Every finding on record at Spring View Nursing & Rehabilitation

Based on interview, record review and review of the facility's investigations, documentation, and policy, the facility failed to ensure its licensed staffs' competencies included active Cardiopulmonary Resuscitation (CPR) certifications for 11 of 11 licensed nursing staffs' personnel files reviewed. On [DATE], staff found R71 unresponsive and without pulse or respirations. R71 had a Full Code status; however, staff failed to attempt and provide lifesaving measures. Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator was provided a copy of the CMS Immediate Jeopardy Template on [DATE] at 11:32 AM and notified the facility's failure to ensure its licensed staffs' CPR certifications were current was likely to cause serious injury, impairment, or death and constituted IJ. IJ was identified at 42 CFR S483.35 Nursing Services, F726, and determined to exist on [DATE], at a highest Scope and Severity (S/S) of L. The facility provided an acceptable IJ Removal Plan on [DATE]. The plan alleged removal of the IJ, and the deficient as of [DATE]. An Extended and IJ Removal Validation Survey was conducted on [DATE], and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on [DATE]. The SSA validated the immediacy of the IJ as removed on [DATE], as alleged. (Refer to F678)The findings include: Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), revised [DATE], revealed the facility was to adhere to residents' rights to formulate advance directives. Per review, the facility would also implement guidelines regarding CPR including CPR certified staff to always be available. Further review revealed staff were to maintain current CPR certifications for healthcare providers through a CPR provider who evaluated proper technique through in-person demonstration of skills. Review of the facility's Registered Nurse (RN), and Licensed Practical Nurse (LPN) Job Descriptions updated [DATE], revealed they must have a current/active CPR certification. Review of the Certified Nurse Aide (CNA) job description dated 12/2018, revealed a current/active CPR certification was preferred for CNAs. Review of R71's Face Sheet revealed the facility admitted the resident on [DATE], with diagnoses of transient ischemic attack (TIA/stroke), cerebral infarction without residual deficits, old myocardial infarction. Further record review revealed the facility discharged R71 due to her death in the facility on [DATE]. Review of the Advanced Directives Comprehensive Care Plan for R71, initiated on [DATE] and revised on [DATE], revealed the resident had a Full Code Status. Further review revealed the interventions included to administer CPR if the resident was found without pulse or respirations. Review of the Kentucky Living Will Directive for R71, dated [DATE], revealed it had been signed by the resident, and the resident's wishes were for life-prolonging treatment not to be withheld or withdrawn. Review of a physician's order, dated [DATE], revealed R71's Code Status was noted as Full Code. Review of the progress note, documented by Licensed Practical Nurse 1 (LPN1), dated [DATE] at 3:15 AM, revealed the nurse had been called to R71's room. Per review, the LPN found the resident with no pulse, respirations, or signs of life. LPN1 did not initiate CPR. Review of 11 out of 11 licensed staffs' personnel records reviewed revealed their CPR certifications were not up to date. The licensed staff included: Registered Nurse (RN) R1, RN2, the Director of Nursing (DON); Licensed Practical Nurse (LPN) LPN1, LPN2, LPN4, LPN6, LPN7, LPN8, LPN9 and LPN10. 1) RN 1 received her CPR certification on [DATE]. 2) RN 2 received her CPR certification on [DATE]. 3) The DON received her CPR certification on [DATE]. 4) LPN 1 received her CPR certification on [DATE]. 5) LPN 4 received her CPR certification on [DATE]. 6) LPN 10 received her CPR certification on [DATE]. 7) LPN 6 received her CPR certification on [DATE]. 8) LPN 7 received her CPR certification on [DATE]. 9) LPN 2 received her CPR certification on [DATE]. 10) LPN 8 received her CPR certification on [DATE]. 11) LPN 9 received her CPR certification on [DATE]. Additional record reviews revealed no documented evidence of prior CPR certifications for the above licensed staff. In interview on [DATE] at 7:45 PM, Licensed Practical Nurse (LPN) stated she received CPR training in [DATE]. However, she stated she could not recall if she had an active CPR certification at the time of R71's death ([DATE]). In interview on [DATE] at 4:25 PM, the Director of Nursing (DON) stated she had been the former Assistant Director of Nursing (ADON) at the time of R71's death. She stated she had been working the evening shift on [DATE]. She further stated she did not initiate CPR due to R71's condition; however, typically a resident with a full code status should have had CPR initiated. In addition, the DON stated she started at the facility about a year ago and was not certified in CPR until [DATE]. In interview on [DATE] at 4:14 PM, the Staff Development Coordinator (SDC) stated she was responsible to ensure staff were CPR certified. She stated most of the nurses should be CPR certified; however, there might be a couple whose CPR had expired, and she had been working on that. Additionally, she further stated she expected staff to follow the facility's policy and orders when CPR was to be performed. In an interview on [DATE] at 9:25 AM, the Staff Development Coordinator stated, When I started this position 4-5 years ago, the Administrator told me it was not required for licensed staff to have an active CPR certification. She stated she had not questioned the Administrator when he told her it was not required, and she did not question it any further. She stated it was in the facility's job descriptions for licensed and certified staff to be CPR certified, and she knew they were supposed to have that certification. In interview on [DATE] at 4:48 PM, the Administrator stated he expected the facility to have proper monitoring of which staff were certified in CPR. He stated that was a responsibility as a licensed nurse. The Administrator stated he had instructed the SDC that the facility should have licensed and certified staff active in their CPR certifications. However, a certified Nurse Aide (CNA) was preferred to have CPR, but it was not a requirement. The Administrator stated there should have been better communication about the requirements of CPR certifications among the staff. He stated knowing if staffs' CPR certifications were active or not was not something he personally tracked on his own; however, it was also a requirement of the facility. In addition, the Administrator stated he should have been overseeing staffs' CPR certifications, and he would be doing that going forward.

Based on interview, record review and review of the facility's policy, the facility failed to ensure the physician was immediately notified of a significant change in a resident's status for 1 of 40 sampled residents, (Resident (R)71). R71 who was full code expired at the facility. Staff failed to initiate CPR and failed to immediately notify the physician.Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template on [DATE] at 11:32 AM and notified that the facility's failure to ensure immediate physician notification of a change was made was likely to cause serious injury, impairment, or death and constituted IJ. IJ was identified at 42 CFR S483.210, Notify of Changes, F580, and was determined to exist on [DATE], at a highest Scope and Severity (S/S) of J. The facility provided an acceptable IJ Removal Plan on [DATE]. The plan alleged the IJ was removed on [DATE]. An Extended and IJ Removal Validation Survey was conducted on [DATE]. The State Survey Agency (SSA) validated the facility's IJ Removal Plan on [DATE]. The SSA validated the immediacy of the IJ had been removed on [DATE], as alleged. The findings include: Review of the facility's policy titled, Notification of Changes, reviewed 02/2025, revealed the facility would promptly inform the resident, consult the resident's physician, and notify the resident's representative when there was a change requiring notification. Further review revealed in an instance of death, the resident's physician was to be notified immediately in accordance with State law. Review of R71's Face Sheet revealed the facility admitted the resident on [DATE]. R71's diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, and old myocardial infarction. Resident 71 expired in the facility on [DATE] Review of the progress note dated [DATE] at 1:57 AM, revealed R71 was abed (staying in bed) with no complaints. The resident's vitals were within normal limits (WNL). Review of the progress note dated [DATE] at 3:15 AM, documented by Licensed Practical Nurse (LPN) 1, revealed the nurse noted going to R71's room and finding the resident with no pulse, respirations, or signs of life. Per review, R71's emergency contact was at the bedside (Resident 2). She stated she did not want any attempts at that time for cardiopulmonary resuscitation (CPR), as the resident had passed peacefully in her sleep. Further review revealed the Nurse Practitioner (NP) was made aware of R71's passing. During interview with R2 (R71's roommate) on [DATE] at 3:45 PM, she stated she was R71's emergency contact. She stated R71 had been sick with pneumonia and they just couldn't get her well. R2 stated she had been awake all hours of the night and morning and at some point, that morning she had woke up and noticed R71 was gone. She stated she pushed her call light, and staff came in the room. R2 further stated she could not remember who all was in the room or what they did because she had been so upset. During interview with the Regional Support Nurse (RSN) on [DATE] at 3:59 PM, she stated she had been the former Unit Manager (UM) at the facility. She stated when she was the UM and arrived at work, she reviewed any events from the previous day and made any needed notifications if they had not been done. The RSN further stated she notified the NP of R71's death after she began her shift on [DATE], so the resident's chart could be closed. During interview with the Director of Nursing (DON) on [DATE] at 4:25 PM, she stated she had been the former Assistant Director of Nursing (ADON). She reported she had been working the evening shift on [DATE]; however, had not been assigned to R71's hall. The DON stated she believed Certified Medication Technician (CMT) 2 had told her the 100-hall nurse needed help. She explained she went to R71's room and the resident was blue, purple, and hard. The DON stated she asked LPN1 what the resident's code status was; however, she felt R71 was too far gone and it was not right to do CPR at that point. She stated she notified the former DON of R71's passing. The DON stated she did not notify the physician since she was not assigned to R71. She stated the nurse assigned to the resident would be the one responsible to notify the physician. During interview with the NP on [DATE] at 5:06 PM, she stated the former UM notified her of R71's death shortly after she arrived at the facility on [DATE]. She stated staff were supposed to notify her or the on-call physician of a resident's death immediately or shortly after it occurred. During interview with LPN 1 on [DATE] at 7:45 PM, she stated R71 had been diagnosed with pneumonia and some other illnesses recently. She stated a Certified Nursing Assistant (CNA) had told her R71 was non-responsive. LPN1 stated going to R71's room and the resident was cold, blue and rigor mortis had started to set in. She stated there were no signs of life for R71. The LPN explained she could not recall who called to notify the physician; however, if she documented having done that, then she should have done what she documented. She further stated staff were supposed to call the physician with any change to a resident when the change occurred. During interview with the Medical Director on [DATE] at 10:36 AM, he stated he expected that he or the NP would be notified immediately when a resident passed away. He further stated he did not remember R71, or whether he had been notified of her death. During an additional interview with the NP on [DATE] at 8:35 AM, she stated she did not give 100 percent accurate information during her first interview. She stated LPN 1 had notified her via a text message on [DATE] at 4:51 AM, (one hour and 36 minutes after the resident's death). The NP stated she would expect to be notified immediately of a resident's death. During interview with the Administrator on [DATE] at 4:48 PM, he stated he expected staff to notify the physician or on-call NP immediately after a resident's death.

