get with S3TN/LPN to put a plan in place. During a phone interview on 05/24/2016 12:05 PM, S26MD revealed he was the attending physician for Resident #23. He confirmed that the nursing home staff should have continued the treatment to her labial wound upon her return 4/1/2016. S26MD stated that the Nurse Practitioner and the staff should have informed him that Resident #23's wound care orders were not transcribed to the nursing home records until 4/15/2016 and she did not receive wound care for the first 14 days when readmitted to the facility on [DATE]. He stated that the first phone call he received regarding the resident's wound was on 4/25/16. S26MD stated he was not notified of the lack of wound care or that the facility did not transcribe the order. Resident #66: Review of the clinical record for Resident # 66 revealed a date of admission on 4/12/16 with [DIAGNOSES REDACTED]. Resident #66's General Nurses' Notes dated 4/12/16 written by S13LPN read: At 2:10 PM Resident admitted to (facility) under the care of S19MD .Dressing noted dry/intact to Right Forearm, Left Heel, and mid lower abdominal wounds to be assessed per facility treatment nurse .S19MD informed of Resident arrival .At 2:15 PM writer faxed D/C (discharge) orders to S19MD's office and healthcare pharmacy .At 3:10 PM writer requested diet order .awaiting call back from MD office .At 3:55 PM writer received a call from (___) at S19MD's office. New orders per S19MD noted to D/C (discontinue) [MEDICATION NAME], D/C Sliding Scale, Blood Glucose Finger sticks twice daily. Call MD on Monday (4/18/16) with results. Diet LCS (Low Concentrated Sweets). Review of the Hospital Discharge Orders to SNF (Skilled Nursing Facility) for Resident #66's admit to the facility on [DATE] revealed: Wound Care to Right Arm and Left Heel Apply wound cleanser, apply All Kare Skin Prep to skin around wound bed, Apply Santyl Ointment toward bed and cover with coverderm. Change Every Day. S13LPN's signature was noted twice on Resident #66's Discharge to SNF orders and was dated 04/12/2016. Review of Resident # 66's April 2016 Physician order [REDACTED]. Review of the Physician's Telephone Orders for Resident #66 revealed there were telephone orders received in April 2016, but there was no documented evidence of a telephone order for wound care to the pressure ulcer on his left heel. During an interview on 5/23/16 at 11:00 AM, S16IDON confirmed there was no documentation of a written physician's orders [REDACTED].#66 was admitted to the facility from the hospital on [DATE] and the resident did have a stage 3 pressure ulcer to his left heel upon admit. Review of Resident # 66's May 2016 Physician order [REDACTED]. Review of the Care Plan for Resident # 66 reflected a problem of being at risk for altered skin integrity related to bottom of left heel with a problem onset date of 4/12/16. Review of the Admission Nursing assessment dated [DATE] signed by S13LPN reflected a wound to the left heel was identified. Review of Resident # 66's Wound Assessment Report dated 4/13/16 and signed by S16 Interim DON for the pressure ulcer to the left heel reflected the wound was identified 4/13/16 and the measurements were length - 2.0 cm, width - 1.8 cm, depth - 0 cm, with 100% [MEDICATION NAME] tissue to the wound bed. Further review of an entry documented by S16IDON on 4/13/16 at 1:26 PM read: Pressure Ulcer to left bottom of heel .wound care orders pending . Review of the April 2016 TAR (Treatment Administration Record) revealed wound care for the left heel pressure ulcer began on 4/16/16. The order on the Treatment Record reflected cleanser pressure ulcer to left heel with wound cleanser, pat dry with 4x4, apply skin prep to skin around wound, apply Santyl to wound bed and cover with Coverderm change daily until healed. The order date was 4/16/16. The start date was 4/16/16. There was no documentation of Resident #66 receiving treatment for [REDACTED]. During a telephone interview on 5/23/16 at 1:30 PM, S19MD confirmed he was the medical director and was the attending physicians for Resident #66. S19MD confirmed that when Resident #66 was admitted to the facility on [DATE], the resident's hospital discharge orders, including the wound care orders, became the nursing home admit orders. S19MD stated this was the process for all admits and readmits to the facility following hospitalization s. S19MD confirmed that he was notified when Resident #66 was admitted to the facility on [DATE] and the hospital discharge orders were faxed to him. S19MD revealed that Resident #66's hospital discharge orders became the facility's admit orders on 4/12/16 and he would change some things like the diet. S19MD stated that the orders for wound care on the resident's hospital discharge order form became the facility's orders for wound care and he would not change the wound care orders until he physically saw the resident and usually still would not change wound care orders without a valid reason. S19MD stated that the facility ' s staff should be aware of the process for wound care orders and should have continued the wound care orders the resident was receiving in the hospital when Resident #66 was admitted on [DATE] with a pressure ulcer to his left heel. S19MD stated Resident #66 should have received the necessary treatments prior to 4/16/16 because the order was present on the 4/12/16 hospital discharge/facility admit paperwork and should have been transcribed to the facility's Treatment Records prior to 4/16/16. He confirmed that Resident #66 should not have had a delay in the treatment of [REDACTED]. During an interview on 5/23/16 at 4:09 PM, S16 Interim DON stated she was not aware that she was responsible for the oversight of care and services until Friday, 5/20/16. She confirmed that she was responsible for reviewing and clarifying the orders for all admits and readmits while she was the interim DON and for ensuring that the staff transcribed and implemented the orders but she did not fully realize this until 5/20/16. S16IDON stated Resident #66 did not receive treatments from April 12 through April 16, 2016 and she missed it because she wasn't fully aware of her responsibilities. S16IDON revealed that the Corporate Nurse (CN) reviewed the Wound Assessment Module for the facility and identified there was a problem with skin assessments and residents not receiving wound care in April. She stated there was no QA for wound care or assessments put in place after the CN identified these problems. On 05/23/2016 at 4:40 PM, S16IDON presented documentation of correspondence sent to her and S1ADMN (Administrator) dated 4/18/16 from the Corporate Nurse (CN) and reported she reviewed Wound Reports for the week ending 04/15/16 and indicated to share the information with S3TN/LPN for her review and correction. She confirmed that the CN identified problems regarding Resident #66 who admitted [DATE] with multiple skin areas with no note by S3TN/LPN assessing his skin upon admission. She reported there were orders for treatment to a surgical site to his abdomen, written on 04/16/16 but he had been in the building since 04/12/16. She reported the CN also noted questions regarding the pressure ulcer to Resident #66 ' s left heel and a wound to the right arm. S16IDON confirmed that the CN identified that Resident #66 was admitted on [DATE] and there was no evidence that anyone addressed his skin issues prior to 4/16/16. She reported that the CN indicated she was very concerned about skin in this building because of inconsistent documentation by S3TN/LPN when a resident admits or readmits with head to toe skin assessments not being completed. S16IDON revealed that the CN wanted her and S1ADMN to take a serious look at the issues and get with S3TN/LPN to put a plan in place. S16IDON confirmed she was responsible for the facility's ongoing Quality Assessment and Assurance Program at the time these quality concerns were identified by the CN and S1ADMN was also aware of the problems but these concerns were not identified as quality concerns so the problems were not addressed as quality concerns. S16IDON confirmed there were other residents identified by the CN with lack of evidence of wound care and assessments being done; but the root cause of the problem was never addressed. S16IDON stated that in hindsight, she realizes now that she and S1ADMN should have addressed the quality problems with the QAA Committee.