Based on interview, record review and review of the facility's policy, the facility failed to ensure the care plan was implemented for one of thirty-three sampled residents, Resident 71 (R71).Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR S483.10 Notification of Changes at the scope and severity (S/S) of a J, 42 CFR 483.21 Comprehensive Care Plans, 42 CFR 483.24 CPR, and 42 CFR 483.35 Nursing Services, at the S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.24 On [DATE], at 11:32 AM the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents' comprehensive person-centered care plans were implemented was likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.210 at F580. The IJ at F678 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25, Quality of Care. The IJ was determined to exist on [DATE]. R71 was care planned as a Full Code Status with interventions that included to administer Cardio-Pulmonary Resuscitation (CPR). However, the facility failed to provide the CPR. The facility provided an acceptable IJ Removal Plan on [DATE]. The IJ Removal Plan alleged the IJ was removed on [DATE]. The SSA validated the facility's IJ Removal Plan on [DATE]. The SSA validated the immediacy of the IJ had been removed on [DATE], as alleged. (Refer to F678)The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised [DATE], revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs. Review of R71's Face Sheet revealed the facility admitted the resident on [DATE]. R71's diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, and old myocardial infarction. R71 expired at facility on [DATE]. Review of an Advanced Directives Comprehensive Care Plan, initiated on [DATE] and revised on [DATE], revealed R71 was a Full Code Status. Interventions included to administer CPR if the resident was found without pulse or respirations. Review of a progress note dated [DATE] at 3:15 AM, revealed Licensed Practical Nurse (LPN) 1 was called to R71's room. LPN1 found R1 with no pulse, respirations, or signs of life. The resident's emergency contact (Resident 2) was at the bedside and stated she did not want any attempts at this time for resuscitation. During an interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 7:45 PM, she stated she was assigned to R71 on [DATE]. She stated when she entered R71's room, the resident was blue, cold, and rigor mortis had started to set in. She stated R71 had no signs of life. LPN1 stated R71 was a full code; however, she did not perform CPR or follow R71's care plan or Advanced Directive. LPN 1 stated a resident's code status could be found in the code binder located on the crash cart, in the resident's care plan, and on their face sheet. LPN 1 stated that she and the former ADON/current DON assessed R71 and believed she was too far gone to start CPR even though they were aware of the resident's full code status. During an interview with the Regional Support Nurse on [DATE] at 3:59 PM, she stated she was the former Unit Manager at the facility. She stated if a resident was assessed to have a Full Code Status, she would expect CPR to have been initiated. She stated it would not be acceptable for an emergency contact to give a verbal order to withhold CPR if the resident's wishes were to have CPR performed. She stated that was not the facility's policy. She stated the resident's wishes and the resident's care plan should be followed. During an interview with the Nurse Practitioner (NP) on [DATE] at 5:06 PM, she stated if a resident had a full code status and they were found unresponsive, she would expect CPR to be initiated. She stated she was always taught that if a resident was a full code, you do CPR until Emergency Management Services (EMS) arrived. She stated even if the emergency contact stated they did not want CPR done; she would expect the facility staff to initiate CPR as the resident wishes stated. During an interview with the Medical Director on [DATE] at 10:36 AM, he stated he expected staff to initiate CPR on a resident if they were a full code. During a second interview with the Director of Nursing (DON) on [DATE] at 4:21 PM, she stated she expected staff to follow every resident's care plan interventions. The DON also stated it was important for resident information to be on the care plan, so every staff member knew what they were supposed to do. During an interview with the Administrator on [DATE] at 4:48 PM, he stated he expected staff to follow care plan interventions and code statuses as per physician orders. He stated her expectation was for care plans to be comprehensive and resident centered. He stated accurate care plans were important, so staff knew how to provide appropriate care for each resident.

Based on interview, record review and review of the facility's policy, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated for 1 of 33 sampled residents, (Resident (R)71). Staff found R71 on [DATE] without pulse or respirations and unresponsive by staff. Resident was a Full Code status; however, no lifesaving measures were attempted. On [DATE], at 11:32 AM the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified the failure to ensure residents were provided CPR was likely to cause serious injury, impairment, or death. This failure constituted IJ at 42 CFR 483.24 F678, 42 CFR 483.10 F580, 42 CFR 483.21 F656, and 42 CFR 483.35 F726. The IJ at F678 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.24, Quality of Care. The IJ was determined to exist on [DATE], when R71 was found without pulse or respiration and CPR was not initiated.The facility provided an acceptable IJ Removal Plan on [DATE]. The plan alleged the IJ was removed on [DATE]. An Extended Survey and IJ Removal Validation was conducted on [DATE]. The State Survey Agency (SSA) validated the facility's IJ Removal Plan on [DATE]. The SSA validated the immediacy of the IJ had been removed on [DATE], as alleged. The findings include: Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), revised [DATE], revealed the facility would adhere to residents' rights to formulate advance directives. In accordance with these rights, the facility would implement guidelines regarding CPR. The policy further stated staff would maintain current CPR certification for healthcare providers. Review of R71's Face Sheet revealed the facility admitted the resident on [DATE]. with diagnoses that included: atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of transient ischemic attack (TIA/stroke), cerebral infarction without residual deficits, and old myocardial infarction. Resident 71 expired in the facility on [DATE]. Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the facility assessed R71 to have a Brief Interview for Mental Status (BIMS) score of a 13 out of 15. This score indicated the resident was cognitively intact. Review of a Physician's Order, dated [DATE], revealed an order for R71 to be a Full Code Status. Review of an Advanced Directives Comprehensive Care Plan that was initiated on [DATE] and revised on [DATE], revealed R71 was a Full Code Status. Interventions included to administer CPR in the event that the resident was found without pulse or respirations. Review of a Kentucky Living Will Directive, dated [DATE], signed by R71, revealed the resident's wishes were for life-prolonging treatment not to be withheld or withdrawn. Review of a Physician's Order, dated [DATE], revealed R71's Code status was Full Code. Review of R2's (R71's Emergency Contact) Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses that included atrial fibrillation and bipolar I disorder. Review of a Quarterly MDS with an ARD of [DATE] revealed the facility assessed R2 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This score indicated the resident was cognitively intact. Review of a progress note dated [DATE] at 3:15 AM, revealed Licensed Practical Nurse (LPN) 1 was called to R71's room. LPN1 found the resident with no pulse, respirations, or signs of life. The resident's emergency contact (Resident2) was at the bedside. R2 informed the staff, that she did not want any attempts at this time for resuscitation. The emergency contact stated the resident passed peacefully in her sleep. During an interview with R2 on [DATE] at 3:45 PM, she stated she was the emergency contact for R71. She stated R71 had been sick with pneumonia, and they just could not get her well. R2 stated she was awake all hours of the night and morning and at some point, that morning she had woke up and noticed R71 was gone (had passed). She stated she pushed her call light staff came in the room. R2 stated she could not remember who all was in the room or what they did because she was so upset. R2 stated R71 was her best friend and their families were estranged. During an interview with Certified Nursing Assistant (CNA) 6 on [DATE] at 7:10 PM, she stated while rounding on the morning of [DATE], she entered R71's room and noticed the resident was blue, her hand was cold, her mouth was starting to become stiff, and her chest was not rising. CNA 6 stated she yelled for help. She stated CNA 5 came into the room and immediately left to get the nurse. She stated Licensed Practical Nurse (LPN) 1 came to R71's room and said the resident was too far gone to perform CPR. She stated they were aware that R71 was a full code and could find that information in the electronic medical record (EMR) or in the code binder that was kept on the crash cart. During an interview with LPN1 on [DATE] at 7;45 PM, she stated she was assigned to R71 on [DATE] up until the resident's death on [DATE]. She stated when she entered R71's room, she (the resident) was blue, cold, and rigor mortis had started to set in. She stated R71 had no signs of life. LPN1 stated R71 was a full code. She stated that resident's code status could be found in the code binder located on the crash cart, in the resident's care plan, and on their face sheet. LPN1 stated that she and the former ADON/current DON (Assistant Director of Nursing/Director of Nursing) had assessed R71 and believed she was too far gone to start CPR even though they were aware of the resident's full code status. During an interview with the Regional Support Nurse on [DATE] at 3:59 PM, she stated she was the former Unit Manager at the facility. She stated if a resident was assessed to have a Full Code Status, she would expect CPR to have been initiated. She stated it would not be acceptable for an emergency contact to give a verbal order to withhold CPR if the resident's wishes were to have CPR performed. She stated that was not the facility's policy. Review of LPN 1's personnel record revealed a CPR certification date of [DATE]. There was no documented evidence of prior CPR certification. During an interview with the Staff Development Coordinator (SDC) on [DATE] at 4:14 PM, she stated she was responsible to ensure staff were CPR certified. She further stated most of the nurses should be CPR certified but there may be a couple that had expired, and she had been working on that. Additionally, she stated she expected staff to follow facility policy and orders when CPR should be performed. During an interview with the Director of Nursing (DON) on [DATE] at 4:25 PM, she stated she had been the former Assistant Director of Nursing. She stated she was working the evening shift on [DATE] but was not assigned to R71's hall. She stated she believed Certified Medication Technician (CMT) 2 came to get her and informed her that the 100-hall nurse needed help. She stated she went to R71's room and the resident was blue, purple, and hard. She stated she asked LPN1 what the resident's code status was, but she felt that she was too far gone, and it was not right to do CPR at that point. She stated she did look into why CPR was not initiated because she had some concerns as well. However, she did state what her concerns were related to CPR. The DON stated she did not initiate CPR due to R71's condition but typically a resident with a full code status should have had CPR initiated. During an interview with the Nurse Practitioner (NP) on [DATE] at 5:06 PM, she stated if a resident had a full code status and they were found unresponsive, she would expect CPR to be initiated. She stated she was always taught that if a resident was a full code, you do CPR until Emergency Management System (EMS) arrived. She stated even if the emergency contact stated they did not want CPR done; she would expect the facility staff to initiate CPR as the resident wishes stated. During an interview with the Medical Director on [DATE] at 10:36 AM, he stated he expected staff to initiate CPR on a resident if they were a full code. During an interview with the Administrator on [DATE] at 4:48 PM, he stated he would expect staff to follow the resident's care plan interventions and code statuses as per physician orders. The Administrator stated he was unable to provide documentation that LPN 1 had an active CPR certification at the time of R71's death.

AMENDED Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents received an accurate Minimum Data Set (MDS) assessment that was reflective of the resident's status at the time of the assessment for three of thirty-three sampled residents (Residents 30, 58, and 59).The findings include: Review of The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 Chapter 1 Section 3 dated 10/01/2024, revealed the Resident Assessment Instrument process had multiple regulatory requirements, including the requirement that the assessment accurately reflected the resident's status. Continued review of the RAI User's Manual revealed the assessment process included direct observation, as well as communication with the resident and direct care staff on all shifts. Review of the facility's policy titled, Documentation in Medical Record, revised 03/01/2025, revealed it was the facility's policy that each resident's medical record contained an accurate representation of the actual experiences of the resident. The assessment would include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Review of R30's Face Sheet revealed the facility admitted R30 on 06/04/2025 with diagnoses which included acute kidney failure, idiopathic aseptic necrosis of unspecified bone, and generalized anxiety disorder. Review of R30's History and Physical, dated 06/02/2025, documented vaping use as every day with the substances of nicotine and tetrahydrocannabinol (THC or marijuana). Review of the Risk Assessment Bundle, dated 06/04/2025, revealed yes to the question Does the resident plan to use tobacco products during stay and indicated the type of smoking product the resident would use as E-cigarettes/Vape. The facility assesses R30 to be a safe smoker and required no supervision. Review of R30's care plan titled R30 participates in smoking activities utilizing a vape with a start date of 06/05/2025. Review of R30's MDS assessment with an ARD of 06/09/2025 revealed the facility assessed R30 with a BIMS score of 15 out of 15, indicating intact cognition. Continued review of the MDS Assessment Section J1300: Current Tobacco Use, revealed the facility coded R30 as a 0, indicating there was no current tobacco use. 2. Review of R58's Face Sheet revealed the facility admitted the resident on 12/16/2024 with diagnoses which included fusion of spine, cervical region, pseudarthrosis after fusion, and cerebral infarction due to embolism of unspecified cerebral artery. Review of History and Physical, dated 12/12/2024, documented R58 as a smoker. Review of the facility's Release of Responsibility for Leave of Absence revealed that 01/18/2025 through 07/31/2025, R58 was signed out 495 times. The resident's sign out was to smoke. Review of (R) 's 58's Comprehensive MDS assessment with an ARD date of 07/31/2025 revealed the facility assessed R58 had a BIMS' score of 11 out of 15, indicating moderate cognitive impairment. Continued review of the MDS Assessment Section J1300: Current Tobacco Use, revealed the facility coded R58 as a 0, indicating there was no current tobacco use. 3. Review of R59's Face Sheet revealed the facility admitted the resident on 03/01/2025 with diagnoses which included type 2 diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, and depression. Review of R59's care plan revealed a problem of R59 participates in smoking activities utilizing smoking tobacco with a start date of 03/02/2025. Review of R59's Comprehensive MDS assessment with an ARD of 03/16/2025 revealed the facility assessed R59 with a BIMS' score of 15 out of 15, indicating intact cognitive function. Review of the MDS Assessment Section J1300: Current Tobacco Use, revealed the facility coded R59 as a 0, indicating there was no current tobacco use. In an interview on 08/11/2025 at 3:41 PM, the MDS Coordinator stated she gathered information for the MDS assessments from the nurses' evaluations, nurses' notes, Certified Nurse Aide Point of Care documentation, and therapy documentation. She stated R58 smokes occasionally and her family takes her out then. In an interview the MDS Nurse on 08/11/2025 at 3:48 PM, she stated that having an incorrectly coded MDS could result in the facility getting fined, or having to return any monies dispersed or could affect a resident's care. In an interview with the Director of Nursing (DON) on 08/11/2025 at 4:22 PM, she stated that someone came in from corporate that audited the MDS assessments. She stated she would expect all residents to have completed MDS assessments. In an interview with the Administrator on 08/11/2025 at 4:46 PM, he stated he expected that the MDS assessments were completed, monitored, and documented as completed. He stated if there was a mistake on the assessment, he expected it to be modified appropriately.

Based on interviews, record reviews, and review of facility policy, it was determined that the facility failed to formulate an advance directive at the discretion of the resident for four of thirty-three sampled residents (R) (R6, 22, 51, and 55). The findings include: Review of the facility's Advance Directive Policy revised on [DATE], revealed it was the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. 1.Record review revealed the facility admitted R51 on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), bronchopneumonia, generalized anxiety disorder, bipolar type. Review of (R) 51's Annual Minimum Data Set (MDS) dated [DATE] revealed the facility assessed R51 to have a Brief interview for Mental Status score (BIMS) of 15 out of 15 which indicated intact cognition. In an interview with R51on [DATE] at 3:45 PM, she stated that she was a full code. R51 stated she was aware (CPR) cardiopulmonary resuscitation was involved in the process. However, review of Resident 51's (R51) Advance Directives/Medical Treatment Decisions, dated [DATE] and signed by the resident, revealed no directive detailing R51's decision to prolong her life and have life sustaining treatment to be provided. 2. Review of R22's Face Sheet revealed the facility admitted the resident on [DATE]. R22's diagnoses included incomplete paraplegia, obsessive compulsive disorder, and borderline personality. Review of (R) 22's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed R22 had a Brief Interview for Mental Status Score (BIMS) of fifteen (15) out of fifteen (15). This score indicated intact cognition. Review of R22's, Advanced Directives/Medical Treatment Decisions, dated [DATE], revealed one version of the document was signed by the resident, but no directive was indicated on the form. Review of a second version of the same form indicated R22 wished to have efforts made to prolong her life and have life-sustaining treatment provided. In an interview with Resident 22 on [DATE] at 4:00 PM, she stated that she was a full code, and that she had formulated an Advanced Directive when she was admitted to the facility. She stated that the Social Services Director came to speak with her this week and asked her what her wishes were, and she stated to her that she was a full code, but she did not sign a new form. In an interview with the Social Services Director (SSD) on [DATE] at 2:51 PM, she stated that on the advance directives form she printed off for R (22) the box was not marked. In an interview with the Administrator on [DATE] at 4:46 PM, he stated he did not have an answer on who marked the advance directive form for Resident 22 or how it got marked after the fact. The Administrator stated he expected staff to complete the necessary forms per facility policy. 3. Review of R55's electronic medical record (EMR) revealed the facility admitted the resident on [DATE], with diagnoses to include: chronic obstructive pulmonary disease (COPD), heart disease, and type 2 diabetes mellitus with diabetic polyneuropathy. Review of the Comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed R55 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident had intact cognitive function. Review of R55's EMR revealed the resident had a Do Not Resuscitate (DNR) Status. Review of an Advance Directives/Medical Treatment Decisions form, dated [DATE], revealed below the resident signature line an unclear set of initials. In an interview on [DATE] at 2:59 PM, the SSD identified the Advance Directives/Medical Treatment Decisions form, dated [DATE] acknowledging the DNR status and signed by an unclear set of initials, as belonging to R55. The SSD acknowledged there was no resident's name on the form anywhere. 4. Review of R6's EMR revealed the facility admitted the resident on [DATE]. R22's diagnoses included cerebrovascular accident (CVA), paraplegia, and aphasia. Review of the Quarterly MDS, with an ARD of [DATE], revealed the facility assessed R6 to have a BIMS's score of 6 out of 15. This score indicated the resident had severe cognitive impairment. Review of R6's EMR revealed a DNR status. Review of an Advance Directives/Medical Treatment Decisions form, dated [DATE], revealed the signature of R6's legal representative. However, on the line requesting if legal representative signed . print name the name printed was the resident's name with the relationship to resident noted as guardian. The line asking type of legal appointment remained blank. In an interview on [DATE] at 2:59 PM, the Social Services Director (SSD) stated the form was incorrectly filled out, that it should have been the representative's name printed and not the resident's name. She also stated the type of legal appointment should not be blank. In an interview with the Social Services Director (SSD) on [DATE] at 2:51 PM, she stated that she completes the assessments for Brief Interview for Mental Status (BIMS) Patient Health Questionnaire-9 (PHQ-9), Social History, and Advance Directives. She stated assessments were completed on admission, quarterly, annually as well if there were any significant changes. The Social [NAME] Director stated that if a resident wanted to change their code status she would help initiate the process.

Based on interviews, record review, and review of facility policy, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one of thirty-three sampled residents (R71). Record review and interviews revealed R71's provisional death certificate was signed by the Staff Development Coordinator (SDC) prior to R71's death. The findings include: The facility was unable to provide a policy related to provisional death certificates.Review of the facility's policy titled, Documentation in Medical Record, revised [DATE], revealed each resident's medical record should contain an accurate representation of the actual experiences of the resident and include information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy further stated documentation should be completed at the time of service. Review of the facility's policy titled, Death of a Resident, Documenting, reviewed 06/2025, revealed appropriate documentation should be made in the clinical record concerning the death of a resident.Review of R71's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses which included: atherosclerotic heart disease of native coronary artery without angina pectoris, cerebral infarction without residual deficits, and old myocardial infarction. The facility discharged R71 due to death in the facility on [DATE].Review of an Advisory Opinion: Pronouncement of Death and Signing Death Certificates from the Kentucky Board of Nursing, revealed a Registered Nurse was authorized to sign the provisional report of death as furnished by the state registrar of vital statistics. However, review of R71's Provisional Death Certificate, dated [DATE], revealed it was signed by the Staff Development Coordinator (SDC) and witnessed by Licensed Practical Nurse (LPN) 1.Review of the facility's staffing schedule dated [DATE] revealed the SDC was not scheduled to work on the 7P-7A shift.During an interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 7:45 PM, she stated she was assigned to R71 on [DATE] up until her death on [DATE]. She stated when she entered R71's room, she was blue, cold, and rigor mortis had started to set in. LPN1 stated R71 had no signs of life. She stated R71 was a full code. LPN1 stated that she and the former ADON/current DON (Assistant Director of Nursing/Director of Nursing) had assessed R71 and believed she was too far gone to start CPR (cardiopulmonary resuscitation) even though they were aware of the resident's full code status. LPN 1 stated she received CPR training in [DATE]. She stated she could not recall if she had an active CPR certification at the time of R71's death. She stated as an LPN, she was not permitted to sign a Provisional Death Certificate, but she had filled one out in the past after a resident had expired. She stated the SDC had signed some blank ones and left them at the nursing desk. LPN 1 was also unable to recall who completed R71's Provisional Death Certificate.During an interview with the SDC on [DATE] at 4:14 PM, she stated she was not working the morning of R71's death and she did not come to the facility at the time of R71's death to sign the provisional death certificate. She stated if her signature was on the report then she should have been at the facility. She further stated that she had signed a few blank provisional death certificates and kept them on each unit. The SDC stated that was what she was told to do by the Administrator when she took the SDC position. She stated since the forms were signed, the LPN working the floor could fill out the form and have another LPN to witness. Additionally, she stated though an LPN could sign the certificates as long as they had a witness. She stated that she or another RN were not usually in the facility during the evening shift (7P-7A) and that was another reason the forms were pre-signed. She stated there was an RN on call and staff did notify them when something happened, but she did not typically come to the facility to pronounce death or sign a provisional death certificate. During an interview with the Director of Nursing (DON) on [DATE] at 4:25 PM, she stated she was working the evening shift (7P-7A) on [DATE] when R71 expired. She stated since she was working, she should have signed R71's provisional death certificate. She stated the SDC may have come in to sign it since she lived close by. The DON stated there were some pre-signed provisional death certificates at the nursing stations that LPNs could complete. She stated she thought LPNs were allowed to do that. The DON stated there was not an RN in the facility most of the time but could come in if needed. She stated she would expect staff to sign a provisional death certificate at the time the death occurred.During an interview with the Medical Director on [DATE] at 10:36 AM, he stated he would not expect staff to sign provisional death certificates until the resident had expired. He stated he would not sign a death certificate until it actually occurred, that was common sense.During an interview with the Administrator on [DATE] at 4:48 PM, he stated a provisional death certificate should not be signed or completed until the time of death or soon after. He stated he would not expect staff to sign them before then. He stated he had never instructed staff to sign a provisional death certificate in advance.