Based on observations, record review and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This failure affected 4 (#23, #66, #60, #10) of 12 (#23, #66, #4, #9, #45, #60, #6, #10, #18, #19, #45, #62) sampled residents from a total of 33 (56, 62, 52, 20, 23, 27, 65, 18, 26, 61, 17, 35, 13, 39, 47, 19, 53, 54, 45, 33, 48, 10, 66, 2, 40, 22, 50, 3, 46, 14, 60, 58, 16) sampled Stage 2 residents. Administration failed to ensure that: 1. A system was in place to ensure nursing staff transcribe and implement orders for wound care when residents (#23, #66) are admitted or readmitted to the facility; 2. Staff followed Policy and the Plan of Care for a resident assessed as an unsafe smoker (#60); and 3. Staff followed the Plan of Care for a resident left unattended after being served a bowl of hot soup (#10). The Immediate Jeopardy (IJ) Situation began on 04/01/2016 at 10:30 AM when Resident #23 returned from a LTAC (Long-Term Acute Care) hospital following treatment for [REDACTED]. The hospital discharge instructions indicated to see MED REC (Medication Reconciliation) which indicated sodium hypochlorite 0.25% solution 1-Dakin's half daily for wound care on re-admission to the nursing home. There was no documented evidence that wound care was performed from 4/1/16 through 4/14/16. There was no oversight and supervision by the registered nurse upon return to the nursing home to ensure transcription, clarification if necessary, and implementation of wound care orders. The order for treatment was transcribed to the Treatment Administration Record on 4/15/16 and Resident #23 began receiving the necessary care and treatment on that date. The resident was sent to the hospital again on 5/4/16 with purulent discharge and enlargement of the right groin wound. On 5/20/16 at 12:55 PM, the survey team notified S1ADMN (Administrator) and S14CorpRN (Corporate Registered Nurse) of the IJ situation. The immediate jeopardy was removed on 5/20/2016 at 3:37 PM. when observations revealed the plan was being implemented. A list of admits/readmits to the facility was reviewed. It was determined that the 2 of 4 residents admitted or readmitted to the facility had orders for wound care. The 2 residents with wound care orders had been transcribed to the MAR and treatment implemented by staff. All of the facility RN staff was in-serviced on responsibility of transcribing orders and the implementation of those orders on newly admitted and readmitted residents. The Immediate Jeopardy (IJ) situation began on 5/18/16 at 9:05 AM when Resident # 60, a Quadriplegic, was observed in the courtyard unsupervised by staff and Resident #67 placed a cigarette in Resident #60 ' s month. Resident # 67 lit the cigarette, and left the courtyard. On 11/4/15 the facility had assessed resident #60 as being unable to demonstrate safe technique for putting out the matches or a lighter, disposing of ash, and unable to hold his cigarette. On 5/18/16 at 9:45 AM, Resident # 60 was observed still sitting in the smoking area unsupervised by staff, when Resident #67 put a cigarette in his month and lit it. Resident #67 left the resident there smoking alone. On 5/18/16 at 4:04 PM, the survey team notified S1 ADMN (Administrator) and S14CorpRN (Corporate Registered Nurse) of the IJ situation that currently existed in the facility. The immediate jeopardy was removed on 5/20/2016 at 2:17 PM., with the deficient practice remaining at a level of actual harm for resident #10 when observations revealed the plan was being implemented. In-servicing training of all staff started at 4:30 PM on 5/18/16 and continuing until all staff has been in-service on the following: smoking plans for residents, the newly implemented smoking times and staff observation for unsafe smokers, and what to do if a resident is observed smoking unsafely. All unsafe smokers were identified. Individual plans for smoking is now posted behind the nurses' station door and is also kept in the smoking box at the nurses' station. On 10/6/15, an actual harm occurred when Resident #10, who was assessed by the facility as requiring extensive assistance and one person physical assist in functional status for eating was served her food tray by the CNA (Certified Nursing Assistant). Resident #10 asked the CNA to warm up the soup. The CNA warmed the soup, and brought it to Resident #10's room set it in front of her, and told her it was hot. The CNA said she left her room to answer a call bell in another resident's room for about 10-15 minutes. During the time the CNA was out of the room Resident #10 attempted to eat the soup and it spilled on her. Resident #10 sustained Second-[MEDICAL CONDITION] the top of the left hand, left forearm, and left lower quadrant of the abdomen after spilling a bowl of hot soup on her when she was left unattended by staff. This deficient practice remains at an actual harm for resident #10. Findings: Cross refer to findings at tag F282 Cross refer to findings at tag F309 Cross refer to findings at tag F323 Cross refer to findings at tag F520 Interview on 5/18/16 at 12:28 PM with S16 Interim DON revealed Resident # 60 tells his CNA or calls on his call bell to notify someone when he wants to go outside to smoke. She stated the CNA would put his smoking apron on him and push his wheelchair outside to the courtyard. She stated that he sometimes would not notify staff prior to going outside with another resident, but the resident would place his smoking apron on him prior to taking him outside. She stated he was able to hold his hands in a way to maneuver his cigarette. She stated Resident #60 would put the cigarette on the ground when he finished it. She stated the facility did not have enough staff to supervise Resident # 60 while he was smoking, and that she would not consider him a safe smoker. During an interview on 5/23/2016 at 10:58 AM, S16IDON (Interim Director of Nursing) confirmed there was no order for Resident #23's wound care on the April 2016 Physician order [REDACTED]. She confirmed that the treatment order with a start date of 4/15/2016 to cleanse surgical site to right labia with wound cleanser, pat dry with 4x4, loosely pack wound with Dakin's 0.25% soaked gauze and cover with ABD pad daily until healed was not transcribed as a readmit order as it should have been when she was readmitted on [DATE]. S16IDON confirmed this resulted in Resident #23 not receiving wound care from 4/1/16 through 4/14/16. S16IDON confirmed that S3TN/LPN (Treatment Nurse/Licensed Practical Nurse) documented on Resident #23's readmit assessment dated [DATE] that the resident complained of mild discomfort during assessment of vaginal area and the packing was not removed at that time. She confirmed there was no documented evidence that any facility staff removed the packing that was present upon admit 4/1/16 and the wound care was not performed until 2 weeks later. S16IDON stated an order was obtained on 4/25/16 for pain medication to be administered prior to wound care, but there was no documentation that staff notified the physician or nurse practitioner of any other wound care concerns until 4/28/16 when the wound care nurse asked the nurse practitioner to evaluate the wound. S16IDON confirmed that S17RN documented clear light green liquid draining around the Foley catheter site on 4/3/16; but S17RN did not notify anyone about the green drainage. S16IDON confirmed that Resident #23's right groin wound continued to deteriorate and she was readmitted to the hospital on [DATE] with an enlarged right groin wound with greenish, purulent drainage and an abscess to her left buttock. S16IDON confirmed Resident #23 has not been readmitted to the facility as of 5/23/2016 and was transferred from the acute care hospital to the LTAC hospital to continue receiving treatment of [REDACTED]. During an interview on 5/23/16 at 1:50 PM, S1Administrator revealed that the facility was adequately staffed and consistently exceeded the number of staff and hours required to meet the needs of the residents. He stated that nursing may not have always utilized the available staff to the best of their ability; but there were more than sufficient staff available. During an interview on 5/23/16 at 4:09 PM, S16 Interim DON (S16IDON) stated she was not aware that she was responsible for the oversight of care and services until Friday, 5/20/16. She confirmed that she was responsible for reviewing and clarifying the orders for all admits and readmits while she was the interim DON and for ensuring that the staff implemented the orders but she did not fully realize this until 5/20/16. S16IDON stated she should have ensured that Resident # 23 had wound care orders and received wound care upon readmission to the facility on [DATE]. S16IDON confirmed Resident #23 missed treatment from 04/01/2016 through 4/14/2016. She reported she was not fully aware that it was her responsibility to review admit and readmit orders, to clarify orders when necessary, and to ensure the implementation of orders. S16IDON revealed that the CN (Corporate Nurse) reviewed the Wound Assessment Module for the facility and identified there was a problem with skin assessments and residents not receiving wound care in April. She stated there was no QA for wound care or assessments put in place after the CN identified these problems. On 05/23/2016 at 4:40 PM, S16IDON presented documentation of correspondence sent to her and S1ADMN (Administrator) dated 4/11/2016. She confirmed this correspondence was when the CN (Corporate Nurse) first identified a problem specific to Resident #23 regarding lack of documentation of the perineal area since 04/01/2016. She confirmed the correspondence dated 4/11/2016 indicated there were issues with S3TN/LPN not updating wounds timely for other residents. S16IDON also reviewed correspondence dated 4/18/16 from the CN and reported the CN reviewed Wound Reports for the week ending 04/15/16 and indicated to share the information with S3TN/LPN for her review and correction. She reported the information regarding Resident #23 read: Resident #23's surgical incision has not been updated in the WAM (Wound Assessment Module) since 04/01/16. S16IDON stated that the CN indicated, This must be updated weekly . She reported that the CN indicated she was very concerned about skin in this building because of inconsistent documentation by S3TN/LPN when a resident admits or readmits with head to toe skin assessments not being completed. S16IDON revealed that the CN wanted her and S1ADMN to take a serious look at the issues and get with S3TN/LPN to put a plan in place. S16IDON confirmed she was responsible for the facility's ongoing Quality Assessment and Assurance Program at the time these quality concerns were identified by the CN and S1ADMN was also aware of the problems but these concerns were not identified as quality concerns so the problems were not addressed as quality concerns. S16IDON confirmed there were other residents identified by the CN with lack of evidence of wound care and assessments being done; but the root cause of the problem was never addressed. S16IDON stated that in hindsight, she realizes now that she and S1ADMN should have addressed the quality problems with the QAA Committee. During an interview with S2DON on 5/19/16 at 9:15 AM, she confirmed that S31CNA documented 1/0 (Supervision/No setup or physical help from staff). She confirmed that according to S31CNA's documentation, S31CNA did not provide set up or physical help/assistance when eating to Resident #10 on 10/6/15. S2DON reported she did not have documented evidence of having retrained staff or performed quality assurance monitoring post incident. Review of an In-Service documented on 1/19/16 revealed discussions of accuracy of the ADL documentation system and encouraging residents to drink fluids and assist those not eating well. The in-service did not include education and training in accident prevention specific to supervision and assistance as needed to prevent accidents while eating hot foods. S16IDON reported on 5/19/16 at 3:30 PM that the facility had no policy for accident prevention. She presented the facility's policy for Feeding A Resident which revealed no measures staff were to take for residents at risk for injury during feeding, and it did not address supervision and assistance as needed to prevent accidents while eating. During an interview on 5/23/16 at 4:09 PM, S16 Interim DON stated she was not aware that she was responsible for the oversight of care and services until Friday, 5/20/16. She confirmed that she was responsible for reviewing and clarifying the orders for all admits and readmits while she was the interim DON and for ensuring that the staff transcribed and implemented the orders but she did not fully realize this until 5/20/16. S16IDON stated Resident #66 did not receive treatments from April 12 through April 16, 2016 and she missed it because she wasn't fully aware of her responsibilities. S16IDON revealed that the Corporate Nurse (CN) reviewed the Wound Assessment Module for the facility and identified there was a problem with skin assessments and residents not receiving wound care in April. She stated there was no QA for wound care or assessments put in place after the CN identified these problems. On 05/23/2016 at 4:40 PM, S16IDON presented documentation of correspondence sent to her and S1ADMN (Administrator) dated 4/18/16 from the Corporate Nurse (CN) and reported she reviewed Wound Reports for the week ending 04/15/16 and indicated to share the information with S3TN/LPN for her review and correction. She confirmed that the CN identified problems regarding Resident #66 who admitted [DATE] with multiple skin areas with no note by S3TN/LPN assessing his skin upon admission. She reported there were orders for treatment to a surgical site to his abdomen, written on 04/16/16 but he had been in the building since 04/12/16. She reported the CN also noted questions regarding the pressure ulcer to Resident #66's left heel and a wound to the right arm. S16IDON confirmed that the CN identified that Resident #66 was admitted on [DATE] and there was no evidence that anyone addressed his skin issues prior to 4/16/16. She reported that the CN indicated she was very concerned about skin in this building because of inconsistent documentation by S3TN/LPN when a resident admits or readmits with head to toe skin assessments not being completed. S16IDON revealed that the CN wanted her and S1ADMN to take a serious look at the issues and get with S3TN/LPN to put a plan in place.