Based on interview, record review, and facility policy review, the facility failed to ensure performance review evaluations were completed for every Certified Nursing Assistant (CNA) at least once every 12 months for 4 of 6 CNAs' personnel records reviewed, (CNA2, CNA6, CNA17, and CNA20). The findings include:Review of the facility's policy titled, Nursing Services and Sufficient Staff, revised 02/03/2025 revealed sufficient staff with appropriate competencies and skill sets were to be provided to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. In addition, the facility must ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents.The Administrator did not provide a Performance Evaluation policy. However, the Administrator's job description dated December 2018 stated job duties included: communicate policies, evaluate performance, provide feedback, assist, observe, and coach.1. Review of CNA 2's personnel file revealed the facility hired the CNA on 03/19/2024. Further review revealed CNA 2 had completed 24.5 hours of training between 07/15/2024 - 12/05/2024. However, there was no documentation of a performance evaluation during the 12-month period. 2. Review of CNA16's personnel file revealed a hire date of 07/27/2022. Further review revealed CNA16 had completed 37.5 hours of training between 01/23/2025 - 07/06/2025. However, there was no documentation of a performance evaluation during the 12-month period.3. Review of CNA17's personnel file revealed a hire date of 05/13/2024. Further review revealed CNA 17 had completed 33.57 hours of training between 03/06/2025-07/15/2025. Further review revealed no documentation of a performance evaluation during the 12-month period.4. Review of CNA 20's personnel file revealed hire date of 04/21/2022. Further review revealed the last evaluation completed was in 2022, with no documentation of performance evaluation during the last 12-month period. During an interview with the Director of Nursing (DON) on 08/11/2025 at 4:32 PM, she stated that she would begin training regarding performance evaluations to begin the yearly evaluation process since she was new to the position. During an interview with the Administrator 08/11/2025 at 5:00 PM, he stated yearly performance evaluation were beneficial; however, he failed to complete them on his part. He stated areas of improvement were not identified when performance evaluations were not completed.

Based on interview, record review and facility policy review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to affect all residents requiring Cardiopulmonary Resuscitation (CPR).The findings include: Review of the facility's document titled, Administrator Job Description, dated 12/2018, revealed the Administrator was to lead and direct the overall operations of the facility in accordance with the customer (resident) needs, government regulations, and company policies. Per review, the Administrator's focus was on maintaining excellent care for the residents while achieving the facility's business objectives. Continued review revealed the Administrator's essential duties included monitoring each department's activities and evaluating performance. Further review revealed the Administrator was also to consult with the department managers concerning the operation of their departments to assist in eliminating/correcting problem areas and/or improvement of services and to provide guidance and leadership to ensure state and federal regulations were met. 1). Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), revised [DATE], revealed the facility was to adhere to residents' rights to formulate advance directives (for its residents). Per review, the policy further noted staff were to maintain current CPR certification for healthcare providers. Review of the facility's Registered Nurse (RN), and Licensed Practical Nurse (LPN) Job Descriptions updated [DATE], revealed they must have a current/active CPR certification. Review of the facility's Certified Nurse Aide (CNA) job description dated 12/2018, revealed a current/active CPR certification was preferred. However, review of personnel records for 15 out of 21 licensed or certified staff revealed they were not up to date with their CPR certifications. Review of R71's Face Sheet revealed the facility admitted the resident on [DATE]. R71 expired in the facility on [DATE]. Review of R71's Advanced Directives Comprehensive Care Plan initiated on [DATE] and revised on [DATE], revealed the resident had a Full Code Status with interventions that included administering CPR in the event the resident was found without pulse or respirations. Review of R71's Kentucky Living Will Directive, dated [DATE], revealed it had been signed by the resident, and noted her wishes were for life-prolonging treatment not to be withheld or withdrawn. Review of the physician's order dated [DATE], revealed R71's code status was ordered as Full Code. Review of the progress note for R71 dated [DATE] at 3:15 AM, revealed LPN1 was called to the resident's room, where she was found with no pulse, respirations, or signs of life. The nursing staff did not provide CPR. Review of the facility's personnel records reviewed revealed 15 of the 21 licensed or certified staff sampled were not CPR certified at the time of R71's death on [DATE]. Per review, staff received their CPR certifications on the following dates: on [DATE]- Certified Medication Aide (CMA) 1, Licensed Practical Nurse (LPN)1, LPN2, LPN4, and Registered Nurse (RN/Director of Nursing (DON); on [DATE]- LPN 9; on [DATE]- CMA 3, CMA 4, CMA 5, LPN 6, LPN 7, LPN 8 LPN 10, RN 1, and RN 2. During an interview with the Staff Development Coordinator (SDC) on [DATE] at 4:14 PM, she stated she was responsible for ensuring staff were CPR certified as required. She stated most of the nurses should be CPR certified, but there might be a couple whose CPR had expired, and she had been working on that. The SDC stated she expected staff to follow the facility's policy and orders for when CPR should be performed. In an additional interview with the SDC on [DATE] at 9:25 AM, she stated, When I started this position 4-5 years ago, the Administrator told me it was not required for licensed staff to have an active CPR certification. She further stated it was in the job descriptions for licensed staff, and she knew they were supposed to have been CPR certified. During interview with the Director of Nursing (DON) on [DATE] at 4:25 PM, she stated she had been the facility's former Assistant Director of Nursing (ADON). She stated she had been working the evening shift on [DATE]. The DON stated she had not initiated CPR due to R71's condition, but typically if a resident had a full code status CPR should have been initiated. She further stated she started at the facility about a year ago and had not been CPR certified until [DATE]. During interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 7:45 PM, she stated she had assigned to R71's care on [DATE], and up until her death. She stated that she and the former ADON/current DON did not start CPR even though they were aware the resident was a full code. LPN 1 further stated she received CPR training in [DATE] and could not recall if she had been actively certified in CPR at the time of R71's death. During interview with the Administrator on [DATE] at 4:48 PM, he stated he expected the facility to have proper monitoring of which staff were to be certified in CPR. The Administrator explained he had instructed the SDC that the facility should have licensed and certified staff active in their CPR certifications. He stated however, a CNA was preferred to have CPR, but it was not required for them. The Administrator stated there should have been better communication among the staff, and he knew there needed to be a lot of improvements made in the facility. He stated knowing if CPR certifications were active or not was not something he personally tracked on his own, but it was also a requirement of the facility. He further stated he should have been overseeing the CPR certification and would be doing that going forward. In interview with the Administrator on [DATE] at 6:02 PM, he stated the facility had QAPI plans and actions and tracked all quality improvement activities. He stated the facility had not identified the issue with the CPR problems prior to the survey team entering the facility. The Administrator stated, We were not aware of any systemic issues. He stated the facility had a QAPI meeting today with the DON, Social Services Director, Infection Control/Staff Development Coordinator, Maintenance Director, Dietary Manager, MDS Coordinator, Nurse Practitioner, and several other staff members attended the meeting. The Administrator stated the Medical Director participated in the meeting via the telephone. He stated the meeting included information regarding, Care Plan Compliance, Staff Education with CPR, Code Status, Education, and Audits. He further stated, going forward education would include better communication with staff to ensure nursing administration was aware of incidents that may or may not occur in the facility that indicated staff needed education.

Based on observation, interview, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five sampled residents reviewed for infection control (Resident (R)73).The findings include:Review of the facility's policy titled, Transmission-Based Precautions, revised 05/21/2025, revealed the facility would take appropriate precautions to prevent transmission of infectious agents. Further review revealed for a resident on Contact Precautions, staff should don (put on) personal protective equipment (PPE) upon room entry (gown and gloves).Review of the facility's policy titled, Infection Prevention and Control Program, revised 02/02/2025, revealed the facility had established and maintained an infection prevention and control program. The program was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Review of Resident 73's (R73) Face Sheet revealed the facility admitted the resident on 09/29/2020 with diagnoses which included necrotizing fasciitis, methicillin resistant staphylococcus aureus infection, and pressure ulcer of unspecified site, unspecified stage. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/2025, revealed the facility assessed R73 to have a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating the resident was severely cognitively impaired.Review of a physician order, dated 06/23/2025, revealed R73 was placed on Contact Isolation Precautions related to a wound infection. Review of R73's wound culture result, dated 07/31/2025, revealed diagnoses of methicillin-resistant staphylococcus aureus (MRSA), enterococcus faecium, and Escherichia coli. Recommendations included to establish Contact Isolation.Observation on 08/10/2025 at 10:00 AM, revealed a sign on R73's door that the resident was on Contact Precautions. Further observation revealed Certified Medication Assistant (CMA) 1 administering medication to R73 without wearing a gown or gloves.During an interview with CMA1 on 08/10/2025 at 10:15 AM, she stated she did not think she needed to wear a gown or gloves since she was not doing direct care. After CMA1 read the Contact Precaution sign on R73's door, she stated she should have put on a gown and gloves before she went into R73's room. CMA 1 stated it was important to do so to prevent the spread of infection.During an interview with the Staff Development Coordinator (SDC)/Infection Preventionist (IP) on 08/11/2025 at 9:25 AM, she stated she had educated all staff on Infection Control. She stated staff were expected to wash their hands and put on PPE prior to entering a resident's room. The SDC stated staff could pass things to other residents if they went room to room without washing their hands or wearing appropriate PPE. She stated she did audits and observations on a weekly basis of staff wearing their PPE and had not had any concerns.During an interview with the Assistant Director of Nursing (ADON) on 08/11/2025 at 10:28 AM, she stated any resident that was in isolation had a sign and isolation tote with supplies hanging on their door. She stated staff should put on PPE before entering rooms for residents on Contact Precautions. The ADON further stated she expected staff to wear PPE per the facility's policy.During an interview with the Director of Nursing (DON) on 08/11/2025 at 2:45 PM, she stated she expected staff to wash their hands and don PPE before going into a resident's room. She stated she thought staff were confused with Enhanced Barrier Precautions and Contact Precautions. The DON stated the facility hosted a skills fair about a month ago which covered infection control. She stated there could be an increased risk of spreading infections when you do not wear proper PPE.During an interview with the Administrator on 08/11/2025 at 4:48 PM, he stated he expected staff to perform proper hand hygiene and put on PPE at the door prior to entering. He stated it could cause potential problems if they did not have the proper gear on.

Based on interviews, record reviews, document review, and facility policy review, it was determined the facility failed to report allegations of abuse to the State Survey Agency (SSA) within two hours for two (2) of three (3) sampled residents (Resident #1 and Resident #22) The findings included: Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 08/30/2022, revealed The facility would designate an Abuse Prevention Coordinator in the facility who would be responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. Further review revealed the policy stated, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframe's: a. Immediately, but not later than two (2) hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or b. Not later than twenty-four (24) hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. 1. Review of Resident #1's, Resident Face Sheet revealed the facility admitted the resident with diagnoses which included Congestive Heart Failure (a progressive heart disease that affects pumping action of the heart muscles), Type Two Diabetes Mellitus, and Dementia. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with the Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of Resident #1's care plan, dated as initiated 01/10/2022, indicated the resident had the potential to become verbally aggressive with other residents and staff. Review of Resident #26's Resident Face Sheet revealed the facility admitted the resident with diagnoses which included Anxiety, Depression, and Mood Disorder due to a known physiological condition with Depressive Features. Review of the Significant Change MDS, dated [DATE], revealed Resident #26 had a BIMS's score of twelve (12), which indicated moderate cognitive impairment. A review of Resident #26's care plan, dated as initiated 04/06/2021, indicated the resident had poor impulse control and episodes of agitation directed towards staff and residents. The care plan further indicated Resident #26 had difficulty socializing with other residents and staff and made repetitive statements with difficulty understanding social cues. Review of an Initial Report, dated 09/26/2022, revealed Resident #1 reported to staff that Resident #26 hit him/her on the arm during a checkers game. Per the report, both residents were separated, there were no injuries, no pain concerns, and an investigation was underway. Review of an incident report, dated 09/26/2022 at 1:20 PM and completed by Licensed Practical Nurse (LPN) #6, revealed LPN #6 was called to the lobby by a certified nursing assistant (CNA) due to Resident #26 hitting Resident #1 on the left arm after an argument over a board game. According to the report, the incident was witnessed by Resident #24. Review of an email (electronic mail), dated 09/26/2022, from the Administrator to the SSA indicated Resident #1's allegation was reported to the SSA at 5:06 PM, which was greater than two hours after facility staff were made aware of the allegation. Review of a Five (5) Working Day Final Report, dated 10/03/2022, indicated Resident #1 reported to staff that Resident #26 hit him/her on the arm during a checkers game that occurred in the lobby. Further review revealed Resident #1 was upset with Resident #26. Both residents were assessed and found to have no injuries. Resident #26 was placed on 1:1 monitoring, and social services and the activities department were notified to provide follow-up for both residents. The report further indicated Resident #26 was apologetic related to the incident and voiced that he/she did not intend to hit Resident #1 on the hand. Both residents asked to resume the board game and socialize with one another as they both enjoyed one another's company. According to the report, the facility did not substantiate the allegation of abuse, as Resident #26 reported he/she did not willfully hit Resident #1. During an interview with Resident #1, on 01/30/2023 at 1:55 PM, the resident reported playing a game when Resident #26 hit his/her arm. Resident #1 stated the incident was reported to the nurse. Per Resident #1 he/she felt safe in the facility around Resident #26 and there had been no further incidents. During an interview with Resident #24, on 02/01/2023 at 9:17 AM, the resident stated he/she liked to sit in the lobby area and play games. Resident #24 stated he/she had never seen a resident hit another resident. Resident #24 stated he/she felt safe in the facility and was not aware of any abuse or neglect that had occurred. Review of an annual MDS, dated [DATE], revealed Resident #24 scored five (5) on a BIMS, indicating severe cognitive impairment. During an interview with LPN #6, on 02/01/2023 at 2:14 PM, LPN #6 stated she and CNA #3 heard Resident #1 yell out, and both staff members entered the lobby at the same time. According to LPN #6, CNA #3 asked Resident #1 what happened, and Resident #1 stated Resident #26 hit his/her arm. Per LPN #6, CNA #3 took Resident #26 out of the lobby to his/her room, and assessed Resident #1 for injuries. LPN #6 stated there was no redness to Resident #1's arm, and she spoke with Resident #24, who was present and witnessed the incident. During an interview on 02/01/2023 at 2:39 PM, the Activity Director (AD) stated Resident #1 and Resident #26 bickered back and forth like siblings over their board games. The AD stated following the incident, both residents were kept separated for a couple of days to cool down. The AD further stated Resident #1 and Resident #26 played the games on their own now with increased supervision in the lobby, and there had been no incidents since. The Director of Nursing (DON) was unavailable for interview during the survey. During an interview, on 02/02/2023 at 1:38 PM, the Administrator stated he was the facility's Abuse Coordinator. Per the Administrator, he expected the State Survey Agency to be notified within two hours of becoming aware of an abuse allegation. 36105 2. Review of Resident #22's Face Sheet revealed the facility admitted the resident with diagnoses which included Quadriplegia (paralysis of all four limbs), Spondylolysis (degeneration of the vertebral column), Muscle Weakness and Nicotine Dependence. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status score of fifteen (15), which indicated the resident was cognitively intact. Review of an Initial Report, dated 09/22/2022, revealed Resident #22 reported to a certified nursing assistant (CNA) that Registered Nurse (RN) #4 administered the resident's medications into his/her mouth with intentional force and forcefully closed the medication cart drawer next to the resident. Review of a Five (5) Working Day Final Report, dated 09/28/2022, indicated Resident #22 alleged that RN #4 forcibly administered his/her medications and slammed the medication cart drawer after the medications were administered. RN #4 was placed on administrative leave pending the results of the investigation. Per the report, there were no witnesses to the incident and no other resident expressed any concerns related to RN #4 or with how their medications were administered. The facility did not substantiate the allegation of abuse; however, to prevent further potential abuse, the certified medication aide on the night shift was to be primarily responsible for the administration of Resident #22's medications. Also, the resident's care plan was updated to indicate that a second staff member be present for all the resident's care. During an interview with Resident #22, on 01/30/2023 at 10:08 AM, he/she stated when medications were late, they would go to find the nurse to get their medications. Per Resident #22, on one occasion, a nurse acted angry and slammed the drawers of the medication cart. Resident #22 stated the nurse put medications in a cup and tipped the medications into the resident's mouth, did not give the resident anything to drink, and then forcefully shut the medication cart drawers. Resident #22 stated the nurse did not push the medication cup against his/her lips or mouth. During an interview on 02/01/2023 at 8:08 AM, RN #4 stated she was the nurse Resident #22 complained about and was suspended on 09/22/2022 due to an allegation of abuse. RN #4 stated that night, the resident waited for her at the medication cart while she was helping another resident. Per RN #4, Resident #22 was upset they had to wait. RN #4 stated, I did not shove the medicine in [the resident's] mouth. I did not slam drawers. RN #4 stated she was helping another resident and had a lot to do, so after giving the resident's medication, she moved on to the next resident. RN #4 stated one of the ways the facility resolved the situation from 09/22/2022 was for her not to give medication to the resident any longer. During an interview on 02/01/2023 at 8:33 AM, Licensed Practical Nurse (LPN) #5 stated Resident #22 was very demanding. She stated the resident expected things to be on the dot. She stated if medication was ten (10) minutes late, the resident would wait at the medication cart, hunt down the nurse and sometimes holler for the nurse. She stated staff tried to keep the resident happy, and the way to do that was doing things exactly when the resident wanted it done. During an interview with CNA #10, on 02/01/2023 at 12:22 PM, CNA #10 stated the resident was impatient, wanted things right away and would get upset if they had to wait. Further review of the Five (5) Working Day Final Report dated 09/28/2022, revealed the Administrator became aware of the allegation involving Resident #22 and RN #4 on 09/22/2022 at approximately 12:55 AM. A review of an email dated 09/22/2022 from the Administrator to the SSA revealed the allegation was reported to the SSA at 3:40 AM, greater than two hours after the Administrator was made aware of the allegation. During an interview on 02/02/2023 at 1:38 PM, the Administrator stated he was the facility's Abuse Coordinator. The Administrator acknowledged he was notified of Resident #22's abuse allegation and that he was the one who reported the allegation to the SSA. He stated the goal was to report allegations of abuse to the SSA within two hours of being notified.

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to thoroughly investigate an allegation of resident-to-resident abuse for one (1) of three (3) sampled residents (Resident #1). Specifically, the facility failed to obtain and document witness statements from the involved residents and any resident/staff member who may have had knowledge of the alleged incident, when Resident #1 alleged that Resident #26 hit Resident #1's arm. The findings included: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 08/30/2022, revealed, Investigation of Alleged Abuse, Neglect and Exploitation: A.) An immediate investigation was warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurred. B.) Written procedures for investigations included: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. Review of Resident #1's Resident Face Sheet revealed the facility admitted the resident with diagnoses that included Congestive Heart Failure (a progressive heart disease that affects pumping action of the heart muscles), Type Two Diabetes Mellitus, and Dementia. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with the Brief Interview for Mental Status (BIMS) examination. The resident's score was thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. The MDS also indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed towards others. Review of Resident #1's care plan, dated as initiated 01/10/2022, indicated the resident had the potential to become verbally aggressive with other residents and staff. Review of Resident #26's Resident Face Sheet revealed the facility admitted the resident with diagnoses which included Anxiety, Depression, and Mood Disorder due to a known physiological condition with Depressive Features. Review of the Significant Change MDS, dated [DATE], revealed Resident #26 had a BIMS score of twelve (12), which indicated moderate cognitive impairment. The MDS indicated Resident #26 had no physical, verbal, or other behavioral symptoms directed towards others. Review of Resident #26's care plan, dated as initiated 04/06/2021, indicated the resident had poor impulse control and episodes of agitation directed towards staff and residents. The care plan further indicated the resident had difficulty socializing with other residents and staff and made repetitive statements with difficulty understanding social cues. Review of an Initial Report dated 09/26/2022, revealed Resident #1 reported to staff that Resident #26 hit Resident #1 on the arm during a checkers game. Per the report, both residents were separated, there were no injuries, no pain concerns, and an investigation was initiated. Review of the incident report, completed by Licensed Practical Nurse (LPN) #6, dated 09/26/2022 at 1:20 PM, revealed LPN #6 was called to the lobby by a certified nursing assistant (CNA) due to Resident #26 hitting Resident #1 on his/her left arm after an argument over a board game. According to the report, the incident was witnessed by Resident #24. Review of Resident #26's Progress Notes, written by LPN #6 and dated 09/26/2022 at 1:20 PM, revealed LPN #6 was called to the lobby by a CNA because Resident #26 and another resident were arguing over a board game and Resident #26 hit the other resident on their left arm. According to the Progress Note, Resident #26 was placed on 1:1 monitoring, and the nurse practitioner (NP) and family member were notified. Review of the Five (5) Working Day Final Report, dated 10/03/2022, indicated Resident #1 reported to staff that Resident #26 hit Resident #1 on the arm during a checkers game that occurred in the lobby. Resident #1 was upset with Resident #26. Both residents were assessed and found to have no injuries. Resident #26 was placed on 1:1 monitoring, and Social Services and the Activities Department were notified to provide follow-up for both residents. The report further indicated Resident #26 was apologetic related to the incident and voiced that he/she did not intend to hit Resident #1 on the hand. Both residents asked to resume the board game and socialize with one another as they both enjoyed one another's company. According to the report, the facility did not substantiate the allegation of abuse, as Resident #26 reported they did not willfully hit Resident #1. There were no witness or resident statements included in the facility's investigation file. During an interview on 01/30/2023 at 1:55 PM, Resident #1 reported playing a game when Resident #26 hit his/her arm. Resident #1 indicated the incident was reported to the nurse. During an interview on 02/01/2023 at 9:17 AM, Resident #24 stated he/she liked to sit in the lobby area and play games. Per Resident #24, he/she had never seen a resident hit another resident. Review of an Annual MDS, dated [DATE], revealed Resident #24 scored five (5) on a BIMS, indicating severe cognitive impairment. During an interview on 02/01/2023 at 10:26 AM, Resident #26 stated he/she was playing checkers with Resident #1, who accused him/her of cheating. Resident #26 confirmed he/she did hit Resident #1 on the arm. Per Resident #26, Resident #1 told the nurse and he/she went to his/her room. During an interview on 02/01/2023 at 2:14 PM, LPN #6 stated she and CNA #3 heard Resident #1 yell out, and both staff members entered the lobby at the same time. According to LPN #6, CNA #3 asked Resident #1 what happened, and he/she stated that Resident #26 hit his/her arm. Per LPN #6, CNA #3 took Resident #26 out of the lobby to his/her room, and she assessed Resident #1 for injuries. LPN #6 stated there was no redness to Resident #1's arm, and she spoke with Resident #24, who was present and witnessed the incident. The Director of Nursing (DON) was unavailable for interview during the survey. During an interview, on 01/31/2023 at 10:30 AM, the Administrator stated that for reportable events, he created Word documents for the initial and the five (5) day report that summarized, what occurred, and submitted those reports to the State by way of email. Per the Administrator, the two (2) reports along with the resident's Progress Notes were the facility's completed investigation. During a follow-up interview on 02/02/2023 at 1:38 PM, the Administrator stated he was the facility's Abuse Coordinator and when there was an allegation of abuse or neglect, he made sure the resident was safe and immediately started the investigation into what happened. The Administrator further stated he expected a complete and thorough investigation to be completed following an abuse allegation, which normally included resident and staff written statements. The Administrator then stated there were no written statements for this investigation because it was resident-to-resident.