Based on observations, record reviews, and interviews, the facility failed to ensure the Quality Assessment and Assurance Committee identified actual quality deficiencies and implemented appropriate plans of action for quality of care issues necessary to correct quality deficiencies in order to implement appropriate plans of action to correct the issues. This failure affected 4 (#23, #66, #60, #10) of 12 (#23, #66, #4, #9, #45, #60, #6, #10, #18, #19, #45, #62) sampled residents from a total of 33 (56, 62, 52, 20, 23, 27, 65, 18, 26, 61, 17, 35, 13, 39, 47, 19, 53, 54, 45, 33, 48, 10, 66, 2, 40, 22, 50, 3, 46, 14, 60, 58, 16) sampled Stage 2 residents. The facility failed to: 1. Have a system in place to ensure nursing staff transcribe and implement orders for wound care when residents (#23, #66) are admitted or readmitted to the facility. 2. Ensure staff followed the Policy and the Plan of Care for a resident assessed as an unsafe smoker (#60); 3. Ensure staff followed the Plan of Care for a resident left unattended after being served a bowl of hot soup (#10); 4. Identify quality deficiencies and develop action plans with monitoring when quality of care issues were identified. The Immediate Jeopardy (IJ) Situation began on 04/01/2016 at 10:30 AM when Resident #23 returned from a LTAC (Long-Term Acute Care) hospital following treatment for [REDACTED]. The hospital discharge instructions indicated to see MED REC (Medication Reconciliation) which indicated sodium hypochlorite 0.25% solution 1-Dakin's half daily for wound care on re-admission to the nursing home. There was no documented evidence that wound care was performed from 4/1/16 through 4/14/16. There was no oversight and supervision by the registered nurse upon return to the nursing home to ensure transcription, clarification if necessary, and implementation of wound care orders. The order for treatment was transcribed to the Treatment Administration Record on 4/15/16 and Resident #23 began receiving the necessary care and treatment on that date. The resident was sent to the hospital again on 5/4/16 with purulent discharge and enlargement of the right groin wound. On 5/20/16 at 12:55 PM, the survey team notified S1ADMN (Administrator) and S14CorpRN (Corporate Registered Nurse) of the IJ situation. The immediate jeopardy was removed on 5/20/2016 at 3:37 PM. when observations revealed the plan was being implemented. A list of admits/readmits to the facility was reviewed. It was determined that the 2 of 4 residents admitted or readmitted to the facility had orders for wound care. The 2 residents with wound care orders had been transcribed to the MAR and treatment implemented by staff. All of the facility RN staff was in-serviced on responsibility of transcribing orders and the implementation of those orders on newly admitted and readmitted residents. The RN will then complete the order review monitor and place it in the DON office for her follow up. Monitoring of this corrective action will be completed by the DON reviewing the admission and readmission orders [REDACTED] The Immediate Jeopardy (IJ) situation began on 5/18/16 at 9:05 AM when Resident # 60, a Quadriplegic, was observed in the courtyard unsupervised by staff and Resident #67 placed a cigarette in Resident #60 ' s month. Resident # 67 lit the cigarette, and left the courtyard. On 11/4/15 the facility had assessed resident #60 as being unable to demonstrate safe technique for putting out the matches or a lighter, disposing of ash, and unable to hold his cigarette. On 5/18/16 at 9:45 AM, Resident # 60 was observed still sitting in the smoking area unsupervised by staff, when Resident #67 put a cigarette in his month and lit it. Resident #67 left the resident there smoking alone. On 5/18/16 at 4:04 PM, the survey team notified S1 ADMN (Administrator) and S14CorpRN (Corporate Registered Nurse) of the IJ situation that currently existed in the facility. The immediate jeopardy was removed on 5/20/2016 at 2:17 PM., with the deficient practice remaining at a level of actual harm for resident #10 when observations revealed the plan was being implemented. In-servicing training of all staff started at 4:30 PM on 5/18/16 and continuing until all staff has been in-service on the following: smoking plans for residents, the newly implemented smoking times and staff observation for unsafe smokers, and what to do if a resident is observed smoking unsafely. All unsafe smokers were identified. Individual plans for smoking is now posted behind the nurses' station door and is also kept in the smoking box at the nurses' station. Monitoring of this corrective action will be completed by administration observing the smoking area randomly during designated smoking times to assure that the smoking plan for unsafe smokers is being followed by both the residents and the staff. This will occur 5 times a week for 6 weeks and then monthly thereafter until compliance is maintained. On 10/6/15, an actual harm occurred when Resident #10, who was assessed by the facility as requiring extensive assistance and one person physical assist in functional status for eating was served her food tray by the CNA (Certified Nursing Assistant). Resident #10 asked the CNA to warm up the soup. The CNA warmed the soup, and brought it to Resident #10's room set it in front of her, and told her it was hot. The CNA said she left her room to answer a call bell in another resident's room for about 10-15 minutes. During the time the CNA was out of the room Resident #10 attempted to eat the soup and it spilled on her. Resident #10 sustained Second-[MEDICAL CONDITION] the top of the left hand, left forearm, and left lower quadrant of the abdomen after spilling a bowl of hot soup on her when she was left unattended by staff. This deficient practice remains at an actual harm for resident #10. Findings: Cross refer to findings at tag F282 Cross refer to findings at tag F309 Cross refer to findings at tag F323 Cross refer to findings at tag F490 Interview on 5/18/16 at 12:28 PM with S16 Interim DON revealed Resident # 60 tells his CNA or calls on his call bell to notify someone when he wants to go outside to smoke. She stated the CNA would put his smoking apron on him and push his wheelchair outside to the courtyard. She stated that he sometimes would not notify staff prior to going outside with another resident, but the resident would place his smoking apron on him prior to taking him outside. She stated he was able to hold his hands in a way to maneuver his cigarette. She stated Resident #60 would put the cigarette on the ground when he finished it. She stated the facility did not have enough staff to supervise Resident # 60 while he was smoking, and that she would not consider him a safe smoker. During an interview on 5/23/2016 at 10:58 AM, S16IDON (Interim Director of Nursing) confirmed there was no order for Resident #23's wound care on the April 2016 Physician order [REDACTED]. She confirmed that the treatment order with a start date of 4/15/2016 to cleanse surgical site to right labia with wound cleanser, pat dry with 4x4, loosely pack wound with Dakin's 0.25% soaked gauze and cover with ABD pad daily until healed was not transcribed as a readmit order as it should have been when she was readmitted on [DATE]. S16IDON confirmed this resulted in Resident #23 not receiving wound care from 4/1/16 through 4/14/16. S16IDON confirmed that S3TN/LPN (Treatment Nurse/Licensed Practical Nurse) documented on Resident #23's readmit assessment dated [DATE] that the resident complained of mild discomfort during assessment of vaginal area and the packing was not removed at that time. She confirmed there was no documented evidence that any facility staff removed the packing that was present upon admit 4/1/16 and the wound care was not performed until 2 weeks later. S16IDON stated an order was obtained on 4/25/16 for pain medication to be administered prior to wound care, but there was no documentation that staff notified the physician or nurse practitioner of any other wound care concerns until 4/28/16 when the wound care nurse asked the nurse practitioner to evaluate the wound. S16IDON confirmed that S17RN documented clear light green liquid draining around the Foley catheter site on 4/3/16; but S17RN did not notify anyone about the green drainage. S16IDON confirmed that Resident #23's right groin wound continued to deteriorate and she was readmitted to the hospital on [DATE] with an enlarged right groin wound with greenish, purulent drainage and an abscess to her left buttock. S16IDON confirmed Resident #23 has not been readmitted to the facility as of 5/23/2016 and was transferred from the acute care hospital to the LTAC hospital to continue receiving treatment of [REDACTED]. During an interview on 5/23/16 at 1:50 PM, S1Administrator revealed that the facility was adequately staffed and consistently exceeded the number of staff and hours required to meet the needs of the residents. He stated that nursing may not have always utilized the available staff to the best of their ability; but there were more than sufficient staff available. During an interview on 5/23/16 at 4:09 PM, S16 Interim DON (S16IDON) stated she was not aware that she was responsible for the oversight of care and services until Friday, 5/20/16. She confirmed that she was responsible for reviewing and clarifying the orders for all admits and readmits while she was the interim DON and for ensuring that the staff implemented the orders but she did not fully realize this until 5/20/16. S16IDON stated she should have ensured that Resident # 23 had wound care orders and received wound care upon readmission to the facility on [DATE]. S16IDON confirmed Resident #23 missed treatment from 