Based on observations, interviews, policy review, and record review, the facility failed to provide a safe smoking area for one (1) of one (1) sampled residents (Resident #22). The findings include: Review of the facility's policy titled, Resident Smoking, revised 10/28/2022, revealed, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. The policy further revealed, two (2). Safety measures for the designated smoking area included, but not [sic] limited to: a. Protection from weather conditions. b. Provision of ashtrays made of noncombustible material and safe design. c. Accessible fire extinguisher. d. Prohibition of oxygen use in the smoking area. e. Located away from exits and common space utilized by other residents to protect non-smoking residents from second-hand smoke. Review of Resident #22's Face Sheet revealed the facility admitted the resident on with diagnoses that included Quadriplegia, Spondylolysis (degeneration of the vertebral column), and Nicotine Dependence. A review of Resident #22's Quarterly Minimum Data Set, dated dated [DATE], revealed the resident had a Brief Interview for Mental Status score of fifteen (15), which indicated Resident #22 had intact cognition. Review of Resident #22's Care Plan, dated 01/11/2023, revealed the facility assessed the resident to be at risk for injury related to being a current smoker. Observation, on 01/30/2023 at 1:24 PM, revealed Resident #22 smoked a cigarette outside in a covered patio (smoking) area. There was no ashtray in the smoking area. Numerous cigarette butts were observed in the grass at the edge of the patio. Resident #22 stated there was no ashtray, noting he/she threw the cigarette butts on the grass. During observations of the smoking area on 01/30/2023 at 2:52 PM, 01/31/2023 at 12:07 PM, and 02/01/2023 at 7:30 AM, revealed no ashtrays in the smoking area. Numerous cigarette butts were observed on the grass at the edge of the patio. During an interview on 02/01/2023 at 7:48 AM, Certified Nursing Assistant (CNA) #12 stated Resident #22 smoked in the smoking area, but she did not know if there was an ashtray or where the resident put out his/her cigarettes. Per CNA #12, she did not know if there was any other smoking safety equipment in the patio area. Interview, on 02/01/2023 at 7:52 AM, with CNA #7 revealed Resident #22 was a safe smoker and went out to smoke up to eight times per day. CNA #7 stated she did not know where the resident put the cigarettes out or, if there was an ashtray or other safety equipment in the patio area. During an interview on 02/01/2023 at 7:59 AM, CNA #8 stated Resident #22 was the only resident who smoked at the facility. CNA #8 stated she thought the resident just threw his/her cigarette butts on the ground when he/she was finished smoking. Interview, on 02/01/2023 at 8:08 AM, with Registered Nurse (RN) #4 revealed Resident #22 was a smoker and went out to smoke three to five times during her shift. RN #4 stated that although there was an ashtray on the patio, Resident #22 tossed his/her cigarette butts everywhere. Interview, on 02/01/2023 at 8:33 AM, with Licensed Practical Nurse (LPN) #5 revealed she thought Resident #22 put out his/her cigarettes in a receptacle like an ashtray, but she did not know if there was any safety equipment on the patio. During an interview on 02/01/2023 at 8:40 AM, LPN #6 stated she completed Resident #22's most recent smoking assessment. LPN #6 stated she watched the resident smoke a cigarette and put the cigarette out by throwing the cigarette on the patio and running over the cigarette butt with his/her wheelchair. LPN #6 stated she could not remember if there was an ashtray in the patio area, but noted the resident should have a sand ashtray to put out the cigarettes. Interview, on 02/01/2023 at 12:28 PM, with Resident #22 revealed there was an ashtray in the patio in the past, but the ashtray went missing a long time ago. Interview, on 02/01/2023 at 1:23 PM, with the Maintenance Director revealed he thought there should be an ashtray in the patio area. The Maintenance Director stated he recently started the position and did not know who was responsible for placing an ashtray or other safety equipment in the patio area. During an interview on 02/02/2023 at 1:57 PM, the Administrator stated there should be ashtrays in the patio area designated as a resident smoking area.

Based on observations, interviews, and policy review, it was determined the facility failed to develop and implement policies in accordance with applicable regulations for smoking areas and smoking safety for one (1) of one (1) resident smoking areas. The findings include: Review of the facility's policy titled, Resident Smoking, revised 10/28/2022 revealed, It was the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. The policy further revealed, 2. Safety measures for the designated smoking area will include, but not limited to: a. Protection from weather conditions. b. Provision of ashtrays made of noncombustible material and safe design. c. Accessible fire extinguisher. d. Prohibition of oxygen use in the smoking area. e. Located away from exits and common space utilized by other residents to protect non-smoking residents from second-hand smoke. The policy did not address required smoking safety standards such as readily available metal containers with self-closing cover devices into which ashtrays could be emptied for the disposing of cigarette butts. Observation, on 01/30/2023 at 1:24 PM, revealed Resident #22 smoking a cigarette outside in a covered patio (resident smoking) area. There was no ashtray in the smoking area and no metal container with a self-closing lid in the patio area. Numerous cigarette butts were observed in the grass at the edge of the patio. During the observation, Resident #22 stated there was no ashtray, noting that he/she threw the cigarette butts in the grass. During observations of the smoking area on 01/30/2023 at 2:52 PM, 01/31/2023 at 12:07 PM, and 02/01/2023 at 7:30 AM, there was no ashtray or other safety equipment in the smoking area. Further observation revealed numerous cigarette butts were noted on the grass at the edge of the patio. Interview, on 02/01/2023 at 1:23 PM, with the Maintenance Director, revealed he thought there should be an ashtray in the patio area. The Maintenance Director stated he recently started the position and did not know who was responsible for placing an ashtray or other safety equipment in the patio area. During an interview on 02/02/2023 at 1:57 PM, the Administrator stated the safety of the smoking areas was the direct responsibility of the Maintenance Director, but the responsibility for safety ultimately rested with the Administrator.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to update and revise the comprehensive nursing care plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 was identified to have a Urinary Tract Infection (UTI) and placed on an antibiotic on [DATE]; however, the facility failed to revise the care plan to address the UTI or use of antibiotics to ensure the treatment was effective and there was no adverse reactions from treatment. The findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, last revised [DATE], revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Closed record review revealed the facility admitted Resident #1 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the re-admission five (5) day MDS scheduled assessment, dated [DATE], revealed the resident had been out to an acute care facility and returned with a indwelling catheter for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Progress Note, Urinalysis and Culture and Sensitivity Report, and Physician Orders, dated [DATE]; revealed Resident #1 was identified to have a UTI on [DATE] and was placed on Microbid (antibiotic) capsule 100 milligrams (mg) by mouth two (2) times a day (BID) from [DATE] through [DATE]. However, review of Resident #1's Comprehensive Care Plan for urinary catheter, with a goal to be free from UTI infection, initiated on [DATE]; revealed the care plan was not updated/revised to address the resident was identified to have a UTI and placed on an antibiotic. There were no interventions to address monitoring/assessing to ensure treatment was effective and there were no adverse effects of the antibiotic. Review of a Nursing Progress Notes, dated [DATE]-[DATE], revealed there was no documented evidence licensed staff assessed/monitored Resident #1's urinary catheter/urine. Interview with Resident #1's family member on [DATE] at 8:30 AM, and review of Progress Notes dated [DATE] at 5:43 PM, and [DATE] at 5:10 PM revealed Resident #1's family member called on [DATE] wanting labs to be done for Resident #1 because the resident sounded weak on the phone, The nurse obtained orders for labs. The family member called the physician because she did not think the nurse was taking the situation seriously and asked that the resident be sent to hospital. The resident was sent to the hospital on [DATE]. Review of the Emergency Department (ED) Summary dated [DATE] at 6:06 PM revealed, Resident #1's urine appearance was described as cloudy, purulent, milky, and pink/straw in color. Review of Hospital Discharge Death Summary dated, [DATE] revealed, Resident 1 was admitted to the hospital, and diagnosed with severe [CONDITION(S)] with Septic Shock associated with acute kidney injury, and acute UTI of unspecific organism or location. Further review of the summary revealed the resident rapidly deteriorated and subsequently expired secondary to Severe [CONDITION(S)] with Septic Shock. He/she was pronounced dead at 9:14 PM on [DATE]. Interview with the MDS Coordinator on [DATE] at 4:21 PM, revealed the care plan was a guide for staff to provide care for the residents, and when there were changes in the resident's care needs they should be added to the care plan. She stated the nurse on duty at the time the order was obtained for Resident #1's antibiotic should have updated the care plan with the antibiotic and there should have been interventions added to monitor for effectiveness of the antibiotic. She revealed the staff who provided care to the resident, would have reviewed the care plan when providing care to the resident, and they would have seen the resident was on an antibiotic and needed to be monitored. Interview (Post Survey) with Licensed Practical Nurse (LPN) #5 on [DATE] at 1:40 PM, revealed she should have updated Resident #1's care plan when Resident #1 was identified to have a UTI and placed on an antibiotic on [DATE]. She stated It must have been an over site on my part. Interview with the Director of Nursing (DON) on [DATE] at 1:54 PM, revealed it would have been a good idea to have appropriate interventions in place to observe for sign and symptoms of UTI when the resident was placed on an antibiotic related to a UTI and also had an urinary catheter. The DON stated, the care plan should have been updated to reflect the resident was placed on an antibiotic while having a catheter, and whoever received the order should have updated the care plan at that time.