04/01/2016 through 4/14/2016. S16IDON stated Resident #66 did not receive treatments from April 12 through April 16, 2016 and she missed it because she wasn't fully aware of her responsibilities. S16IDON again stated that she was not fully aware that it was her responsibility to review admit and readmit orders, to clarify orders when necessary, and to ensure the implementation of orders. S16IDON revealed that the CN (Corporate Nurse) reviewed the Wound Assessment Module for the facility and identified there was a problem with skin assessments and residents not receiving wound care in April. She stated there was no QA for wound care or assessments put in place after the CN identified these problems. On 05/23/2016 at 4:40 PM, S16IDON presented documentation of correspondence sent to her and S1ADMN (Administrator) dated 4/11/2016. She confirmed this correspondence was when the CN (Corporate Nurse) first identified a problem specific to Resident #23 regarding lack of documentation of the perineal area since 04/01/2016. She confirmed the correspondence dated 4/11/2016 indicated there were issues with S3TN/LPN not updating wounds timely for other residents. S16IDON also reviewed correspondence dated 4/18/16 from the CN and reported the CN reviewed Wound Reports for the week ending 04/15/16 and indicated to share the information with S3TN/LPN for her review and correction. She reported the information regarding Resident #23 read: Resident #23's surgical incision has not been updated in the WAM (Wound Assessment Module) since 04/01/16. S16IDON stated that the CN indicated, This must be updated weekly . S2DON confirmed that the CN also identified problems regarding Resident #66 who admitted [DATE] with multiple skin areas with no note by S3TN/LPN assessing his skin upon admission. She reported there were orders for treatment to a surgical site to his abdomen, written on 04/16/16 but he had been in the building since 04/12/16. She reported that the CN also noted questions regarding the pressure ulcer to Resident #66's left heel and a wound to his right arm. S16IDON confirmed that the Corporate Nurse identified that Resident #66 was admitted on [DATE] and there was no evidence that anyone addressed his skin issues prior to 4/16/16. She reported that the CN indicated she was very concerned about skin in this building because of inconsistent documentation by S3TN/LPN when a resident admits or readmits with head to toe skin assessments not being completed. S16IDON revealed that the CN wanted her and S1ADMN to take a serious look at the issues and get with S3TN/LPN to put a plan in place. During this interview on 5/23/16 at 4:40 PM, S16IDON confirmed she was responsible for the facility's ongoing Quality Assessment and Assurance Program at the time these quality concerns were identified by the CN and S1ADMN was also aware of the problems but these concerns were not identified as quality concerns so the problems were not addressed as quality concerns. S16IDON confirmed there were other residents identified by the CN with lack of evidence of wound care and assessments being done; but the root cause of the problem was never addressed. S16IDON stated that in hindsight, she realizes now that she and S1ADMN should have addressed the quality problems with the QAA Committee. Review of personnel file for S3TN/LPN revealed no in-service training or counseling regarding treatments not provided, assessments not done, or any other issues identified by the Corporate Nurse in April 2016 to present. During an interview on 05/24/2016 9:42 AM, the Corporate Nurse (CN) provided documentation of an In-service dated 2/16/16 timed 10:00 AM and stated that staff was instructed on verifying orders, double checking new orders and return orders from hospital stays and 2 nurses were supposed to verify and both sign off on them. She stated that the nurse that provided the in-service was no longer employed by the facility and she was not sure if something was identified that necessitated the need for an in-service. She stated that S2DON was out on leave at that time but her handwriting was noted at beginning of in-service. The CN revealed that S16IDON was the Acting/Interim DON at time of in-service on 2/16/16. The In-service dated 02/16/2016, timed 10:00 AM, was reviewed with S2DON, S16IDON, and the Corporate Nurse (CN) on 5/24/2016 at 9:49 AM. The In-Service included that staff Must verify orders. Double check new orders, return orders from hospital stay, 2 nurses verify, and both are to sign off on them. S2DON, S16IDON, and the CN verified there was no Quality Assurance measures put in place or monitoring to ensure the deficient practice identified would not recur. S16IDON stated she was responsible for Quality Assurance at the time of the in-service on 2/16/16 and she could not recall what was discussed. S16IDON confirmed she signed the In-Service Training and S3TN/LPN signed the In-Service Training. S2DON stated that the February 2016 in-service was held when staff was checking for new orders on the chart and the orders from the hospital could not be located so staff was in-serviced to keep the hospital discharge orders on the chart. S2DON denied that the facility had identified concerns with orders not being followed and stated that care was being provided per orders in February. S2DON and S16IDON revealed there was no monitoring done after the In-service was held on 2/16/16 to ensure 2 nurses were double checking orders when residents returned from hospital stays to verify complete and accurate orders. During an interview with S2DON on 5/19/16 at 9:15 AM, she confirmed that S31CNA documented 1/0 (Supervision/No setup or physical help from staff). She confirmed that according to S31CNA's documentation, S31CNA did not provide set up or physical help/assistance when eating to Resident #10 on 10/6/15. S2DON reported she did not have documented evidence of having retrained staff or performed quality assurance monitoring post incident. Review of an In-Service documented on 1/19/16 revealed discussions of accuracy of the ADL documentation system and encouraging residents to drink fluids and assist those not eating well. The in-service did not include education and training in accident prevention specific to supervision and assistance as needed to prevent accidents while eating hot foods. S16IDON reported on 5/19/16 at 3:30 PM that the facility had no policy for accident prevention. She presented the facility's policy for Feeding A Resident which revealed no measures staff were to take for residents at risk for injury during feeding, and it did not address supervision and assistance as needed to prevent accidents while eating. On 05/24/2016 at 9:56 AM, interviews were conducted with S2DON (Director of Nursing) and S16Interim DON. S2DON revealed she was responsible for the facility's Quality Assessment and Assurance (QAA) Program and S16IDON was responsible while she was out on medical leave for the past few months. S16IDON stated that the most recent quarterly QAA meeting was held on 4/8/16 and she was present for that meeting. S16IDON stated that topics discussed at the QAA meetings included wound rates, the infection control rate, incident/accident trends, any patterns, family issues, dietary issues, therapy issues, nursing concerns, or staffing concerns would be discussed. S16IDON reviewed the minutes for the 4/8/16 QAA meeting and stated there were no nursing concerns identified or discussed at the 4/8/16 QAA meeting. S16IDON stated she did not address the wound care concerns identified by the Corporate Nurse during the 4/8/16 QAA the meeting because she thought the meeting was to discuss problems or concerns that occurred in January, February, and March. S16IDON confirmed that the facility's QAA program to identify potential or actual quality deficiencies was an ongoing process. S2DON stated that any quality concerns or deficiencies identified by the corporate nurse or any other staff person regarding resident care and services should be addressed as soon as the facility is aware of the problem to ensure the issue does not recur. S2DON stated the facility does have daily QA meetings and issues are discussed and action plans are developed at that time when needed. S16IDON confirmed that quality deficiencies were identified by the Corporate Nurse and those concerns were communicated to her and S1ADMN regarding serious issues with wounds in the facility but she (S16IDON) did not consider the areas quality concerns when residents were not being assessed and/or were not receiving wound care and treatments. S16IDON stated that she addressed issues identified with treatments not being provided by verbally discussing the corporate nurse ' s concerns with S3TN/LPN and then trying to correct each concern for each individual resident, including Resident #23 and #66. S16IDON revealed that she and S1ADMN were aware of major concerns with treatments and care and services not being provided but she did not bring the concerns to the attention of the QAA committee to identify the root cause of the problem. S16IDON stated she did not look at what caused the treatment orders to be missed and if she had brought it to the QAA Committee, the facility could have addressed, What is happening? Why did we miss this? S16IDON stated that S1ADMN was aware of the problem but it was a nursing issue and she did not discuss it with him. S16IDON revealed that no in-services or training was provided to S3TN/LPN or any other staff. S16IDON stated an action plan with monitoring was never developed regarding staff not transcribing and implementing orders for residents that admit or readmit from hospital stays and there was no QAA plan developed regarding treatments or wound care.