Based on interview, record review, and hospital record review, it was determined the facility failed to ensure one (1) of three (3) sampled residents with an indwelling catheter received appropriate care and services (Resident #1). On [DATE], Resident #1 was identified to have an Urinary Tract Infection (UTI) and placed on an antibiotic. Licensed staff failed to assess/monitor the resident's urinary catheter and urine for appearance and odor to ensure the antibiotic was effective. The findings include: Interview with the Director of Nursing (DON) on [DATE] at 3:13 PM, revealed she was not sure if there was an actual facility policy related to nursing assessing a resident that is taking an antibiotic for a urinary tract infection. The DON stated as the DON, she expected nursing staff to assess the resident and document at least once a shift. She further revealed the assessment should include observation of the appearance of the urine while on antibiotic to ensure the antibiotic was being effective, as a nursing standard of practice. Review of the facility policy, titled Urinary Tract Infections/Bacteriuria - Clinical Protocol, last revised [DATE], revealed nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail. Closed record review revealed the facility admitted Resident #1 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as interviewable with a Brief Interview of Mental Status (BIMS) score of thirteen (13). Further review of the MDS revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Care Plan for urinary catheter initiated on [DATE]; revealed a goal for resident to be free from UTI infection by next review date of [DATE]) with interventions for catheter care. Review of a Daily Skill Observation Note, dated [DATE] at 3:05 PM, revealed Resident #1's urinary catheter was patent to bedside drainage with thick, cloudy urine, and odor noted. Further review revealed the resident had no vomiting noted and Tylenol was given for temperature. Further review of the note revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Progress Note, dated [DATE], revealed the facility received labs back on resident for UA and C&S, and the physician was notified with an order received to start resident on [MEDICATION(S)] one-hundred (100) mg by mouth twice-a-day times eight (8) days. The nurse documented resident would continue to be monitored. Review of Resident #1's Physician Orders dated [DATE], revealed to administer [MEDICATION(S)] capsules (antibiotic) 100 milligram (mg), give one (1) capsule by mouth two (2) times a day (BID) for UTI, with a start date of [DATE] and ending on [DATE] related to UTI. Further review of Resident #1's Comprehensive Care Plan for urinary catheter initiated on ,d+[DATE]//2020 revealed the care plan was not updated to address resident being diagnosed with an actual UTI and being placed on antibiotic on [DATE]. Review of Nursing Progress Notes, dated [DATE] at 3:26 PM revealed Resident #1 continued to receive [MEDICATION(S)] BID for UTI without adverse reaction. The resident's urinary catheter was patent and intact to bedside drainage with clear yellow urine present. The resident continued to require assist of two (2) with activities of daily living (ADL), personal care (PC) and transfers, with no complaints voiced. The nurse documented the resident would continued to be monitored. However; review of the Nursing Progress Notes revealed there was no documented evidence licensed staff monitored/assessed Resident #1's catheter/urine related to UTI and effectiveness of antibiotic therapy on [DATE], [DATE], [DATE], [DATE] and [DATE] (five {5} days). In addition, there was no documented evidence licensed staff monitored the resident's catheter/urine for signs of a UTI after the antibiotic was completed by licensed staff from [DATE]-[DATE]. Review of a Nursing Progress Note, dated [DATE] at 5:43 PM, revealed Resident #1's daughter called wanting labs completed. A Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Brain Natriuretic Peptide (BNP), Chest X-ray, and UA with C & S was ordered and daughter was made aware. However, there was still no evidence the resident's catheter/urine was assessed to ensure no symptoms of UTI. Review of Urinalysis Laboratory Summary Report dated [DATE] at 6:33 PM, revealed Resident #1's urine color was yellow and appearance was turbid (cloudy, unclear and murky appearance) when the specimen was obtained on [DATE]. Review of a Nursing Progress Note, dated [DATE] at 5:10 PM, revealed the physician office called with an order to send Resident #1 to hospital emergency room (ER) as resident continued to have weakness, with two (2) episodes of loose stool this shift. Further review of the note revealed Emergency Medical Services (EMS) was called for transport, hospital ER was called with report, and daughter was notified of order to send to hospital ER. Review of the Emergency Department (ED) Summary dated [DATE] at 6:06 PM revealed, Resident #1's urine appearance was described as cloudy, purulent, milky, and pink/straw in color. Review of Hospital Discharge Death Summary dated, [DATE] revealed, Resident 1 was admitted to the hospital, and upon arrival, he/she was hypoxic (low oxygen in blood), desaturating (amount of O2 in blood decreasing) and obtunded (alertness or consciousness is moderately reduced). Further review of the Summary revealed Resident #1 was treated with IV fluids and IV antibiotics. He/she was found to have severe [CONDITION(S)] with Septic Shock associated with acute kidney injury, and acute UTI of unspecific organism or location. Serum creatinine 6.4 (0.,d+[DATE].1 normal range) with metabolic acidosis [MEDICATION(S)] of eleven (11) (,d+[DATE] normal range). The resident was started on [MEDICATION(S)] drip. Patient rapidly deteriorated and subsequently expired secondary to Severe [CONDITION(S)] with Septic Shock. He/she was pronounced dead at 9:14 PM on [DATE]. Interview with Resident #1's family member on [DATE] at 8:30 AM, revealed she had a phone conversation with resident on [DATE], due to not being able to visit due to the COVID 19 Virus. She stated during the phone conversation, the resident's voice sounded much weaker than normal and there was just something not right about the conversation. She revealed the resident was slower to respond during the conversation and indicated that he/she had been sick at his/her stomach and had vomited several times. She stated she called and spoke with Licensed Practical Nurse (LPN) #1 on [DATE], and LPN #1, indicated to her that Resident #1 was his/her normal self, and that she (LPN #1) had been in the room several times that day, and did not notice a change in the resident. She further revealed she knew the resident recently had a UTI, and had been on an antibiotic, and was not getting any better. She stated she called LPN #1 and requested LPN #1 call the physician and see about having more labs drawn. She stated she then called the physician herself and requested her parent be sent out as she did not think the nurse was taking her seriously. She revealed she met the resident at the emergency room (ER), and was so glad she met the resident at the ER, as the resident passed away shortly after he/she was admitted to the hospital. Interview with LPN #1 on [DATE] at 12:23 PM and on [DATE] at 12:30 PM, revealed she recalled Resident #1's daughter calling her on [DATE] to inquire about the resident's condition and that the resident had mentioned to her he/she had vomited. LPN #1 stated she told the daughter she had been in the room several times and the resident was alert and talkative and she had taken his/her vital signs and they were normal. She revealed she told the daughter that the resident did not mention he/she had vomited, or was sick to his/her stomach. LPN #1 further, revealed she called the Nurse Practitioner (NP) on [DATE] to request labs as the daughter had requested and did not recall looking at Resident #1's urine that day. She further stated, she does not generally chart on a resident unless there is a concern and the resident. The resident was no longer on an antibiotic, as the last antibiotic had been completed on [DATE] so there was no need to chart related to the resident's urinary condition. She stated she charts in the progress note or skilled note when a resident is on antibiotic related to the color and consistency of the urine, and if there are any concerns related to the antibiotic effectiveness. Further interview with LPN #1 revealed she was Resident #1's nurse on [DATE], and she did not recall looking at the resident's urine, but had completed the COVID-19 assessment which included temperature, pulse, respirations, blood pressure, lung sounds and oxygen saturations and nothing was out of the ordinary. She stated the resident was alert, orientated and talkative. Interview with LPN #6 on [DATE] at 1:01 PM, revealed she had provided care for Resident #1 on [DATE] from 7 AM -7 PM shift, and she recalled the resident talking with the daughter over the phone for an extended amount of time, as they were participating in a special church service over the phone. LPN #6 stated she did not recall any concerns with the resident and the resident had completed his/her antibiotic on [DATE]; therefore; there was no special documentation required. LPN #6 revealed just because someone has a urinary catheter, does not mean we as nurse's are required to document every shift related to the urinary catheter, and if there was a concern with the urine she would chart by exception; such as signs and symptoms of infection. She stated it is a standard of nursing practice to document on a resident that is on an antibiotic, regarding the effectiveness of the antibiotic, such as the color, consistency and odor. She further stated if staff do not observe the urine how are they to know if the antibiotic is being effective or not. She further stated, she was unsure of the color or consistency of Resident #1's urine on [DATE] and if she did not chart it, she would not be able to recall that far back. Interview with Registered Nurse (RN) #2 on [DATE] at 9:44 AM, revealed she had worked on [DATE], 7 AM - 7 PM shift, and she could not recall if she had charted on Resident #1. RN #2 stated if a resident has a urinary catheter and was on an antibiotic, licensed staff are supposed to chart an observation such as color, odor, and amount of urine to ensure the antibiotic is being effective. RN #2 revealed she was not sure what the facility policy stated but it was a standard of nursing practice. She further stated, If you do not access the urine, how are you going to know if the antibiotic is being effective. Interview with RN #3 on [DATE] at 11:15 PM, revealed she worked on [DATE] 7 PM - 7 AM shift and used a clean urinary bag to obtain the UA and C & S. RN #3 stated she could not recall if she had documented anything in the nurses notes related to the color or consistency of the urine. She further stated, she was unaware of the facility policy related to assessing a resident when they were on an antibiotic but it was a standard of nursing practice to chart when a residents is on an antibiotic to ensure the effectiveness of the medication. RN #3 revealed if licensed staff don't look at the urine, how are they going to know if the medication is working effectively. Interview with Certified Nurse Aide (CNA) #1 on [DATE] at 1:09 PM, revealed she had taken care of Resident #1 on [DATE], and the resident was her normal self. She stated she recalled seeing the resident's urine that day and it was the resident's normal cloudy color. She further reported the resident had poor intake and poor appetite for several days, but that was not abnormal for the resident. Further interview revealed, she had not witnessed any vomiting episodes. Interview with CNA #2 on [DATE] at 1:26 PM, revealed she had helped provide care for Resident #1 on [DATE]. CNA #2 stated the resident had two (2) episodes of diarrhea, and the resident indicated he/she was tired. CNA #2 further revealed she did not recall observing the resident's urine and did not witness any vomiting episodes. Interview with Nurse Practitioner (NP) on [DATE] at 11:47 AM and [DATE] at 10:23 AM, revealed the nurse called her on [DATE] and indicated the daughter requested more labs to be drawn on her parent, because the daughter was concerned her parent was not his/her normal self. The NP stated she saw Resident #1 on the morning of [DATE] and completed a physical assessment on the resident, and the resident was alert, oriented, and talkative and the color of the resident's urine was a hazy, amber color. The NP further revealed she was not aware of the facility policy related to monitoring a resident with a urinary catheter, but as a general nursing standard of practice she would at least expect some documentation in the clinical record to ensure the antibiotic was being effective and that there were no signs and symptoms of infection. Interview (Post Survey) with the Director of Nursing (DON), on [DATE] at 12:19 PM, revealed to ensure licensed staff are assessing the residents she reviews residents' clinical progress notes and staff as a team to discuss the residents at the daily Clinical Meeting.