Based on record reviews, interviews, and observations, the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care by failing to follow the plan of care for 1(#60) of 4(#4, #9, #45, #60) residents identified by the facility as unsafe smoker and for 1 (#10) left unattended after being served a bowl of hot soup of 6 (#6, #10, #18, #23, #19, #45, #62 residents reviewed for assistance with feeding. The Immediate Jeopardy (IJ) situation began on 5/18/16 at 9:05 AM when Resident # 60, a Quadriplegic, was observed in the courtyard unsupervised by staff and Resident #67 placed a cigarette in Resident #60 ' s mouth. Resident # 67 lit the cigarette, and left the courtyard. On 11/4/15 the facility had assessed resident #60 as being unable to demonstrate safe technique for putting out the matches or a lighter, disposing of ash, and unable to hold his cigarette. On 5/18/16 at 9:45 AM, Resident # 60 was observed unsupervised by staff when Resident #67 put a cigarette in his month and lit it. Resident #67 left the resident there smoking alone. On 10/6/15, an actual harm occurred when Resident #10, who was assessed by the facility as requiring extensive assistance and one person physical assist in functional status for eating was served her food tray by the CNA. Resident #10 asked the CNA to warm up the soup. The CNA warmed the soup, and brought it to Resident #10's room set it in front of her, and told her it was hot. The CNA said she left her room to answer a call bell in another resident's room for about 10-15 minutes. During the time the CNA was out of the room Resident #10 attempted to eat the soup and it spilled on herself. Resident #10 sustained Second-[MEDICAL CONDITION] the top of the left hand, left forearm, and left lower quadrant of the abdomen after spilling a bowl of hot soup on her when she was left unattended by staff. On 5/18/16 at 4:04 PM, the survey team notified S1 ADMN (Administrator) and S14CorpRN (Corporate Registered Nurse) of the IJ situation that currently existed in the facility. The facility provided a plan of removal on 5/19/16 that included the following: Problem: (Resident #60) observed by surveyor twice on 05-18-16 outside smoking and not following smoking plan. Intervention: 1. All staff on all shifts in-serviced starting at 4:30 PM on 5/18/16 and continuing until all staff has been completed on the following: smoking plans for residents, the newly implemented smoking times and staff observation for unsafe smokers, and what to do if a resident is observed smoking unsafely. 2. A list of all the smokers and their individual plans for smoking is now posted behind the nurse's station door and also kept in the smoking box at the nurse ' s station. 3. Identified unsafe smokers, # 60, #4, and #9 (currently hospitalized ), and #45 (also currently hospitalized ) will have their cigarettes kept in the smoking box at the nurses station and will have cigarettes passed out to them, and be observed/assisted by a staff member, at the designated smoking times for unsafe smokers (every two hours from 9 AM-7 PM daily). These residents had this smoking plan reviewed with them and have signed an agreement with this plan. 4. A meeting was held with all the facility smokers by the social worker on 5-18-16 at 4:30 PM and explained to them that sharing of cigarettes and lighters or lighting other resident's cigarettes will not be tolerated. If a resident is observed lighting another resident's cigarette the administrator is to be informed and the resident doing the lighting of the cigarette will be considered an unsafe smoker with smoking paraphernalia being taken away. Current safe smokers are still allowed to smoke at time of their choosing. The smoking residents all signed the in-service sheet indicating their presence at the meeting. 5. All residents who smoke have had their smoking assessments and care plans reviewed and updated, if necessary, to reflect current individualized smoking abilities and plans. 6. Smoking orders have been reviewed and updated, if necessary, to reflect the current individualized smoking plans. 7. All residents who smoke have had their clothing and wheelchairs, if applicable, checked for burn holes. Monitoring: 1. Monitoring of this corrective action will be completed by administration observing the smoking area randomly during designated smoking times to assure that the smoking plan for unsafe smokers is being followed by both the residents and the staff. This will occur 5 times a week for 6 weeks and then monthly thereafter until compliance is maintained. 2. Residents who smoke will have their smoking assessment, care plan, and order reviewed and updated, if necessary, if their smoking safety or ability changes and at a minimum with each staffing to reflect any changes or need for staff observation. Nursing administration will monitor the care plan, smoking assessment, and order for smoking on each resident as they come up due for staffing. This will occur weekly until all the smoking residents have been staffed and then monthly thereafter until compliance is maintained. 3. Monitoring of the list of residents who smoke for accuracy will be completed by nursing administration reviewing the list behind the nurse ' s station door and in the smoking box weekly for 6 weeks and then monthly thereafter until compliance is maintained. The immediate jeopardy was removed on 5/19/16 at 2:17 PM. This deficient practice remains at the level of actual harm. Findings: Review of the facility's Smoking Policy revealed (in part): .it may be necessary to place smoking restrictions on individual residents because of safety and medical reasons. Should this become necessary, such information will be noted on the resident's care plan. DO NOT allow residents who have been classified as NON-RESPONSIBLE to smoke alone. Resident #60. Review of Resident # 60's May 2016 Physician order [REDACTED]. Further review of the physician orders [REDACTED]. Review of the Safe Smoking assessment dated [DATE] for Resident #60 and signed by the former CCC (Clinical Care Coordinator) and S7CCC reflected the resident cannot light and smoke a cigarette or other smoking device while demonstrating safe technique for putting out the matches or lighter and disposing of ash. The assessment further reflected the resident was not able to physically hold the smoking device while smoking. Resident #60's Safe Smoking Assessment form dated 11/4/15 revealed: Current Smoking Plan for this resident is as follows: Resident is alert. He can't hold his cigarettes. He is a Quadriplegic. Has smoking apron for prevention of cig (cigarette)[MEDICAL CONDITION] clothes. According to the description of a safe smoker on the Safe Smoking Assessment form, Resident # 60 was not assessed as a safe smoker. The Safe Smoking Assessment was completed upon admit and was reviewed quarterly and if any part of the assessment changed, a new assessment was required. Quarterly Update of the Safe Smoking Assessment was signed by S7CCC on 02/16/2016 and 05/17/2016 indicating Resident #60's Safe Smoking Assessment was reviewed on those dates and he remained an unsafe smoker. Review of Resident # 60's Care Plan filed in his clinical record reflected the resident was at potential for injury related to smoking. Goal: Will follow the designated smoking plan. Target Date: 08/31/2016. Approaches for this problem included (in part): ensure cigarettes are safely extinguished; hold cigarette for resident while smoking, and smoking apron to be worn to prevent [MEDICAL CONDITION] clothes. During an interview on 5/16/16 at 2:04 PM, Resident #60 was observed sitting in his wheelchair in the Courtyard. He was wearing a smoking apron and Resident #60 had contractures to both hands. Resident #60 stated that he was a smoker and that he wore the smoking apron while smoking to prevent burning himself. He stated that due to his [MEDICAL CONDITION] and contractures to both hands, the staff was supposed to place his cigarette in his mouth and he smoked it until he had completed the cigarette. He stated he then would spit the cigarette out on the ground. He was not smoking at the time of this observation and interview. Observation on 5/18/16 at 9:05 AM revealed Resident # 60 was assisted to the outdoor courtyard in his wheelchair by Resident # 67, and he was wearing his smoking apron. Resident # 67 placed a cigarette in Resident # 60's mouth, lit the cigarette with a cigarette lighter, and left the courtyard. The cigarette stayed in Resident # 60's mouth while he smoked it. The resident was observed to smoke the cigarette without using his hands and no one holding the cigarette for him. When the resident finished smoking the cigarette, he turned his head to his left side and spit the cigarette butt to the ground. While he was smoking the cigarette, there was no staff supervision in the courtyard. Observation of Resident # 60 on 5/18/16 at 9:45 AM revealed Resident # 60 continued to sit in the courtyard in his wheelchair. Resident # 67 again placed a cigarette in Resident # 60's mouth and lit the cigarette with a cigarette lighter. Resident #67 was observed leaving the courtyard and Resident #60 unattended. The cigarette stayed in Resident # 60's mouth while he smoked it. Resident # 60 was observed to smoke the cigarette without using his hands and no one held the cigarette for him. When he finished smoking the cigarette, he turned his head to the left side and spit the cigarette butt onto the ground. There was no staff present for supervision while he was smoking. There were 5 cigarette butts noted to be on the concrete patio next to Resident # 60's wheelchair at that time. During an interview on 5/18/16 at 9:50 AM, Resident # 60 confirmed Resident # 67 had assisted him to the courtyard this morning and placed a cigarette in his mouth and lit the cigarette for him on 2 separate occasions and left him unattended in the courtyard on both occasions. He confirmed that he spit the lit, smoked, cigarette butts onto the ground when he finished smoking the cigarette. He confirmed that either a staff member or a resident would assist him to the courtyard each time he wanted to smoke, then someone would place the cigarette in his mouth and light the cigarette for him. Resident #60 stated that he could not physically hold the cigarette with his hands and that no one else held his cigarette for him while he was smoking. Resident #60 denied staff checking on him while he was in the courtyard smoking. Resident #60 stated that he called facility staff from his cell phone located in his groin area when he was ready to be assisted back into the facility. Resident #60 stated that his phone was set to speaker and he was able to hit one button on the phone with his hand since he could not hold the phone and he spoke to staff through the speaker. Interview on 5/18/16 at 12:20 PM with S9CNA revealed staff or another resident assists Resident # 60 to the courtyard when he wants to smoke. She stated the one that takes him out to smoke is the one that puts his smoking apron on him, places the cigarette in his mouth, and lights it. She stated no one held the cigarette for him, but that he kept the cigarette in his mouth the whole time he was smoking it. She stated Resident # 60 would turn his head to his side and spit the remainder of the lit, smoked cigarette butt out to the ground when he was finished. Interview on 5/18/16 at 12:28 PM with S16 Interim DON revealed Resident # 60 tells his CNA or calls on his call bell to notify someone when he wants to go outside to smoke. She stated the CNA would put his smoking apron on him and push his wheelchair outside to the courtyard. She stated that he sometimes would not notify staff prior to going outside with another resident, but the resident would place his smoking apron on him prior to taking him outside. She stated he was able to hold his hands in a way to maneuver his cigarette. She stated Resident #60 would put the cigarette on the ground when he finished it. She stated the facility did not have enough staff to supervise Resident # 60 while he was smoking, and that she would not consider him a safe smoker. Interview on 5/18/16 at 12:40 PM with S7 CCC confirmed she was the nurse that performed the safe smoking assessment for Resident # 60. She stated he had bilateral hand contractures and was quadriplegic. S7CCC confirmed her signatures on the Safe Smoking assessment dated [DATE] and confirmed she signed indicating she performed the Quarterly Updates of the Safe Smoking Assessment on 02/16/2016 and 05/17/2016 indicating Resident #60 ' s Safe Smoking Assessment was reviewed on those dates and he remained an unsafe smoker. She stated she was told by others that Resident # 60 had placed his cigarette in his mouth, but had not seen this. S7CCC confirmed when she signed his quarterly update on 05/17/2016 indicating he remained an unsafe smoker, staff should be following his plan of care which included holding the cigarette for Resident #60 while he smoked and ensuring his cigarettes were safely extinguished. During an interview on 5/18/16 at 1:05 PM, S2DON revealed the care plan filed in the chart was the one that staff has and it should be the current one that is followed. She confirmed that Resident #60's care plan included staff ensuring cigarettes were safely extinguished and holding his cigarette while he smoked. Interview on 5/18/16 at 3:20 PM with S28 CNA revealed she had seen ashes on Resident # 60's clothes before. On 5/18/16 at 3:20 PM a staff person accompanied the surveyor to the resident room to give access to the resident ' s clothes for observations. With the staff person present, an observation of Resident # 60's clothes that were hanging in his closet and clothes that were in his dresser drawers revealed the following: a pair of gray wind pants with a burn hole noted to the right thigh area; a gray tee shirt with a burn hole just above the pocket on the left chest area; a navy blue polo style shirt with a burn hole on the left upper chest area; a light blue striped polo style shirt with a burn hole on the back upper area of the left side; a black, long sleeved, fleece pullover shirt with a burn hole on the left arm; and a black and gray, long sleeved, fleece pullover shirt with a burn hole noted to the left upper chest area. Interview on 5/18/16 at 3:30 PM with Resident # 60 confirmed that he could not hold a cigarette with his hands. Interview on 5/19/16 at 3:26 PM with S16IDON (Interim Director of Nursing) revealed there was no policy and procedure on Accident Prevention. She stated the only policy regarding accidents was related to fall prevention. Resident #10 Review of the facility's MDS (Minimum Data Set) assessment for Resident #10 which had a reference date of 7/28/15, revealed she had [DIAGNOSES REDACTED]. Further review of the MDS revealed the facility had assessed Resident #10's functional status related to eating in Section G. Activities of Daily Living Assistance. H. Eating- how resident eats and drinks, regardless of skill . as 3/2. Three (3) indicating Extensive Assistance- resident involved in activity, staff provides weight-bearing support, and two (2) meaning one person physical assist. Review of the plan of care for Resident #10 revealed the facility care planned the physician order [REDACTED]. In addition the facility care planned Potential for Malnutrition, Dehydration, and Weight Loss on 5/12/14 which included for CNA staff to Cue and/or supervise dining . Review of S27LPN's nurse's note dated 10/6/15 at 9:48 PM read: At 7:30 PM notified by A Hall, CNA that resident reached to eat a cup of hot noodles when the hot cup tilted and spilled on her left forearm and left abdomen. Immediately assessed resident for any injury. Noted a blister to left inner forearm/left hand, and reddening to left abdominal region. Resident c/o (complained of) pain 10/10 at affected areas. Cool compresses are applied and (S24NP) is notified. NP (Nurse Practitioner) agreed that cool compressed and observation were necessary for these injuries . (SIC) Further review of the nurse's notes revealed that S22LPN documented on 10/7/15 at 1:52 PM, .Left hand, forearm & left abd (abdomen) noted blistered & red, PRN pain MED given . Review of S24NP's progress note dated 10/8/15 revealed, Diagnosis & Assessment: Second-[MEDICAL CONDITION] the top of the left hand and left lower quadrant of the abdomen- she spilled a bowl of hot soup on herself this weekend. Resulting in a second degree burn of the top left hand and left lower quadrant of her abdomen. She has an allergy to [MEDICATION NAME]'s we were unable to use Silverdene to help prevent infection. She is also allergic to [MEDICATION NAME] . I have ordered [MEDICATION NAME] 250mg qd (every day) for 7 days. Clean wound dly (daily) with sterile water. TAO oitn (ointment) to wounds. Light dressing to be changed daily. (SIC) During interview with S24NP on 5/19/16 at 2:45 PM, she confirmed her assessment and [DIAGNOSES REDACTED].#10's left hand and left lower quadrant of the abdomen. Review S31CNA's documentation of assistance and supervision she provided Resident #10 on 10/6/15 revealed she documented on the ADL (Activities of Daily Living) Assistance and Support record Eve (Evening) 1/0 (S31CNA ' s initials). The ADL Assistance and Support document revealed that 1/0 meant the following: ADL Self-Performance-1 (one) = Supervision-oversight, encouragement or cueing; ADL Support Provided- 0 (zero) = No set up or physical help from staff. In addition, S31CNA documented 1/0 again on the day after the incident 10/7/15. During an interview with S2DON on 5/19/16 at 9:15 AM, she confirmed that S31CNA documented 1/0 (Supervision/No setup or physical help from staff). She confirmed that according to S31CNA's documentation, S31CNA did not provide set up or physical help/assistance when eating to Resident #10 on 10/6/15. S2DON reported she did not have documented evidence of having retrained staff or performed quality assurance monitoring post incident. During a telephone interview with S31CNA on 5/19/16 at 9:45 AM, she confirmed that she was the CNA (Certified Nursing Assistant) assigned and working with Resident #10 on 10/6/15 at the time Resident #10 was burned. She stated Resident #10 asked for her food, so she (S31CNA) warmed up the soup and brought it to Resident #10's room. S31CNA stated, I told her it was hot and showed her the steam; I left her room to answer a call bell in another resident's room for about 10-15 minutes; when I returned to her room she was crying and had spilled her soup on her arm, hand, and her stomach . I asked her if she was burned and she said yes. S31CNA stated that The resident was not on feeding assistance at the time of the incident. During an interview on 5/19/16 at 11:10 AM, Resident #10 revealed she communicated via her cell phone using her left hand. Observation of Resident #10 at this time revealed her right hand was splinted and she was unable to move it. She typed with her left hand, using one finger, and demonstrated to surveyor how she could only reach towards her right side ½ ways across her body with her left hand/arm. Resident #10 confirmed she was burned with hot soup while she attempted to eat the soup. She reported the cup of soup was full and she could not see into the top of the cup and it spilled on her. She reported that no one was in the room at the time the soup spilled to assist her. She reported the CNA left her room to see about another resident. She reported she was crying and yelling, and punched her call bell at the time of the incident, but it took 10-15 minutes for the CNA to return. Further observation on 5/23/16 at 1:45 PM of Resident #10 revealed red/pink scarring in areas to Resident #10's left wrist/hand and left lower abdominal area.

Based on observation, record review, and interview the facility failed to ensure that residents received adequate supervision to prevent accidents for 1 (# 60) of 4 (# 4, #9, #45,#60) residents identified by the facility as an unsafe smoker out of a total of 4 residents identified as unsafe smokers and to a resident left unattended after being served a bowl of hot soup for 1 (#10 ) of 6 ( #6, #10, #18, #19, #23, #45 #62) residents reviewed for assistance with feeding. The Immediate Jeopardy (IJ) situation began on 5/18/16 at 9:05 AM when Resident # 60, a Quadriplegic, was observed in the courtyard unsupervised by staff and Resident #67 placed a cigarette in Resident #60 ' s month. Resident # 67 lit the cigarette, and left the courtyard. On 11/4/15 the facility had assessed resident #60 as being unable to demonstrate safe technique for putting out the matches or a lighter, disposing of ash, and unable to hold his cigarette. On 5/18/16 at 9:45 AM, Resident # 60 was observed still sitting in the smoking area unsupervised by staff, when Resident #67 put a cigarette in his month and lit it. Resident #67 left the resident there smoking alone. On 10/6/15, an actual harm occurred when Resident #10, who was assessed by the facility as requiring extensive assistance and one person physical assist in functional status for eating was served her food tray by the CNA. Resident #10 asked the CNA to warm up the soup. The CNA warmed the soup, and brought it to Resident #10's room set it in front of her, and told her it was hot. The CNA said she left her room to answer a call bell in another resident's room for about 10-15 minutes. During the time the CNA was out of the room Resident #10 attempted to eat the soup and it spilled on her. Resident #10 sustained Second-Degree Burns to the top of the left hand, left forearm, and left lower quadrant of the abdomen after spilling a bowl of hot soup on her when she was left unattended by staff. On 5/18/16 at 4:04 PM, the survey team notified S1 ADMN (Administrator) and S14CorpRN (Corporate Registered Nurse) of the IJ situation that currently existed in the facility. The facility provided a plan of removal that included the following: Problem: (Resident #60) observed by surveyor twice on 05-18-16 outside smoking and not following smoking plan. Intervention: 1. All staff on all shifts in-serviced starting at 4:30 PM on 5/18/16 and continuing until all staff has been completed on the following: smoking plans for residents, the newly implemented smoking times and staff observation for unsafe smokers, and what to do if a resident is observed smoking unsafely. 2. A list of all the smokers and their individual plans for smoking is now posted behind the nurses ' station door and also kept in the smoking box at the nurses ' station. 3. Identified unsafe smokers, # 60, #4, and #9 (currently hospitalized ), and #45 (also currently hospitalized ) will have their cigarettes kept in the smoking box at the nurses station and will have cigarettes passed out to them, and be observed/assisted by a staff member, at the designated smoking times for unsafe smokers (every two hours from 9 AM-7 PM daily). These residents had this smoking plan reviewed with them and have signed an agreement with this plan. 4. A meeting was held with all the facility smokers by the social worker on 5-18-16 at 4:30 PM and explained to them that sharing of cigarettes and lighters or lighting other resident's cigarettes will not be tolerated. If a resident is observed lighting another resident's cigarette the administrator is to be informed and the resident doing the lighting of the cigarette will be considered an unsafe smoker with smoking paraphernalia being taken away. Current safe smokers are still allowed to smoke at time of their choosing. The smoking residents all signed the in-service sheet indicating their presence at the meeting. 5. All residents who smoke have had their smoking assessments and care plans reviewed and updated, if necessary, to reflect current individualized smoking abilities and plans. 6. Smoking orders have been reviewed and updated, if necessary, to reflect the current individualized smoking plans. 7. All residents who smoke have had their clothing and wheelchairs, if applicable, checked for burn holes. Monitoring: 1. Monitoring of this corrective action will be completed by administration observing the smoking area randomly during designated smoking times to assure that the smoking plan for unsafe smokers is being followed by both the residents and the staff. This will occur 5 times a week for 6 weeks and then monthly thereafter until compliance is maintained. 2. Residents who smoke will have their smoking assessment, care plan, and order reviewed and updated, if necessary, if their smoking safety or ability changes and at a minimum with each staffing to reflect any changes or need for staff observation. Nursing administration will monitor the care plan, smoking assessment, and order for smoking on each resident as they come up due for staffing. This will occur weekly until all the smoking residents have been staffed and then monthly thereafter until compliance is maintained. 3. Monitoring of the list of residents who smoke for accuracy will be completed by nursing administration reviewing the list behind the nurse's station door and in the smoking box weekly for 6 weeks and then monthly thereafter until compliance is maintained. The immediate jeopardy was removed on 5/20/2016 at 2:17 PM. The deficient practice remains at a level of actual harm for resident #10. Findings: Review of the facility's Smoking Policy revealed (in part): .it may be necessary to place smoking restrictions on individual residents because of safety and medical reasons. Should this become necessary, such information will be noted on the resident's care plan. DO NOT allow residents who have been classified as NON-RESPONSIBLE to smoke alone. Resident #60. Review of Resident # 60's May 2016 Physician order [REDACTED]. Further review of the physician orders [REDACTED]. Review of the Safe Smoking assessment dated [DATE] for Resident #60 and signed by the former CCC (Clinical Care Coordinator) and S7CCC reflected the resident cannot light and smoke a cigarette or other smoking device while demonstrating safe technique for putting out the matches or lighter and disposing of ash. The assessment further reflected the resident was not able to physically hold the smoking device while smoking. Resident #60's Safe Smoking Assessment form dated 11/4/15 revealed: Current Smoking Plan for this resident is as follows: Resident is alert. He can't hold his cigarettes. He is a Quadriplegic. Has smoking apron for prevention of cig (cigarette) burns in clothes. According to the description of a safe smoker on the Safe Smoking Assessment form, Resident # 60 was not assessed as a safe smoker. The Safe Smoking Assessment was completed upon admit and was reviewed quarterly and if any part of the assessment changed, a new assessment was required. Quarterly Update of the Safe Smoking Assessment was signed by S7CCC on 02/16/2016 and 05/17/2016 indicating Resident #60's Safe Smoking Assessment was reviewed on those dates and he remained an unsafe smoker. Review of Resident # 60's Care Plan filed in his clinical record reflected the resident was at potential for injury related to smoking. Goal: Will follow the designated smoking plan. Target Date: 08/31/2016. Approaches for this problem included (in part): ensure cigarettes are safely extinguished; hold cigarette for resident while smoking, and smoking apron to be worn to prevent cigarette burns to clothes. During an interview on 5/16/16 at 2:04 PM, Resident #60 was observed sitting in his wheelchair in the Courtyard. He was wearing a smoking apron and Resident #60 had contractures to both hands. Resident #60 stated that he was a smoker and that he wore the smoking apron while smoking to prevent burning himself. He stated that due to his quadriplegia and contractures to both hands, the staff was supposed to place his cigarette in his mouth and he smoked it until he had completed the cigarette. He stated he then would spit the cigarette out on the ground. He was not smoking at the time of this observation and interview. Observation on 5/18/16 at 9:05 AM revealed Resident # 60 was assisted to the outdoor courtyard in his wheelchair by Resident # 67, and he was wearing his smoking apron. Resident # 67 placed a cigarette in Resident # 60's mouth, lit the cigarette with a cigarette lighter, and left the courtyard. The cigarette stayed in Resident # 60's mouth while he smoked it. The resident was observed to smoke the cigarette without using his hands and no one holding the cigarette for him. When the resident finished smoking the cigarette, he turned his head to his left side and spit the cigarette butt to the ground. While he was smoking the cigarette, there was no staff supervision in the courtyard. Observation of Resident # 60 on 5/18/16 at 9:45 AM revealed Resident # 60 continued to sit in the courtyard in his wheelchair. Resident # 67 again placed a cigarette in Resident # 60's mouth and lit the cigarette with a cigarette lighter. Resident #67 was observed leaving the courtyard and Resident #60 unattended. The cigarette stayed in Resident # 60's mouth while he smoked it. Resident # 60 was observed to smoke the cigarette without using his hands and no one held the cigarette for him. When he finished smoking the cigarette, he turned his head to the left side and spit the cigarette butt onto the ground. There was no staff present for supervision while he was smoking. There were 5 cigarette butts noted to be on the concrete patio next to Resident # 60's wheelchair at that time. During an interview on 5/18/16 at 9:50 AM, Resident # 60 confirmed Resident # 67 had assisted him to the courtyard this morning and placed a cigarette in his mouth and lit the cigarette for him on 2 separate occasions and left him unattended in the courtyard on both occasions. He confirmed that he spit the lit, smoked, cigarette butts onto the ground when he finished smoking the cigarette. He confirmed that either a staff member or a resident would assist him to the courtyard each time he wanted to smoke, then someone would place the cigarette in his mouth and light the cigarette for him. Resident #60 stated that he could not physically hold the cigarette with his hands and that no one else held his cigarette for him while he was smoking. Resident #60 denied staff checking on him while he was in the courtyard smoking. Resident #60 stated that he called facility staff from his cell phone located in his groin area when he was ready to be assisted back into the facility. Resident #60 stated that his phone was set to speaker and he was able to hit one button on the phone with his hand since he could not hold the phone and he spoke to staff through the speaker. Interview on 5/18/16 at 12:20 PM with S9CNA revealed staff or another resident assists Resident # 60 to the courtyard when he wants to smoke. She stated the one that takes him out to smoke is the one that puts his smoking apron on him, places the cigarette in his mouth, and lights it. She stated no one held the cigarette for him, but that he kept the cigarette in his mouth the whole time he was smoking it. She stated Resident # 60 would turn his head to his side and spit the remainder of the lit, smoked cigarette butt out to the ground when he was finished. Interview on 5/18/16 at 12:28 PM with S16 Interim DON revealed Resident # 60 tells his CNA or calls on his call bell to notify someone when he wants to go outside to smoke. She stated the CNA would put his smoking apron on him and push his wheelchair outside to the courtyard. She stated that he sometimes would not notify staff prior to going outside with another resident, but the resident would place his smoking apron on him prior to taking him outside. She stated he was able to hold his hands in a way to maneuver his cigarette. She stated Resident #60 would put the cigarette on the ground when he finished it. She stated the facility did not have enough staff to supervise Resident # 60 while he was smoking, and that she would not consider him a safe smoker. Interview on 5/18/16 at 12:40 PM with S7 CCC confirmed she was the nurse that performed the safe smoking assessment for Resident # 60. She stated he had bilateral hand contractures and was quadriplegic. S7CCC confirmed her signatures on the Safe Smoking assessment dated [DATE] and confirmed she signed indicating she performed the Quarterly Updates of the Safe Smoking Assessment on 02/16/2016 and 05/17/2016 indicating Resident #60's Safe Smoking Assessment was reviewed on those dates and he remained an unsafe smoker. She stated she was told by others that Resident # 60 had placed his cigarette in his mouth, but had not seen this. S7CCC confirmed when she signed his quarterly update on 05/17/2016 indicating he remained an unsafe smoker, staff should be following his plan of care which included holding the cigarette for Resident #60 while he smoked and ensuring his cigarettes were safely extinguished. During an interview on 5/18/16 at 1:05 PM, S2DON revealed the care plan filed in the chart was the one that staff has and it should be the current one that is followed. She confirmed that Resident #60's care plan included staff ensuring cigarettes were safely extinguished and holding his cigarette while he smoked. Interview on 5/18/16 at 3:20 PM with S28CNA revealed she had seen ashes on Resident # 60's clothes before. On 5/18/16 at 3:20 PM a staff person accompanied the surveyor to the resident room to give access to the resident ' s clothes for observations. With the staff person present, an observation of Resident # 60's clothes that were hanging in his closet and clothes that were in his dresser drawers revealed the following: a pair of gray wind pants with a burn hole noted to the right thigh area; a gray tee shirt with a burn hole just above the pocket on the left chest area; a navy blue polo style shirt with a burn hole on the left upper chest area; a light blue striped polo style shirt with a burn hole on the back upper area of the left side; a black, long sleeved, fleece pullover shirt with a burn hole on the left arm; and a black and gray, long sleeved, fleece pullover shirt with a burn hole noted to the left upper chest area. Interview on 5/18/16 at 3:30 PM with Resident # 60 confirmed that he could not hold a cigarette with his hands. Interview on 5/19/16 at 3:26 PM with S16 Interim DON revealed there was no policy and procedure on Accident Prevention. She stated the only policy regarding accidents was related to fall prevention. Resident #10 Review of the facility's MDS (Minimum Data Set) assessment for Resident #10 which had a reference date of 7/28/15, revealed she had [DIAGNOSES REDACTED]. Further review of the MDS revealed the facility had assessed Resident #10's functional status related to eating in Section G. Activities of Daily Living Assistance. H. Eating- how resident eats and drinks, regardless of skill . as 3/2. Three (3) indicating Extensive Assistance- resident involved in activity, staff provides weight-bearing support, and two (2) meaning one person physical assist. Review of the plan of care for Resident #10 revealed the facility care planned the physician order [REDACTED]. In addition the facility care planned Potential for Malnutrition, Dehydration, and Weight Loss on 5/12/14 which included for CNA staff to Cue and/or supervise dining . During an interview with S16RN/IDON on 5/18/16 at 8:04 AM, she reported that an incident had occurred on 10/6/15 related to a burn, and she presented copy of the investigation report and nurse's notes. Review of the incident report dated 10/6/15, prepared and signed by S27LPN, revealed the following in part: Incident Type: Burn-direct heat exp; Type of Injury: 2nd degree burn; Location: Resident's room; Equipment: Bed-electric; Activity at time: Reaching; Incident Reported by: (S31CNA); Reported to Supervisor: Yes; Date/Time: 10/06/15 07:30 PM; Narrative of incident and description of injuries: Notified by A hall, CNA that resident reached to eat a cup of hot noodles when the hot cup titled and spilled on her left forearm and left abdomen. Noted a 4 in. long x 2 1/2 in. wide blister to left inner forearm, small 1/2 in. blisters to left hand, and reddened area to left abdominal region. Immediate Actions Taken: Immediately assessed for injury, vitals obtained, cool compresses applied to affected areas . (SIC) Review of S27LPN's nurse's note dated 10/6/15 at 9:48 PM read: At 7:30 PM notified by A hall, CNA that resident reached to eat a cup of hot noodles when the hot cup tilted and spilled on her left forearm and left abdomen. Immediately assessed resident for any injury. Noted a blister to left inner forearm/left hand, and reddening to left abdominal region. Resident c/o (complained of) pain 10/10 at affected areas. Cool compresses are applied and (S24NP) is notified. NP (Nurse Practitioner) agreed that cool compressed and observation were necessary for these injuries . (SIC) Further review of the nurse's notes revealed that S22LPN documented on 10/7/15 at 1:52 PM, .Left hand, forearm & left abd (abdomen) noted blistered & red, PRN pain MED given . Review of S24NP's progress note dated 10/8/15 revealed, Diagnosis & Assessment: Second-degree burns to the top of the left hand and left lower quadrant of the abdomen- she spilled a bowl of hot soup on herself this weekend. Resulting in a second degree burn of the top left hand and left lower quadrant of her abdomen. She has an allergy to sulfur's we were unable to use Silverdene to help prevent infection. She is also allergic to penicillins . I have ordered Levaquin 250 mg qd (every day) for 7 days. Clean wound dly (daily) with sterile water. TAO oitn (ointment) to wounds. Light dressing to be changed daily. (SIC) During interview with S24NP on 5/19/16 at 2:45 PM, she confirmed her assessment and [DIAGNOSES REDACTED].#10's left hand and left lower quadrant of the abdomen. Review S31CNA's documentation of assistance and supervision she provided Resident #10 on 10/6/15 revealed she documented on the ADL (Activities of Daily Living) Assistance and Support record Eve (Evening) 1/0 (S31CNA's initials). The ADL Assistance and Support document revealed that 1/0 meant the following: ADL Self-Performance-1 (one) = Supervision-oversight, encouragement or cueing; ADL Support Provided- 0 (zero) = No set up or physical help from staff. In addition, S31CNA documented 1/0 again on the day after the incident 10/7/15. During an interview with S2DON on 5/19/16 at 9:15 AM, she confirmed that S31CNA documented 1/0 (Supervision/No setup or physical help from staff). She confirmed that according to S31CNA's documentation, S31CNA did not provide set up or physical help/assistance when eating to Resident #10 on 10/6/15. S2DON reported she did not have documented evidence of having retrained staff or performed quality assurance monitoring post incident. Review of an In-Service documented on 1/19/16 revealed discussions of accuracy of the ADL documentation system and encouraging residents to drink fluids and assist those not eating well. The in-service did not include education and training in accident prevention specific to supervision and assistance as needed to prevent accidents while eating hot foods. During a telephone interview with S31CNA on 5/19/16 at 9:45 AM, she confirmed that she was the CNA (Certified Nursing Assistant) assigned and working with Resident #10 on 10/6/15 at the time Resident #10 was burned. She stated Resident #10 asked for her food, so she (S31CNA) warmed up the soup and brought it to Resident #10's room. S31CNA stated, I told her it was hot and showed her the steam; I left her room to answer a call bell in another resident's room for about 10-15 minutes; when I returned to her room she was crying and had spilled her soup on her arm, hand, and her stomach . I asked her if she was burned and she said yes. S31CNA stated that the resident was not on feeding assistance at the time of the incident. During an interview on 5/19/16 at 11:10 AM, Resident #10 revealed she communicated via her cell phone using her left hand. Observation of Resident #10 at this time revealed her right hand was splinted and she was unable to move it. She typed with her left hand, using one finger, and demonstrated to surveyor how she could only reach towards her right side ½ ways across her body with her left hand/arm. Resident #10 confirmed she was burned with hot soup while she attempted to eat the soup. She reported the cup of soup was full and she could not see into the top of the cup and it spilled on her. She reported that there was no one in the room at the time the soup spilled, to assist her. She reported the CNA left her room to see about another resident. She reported she was crying and yelling, and punched her call bell at the time of the incident, but it took 10-15 minutes for the CNA to return. Further observation on 5/23/16 at 1:45 PM of Resident #10 revealed red/pink scarring in areas to Resident #10's left wrist/hand and left lower abdominal area. S16IDON reported on 5/19/16 at 3:30 PM that the facility had no policy for accident prevention. She presented the facility's policy for Feeding A Resident which revealed no measures staff were to take for residents at risk for injury during feeding, and it did not address supervision and assistance as needed to prevent accidents while eating.