Based on interview, record review, and facility policy review, it was determined the facility did not inform state agencies of an allegation of misappropriation of medications for one (1) of three (3) sampled residents (Resident #1). Certified Medication Aide (CMT) #1 alleged someone had taken a card (30 pills) of Resident #1's oxycodone (narcotic pills) on 08/01/19; however, the facility failed to report the allegation to the appropriate regulatory, investigative and/or law enforcement agency per facility policy. The findings include: Review of facility policy titled, Alleged Abuse/Potential Neglect/Exploitation/Investigation, last revised 08/22/17 revealed to provide an environment that promotes dignity and respect for all residents and one that prohibits abuse and/or neglect, misappropriation of resident property, and/or exploitation. Further review revealed any person that knows or has reasonable cause to suspect that a resident is being abused including misappropriation of property shall immediately report such knowledge or suspicion to their supervisor, charge nurse, designee, or Administrator; who will then notify the Administrator or appropriate designee. Administrator or DON will then notify the appropriate regulatory, investigative and/or law enforcement immediately but not later than 2 hours after the allegation is made if the allegation involves serious body injury, or abuse. Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful; temporary, or permanent use of a resident's belonging or money without the resident's consent. Review of a document dated 08/01/19, provided by the Director of Nursing (DON) on 08/23/19 at approximately 5:00 PM, revealed she was notified that CMT #1 would not accept narcotic cart keys from Registered Nurse (RN) #1 because he felt the narcotic count was off. Document is summarized as CMT #1 stated a narcotic card was missing from the cart for Resident #1 and after discussion by Unit Manager and DON there was no evidence of any missing medications or sheets. Interview with CMT #1 on 08/23/19 at 11:35 AM revealed when he came to work on 08/01/19, he counted off the narcotics with RN #1. CMT #1 stated there was a discrepancy in the count of Resident #1's Oxycodone 5/325 mg as needed pain medication. CMT #1 revealed there had always been a card and a narcotic sheet for (30) Oxycodone 5/325 mg pills for Resident #1 but it was not there when they did the count. He stated he knows it was there the day before when he had left and he counted those pills two (2) times a day times five (5) days a week and knows what was in the cart. CMT #1 stated he told RN #1 that there should be (30) more pills and she told him there was no sheet for it and walked off. CMT #1 revealed he gave the keys back to RN #1 and stated that he was not taking the cart with missing medications and there was a process that needed to be completed when something like this happens. RN #1 called the Unit Manager (UM) and the Unit Manager told RN #1 to go home. Interview with Registered Nurse #1 on 08/25/19 at 6:52 AM revealed CMT #1 had come in and counted with her, took the keys, started walking away then turned around and came back and stated a card of narcotics was missing for Resident #1. RN #1 stated they had counted all the cards and the sheets and CMT #1 kept saying they were missing. RN #1 stated she walked off and called the Unit Manager, telling her of the situation, and the UM asked another nurse to verify the count. RN #1 revealed she recounted the cart with LPN #4, and LPN #4 informed the Unit Manager the count was correct. RN #1 stated she was told she could go home. Interview on 08/26/19 at 1:23 PM with (HR) human resources revealed, if someone said a residents' medications were missing it would be considered misappropriation. Interview on 08/23/19 at 9:22 AM and on 08/26/19 at 5:45 PM, 6:35 PM and 6:40 PM with the DON and Administrator revealed they were aware of the concerns of CMT #1 but did not consider it an allegation of misappropriation of property because it was pain medications. The Administrator and DON stated they felt they had followed their policies related to these allegations, but did not feel they were allegations.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure an allegation of misappropriation of narcotics was thoroughly investigated for two (2) of three (3) sampled residents. Resident #1 related to a (30) thirty-card count of oxycodone and the pharmacy narcotic sheet with count was alleged to have gone missing per CMT #1, and Resident #2 requested a pain (Norco 10/325 mg) medication but was told it was too early to have one because she had already taken one.] The findings include: Review of facility policy titled, Alleged Abuse/Potential Neglect/Exploitation/Investigation, last revised 08/22/17, revealed it is the policy of this facility to provide an environment that promotes dignity and respect for all residents and one that prohibits abuse and/or neglect, misappropriation of resident property, and/or exploitation through the following. Check employment references, gather as much pertinent information as is available. Review work history. Identification: facility will strive to sustain ongoing systems to pro-actively identify events and occurrences that may constitute or contribute to the abuse. Protect: In order to prevent potential harm while the investigation is in progress, any employee accused will be relieved from duty until the timely investigation is complete. If the allegations is not substantiated, the employee will be reinstated. If the findings of the investigation is substantiated, further disciplinary actions will be taken. The name of the person reporting the allegation will remain confidential, only bin disclosed to the agencies involved. The investigation will be conducted in a manner that attempts to protect the privacy and confidentiality of the victim, the person reporting and the alleged perpetrator. Report and Investigate: any person that knows or has reasonable cause to suspect that a resident is being abuse including misappropriation of property shall immediately report such knowledge or suspicion to their supervisor, charge nurse, designee, or Administrator allegation are to be reported to the supervisor, charge nurse, designee, who will then notify the Administrator or appropriate designee. Administrator or DON will then notify the appropriate regulatory, investigative and/or law enforcement immediately but not later than 2 hours after the allegation is made if the allegation involves serious body injury, or abuse. Allegations of abuse, misappropriation of property--will be thoroughly investigated. The facility will have evidence that all allegation are thoroughly investigated; including misappropriation of resident property. The investigation can include, but is not limited to: the names of residents involved, date and time of incident, assessment of finding of resident, circumstances surrounding the incident, where incident took place, name of person(s) alleged with committing the act, names of witnesses, recommendations for corrective action to prevent reoccurrence, written records of findings obtained from interviews conducted, responsive actions, preventative measures recommended for implementation, and other information that may be requested or appropriate. Procedure: allegations of misappropriation are to be reported to the supervisor persons receiving report are to immediately inform Administrator or DON or designated person on call. Interventions to protect the resident(s) should be taken to avoid potential for harm during the investigative process, and should commence as soon as possible following receipt of allegation with a thorough investigation to gather facts regarding allegation; allegations should be reported to regulatory and investigative agencies. Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful; temporary, or permanent use of a resident's belonging or money without the residents consent. Review of facility policy undated and entitled, Drug Diversion Procedure, revealed; suspected drug diversion will be investigated and in the event that substantial evidence supports a belief that diversion had occurred, appropriate disciplinary and reporting actions will be taken. Diversion: theft of facility drugs, including use, unauthorized possession or removal from the premises of any amount of drugs, including unused amounts of drugs provided to patients or other drugs that have been discarded. Procedure: During the investigation the employee(s) suspected of participation in the diversion will be suspended without pay pending the outcome of the investigation. If upon completion of the investigation, the evidence supporting the suspicion of drug diversion is deemed insufficiently substantial to support a finding that diversion has occurred: the facts of the investigation will be documented. A record will be made in the employees personnel file indication that substantial evidence does not support the allegations or suspicion of diversion. Review of facility policy undated and entitled, Controlled Medication & controlled Medication Record Count Procedure revealed; When a controlled medication is discontinued, both the medication and the narcotic drug record will continue to be counted. The director of Nursing (DON) will be notified and he/she or his/her designee will remove the medication from the cart and sign with the nurse on duty to verify the count and adjust the controlled medication record count. No medication nor controlled record log may be removed from the sheet count book, by anyone except the DON or designee of the duty to, in writing. In the event a discrepancy is noted, efforts should be made to identify the cause of the discrepancy, if the cause is not determined, the DON should be notified. Review of Rules of Conduct for employees revealed, Employees may be placed on suspension pending investigation by supervisor or department supervisor, in consultation with human resources, for one to five days as permitted by applicable law. When the investigation is complete, employee will be informed of the decision and disciplinary action, if any. Interview on 08/23/19 at 11:35 AM with Certified Medication Technician (CMT) #1 stated he had worked and knew that Resident #1 had PRN pain medication (Oxy 5's) in the cart with a narcotic sheet for (30) thirty oxycodone 5/325 mg and there was a discrepancy with the count of the Oxycodone for Resident #1 and the medication had always been there and was there the day before when he had left; it was always there and CMT #1 stated he counted it 2X a day X5 days a week and knows what is in the cart. CMT #1 stated that he had told the RN #1 that there should be (30) more pills and she had told him there was no sheet for it and walked off and stated again no sheet for it. CMT #1 stated he gave the keys back to RN #1 and stated that he was not talking the cart with missing meds and there was a process that is done when something like this happens; CMT stated RN #1 called the Unit Manager (UM) and was told to go home. Additionally, Resident #2 had complained of pain and CMT #1 stated he could not give pain (Norco 10/325 mg) medication to Resident #2 because the pain medication had been signed out before he came on shift that it had been given to the resident. Additionally, Resident #2 stated they did not receive any pain medication at 3:47 AM from RN #1 because he/she had slept all night. Additionally, CMT stated this was overheard by the Transportation Director. CMT #1 stated that no one was drug tested and no statement was asked of him and he had went to the office and explained the occurrence to the Administrative staff. Interview on 08/23/19 at 6:30 PM with Transportation Director (TD) revealed that she had overheard Resident #2 stating that she had wanted a pain pill for long distance trip out of town but had been told that she had already been given a pain pill early in the morning but the resident had stated they did not receive a pain pill. Additionally, TD stated she had informed the DON upon returning from taking Resident #2 to the physician on the same day of the allegation. Interview on 08/23/19 at 1:23 PM with Resident #2 revealed she had not taken a pain pill through the night because he/she slept all night and had requested one but been told that one had been signed out as given already. Interview on 08/23/19 at 6:00 PM and 08/26/19 at 5:56 PM with Unit Manager revealed she had been called by RN #1 and told of the allegation against her by CMT #1 and she had told RN #1 she could leave. Additionally UM #1 stated she felt they had followed their policies. Interview on 08/23/19 at 9:22 AM and on 08/26/19 at 5:45 PM, 6:35 and 6:40 PM with DON and Administrator revealed she had not done documented an investigation related to the allegation or any of the verbal statements she had with staff, and just discussed it among the administrative staff and they would not jeopardize the residents, and the first people they would contact would be the police and the state regulatory office. However, DON provided a typed statement on 08/23/19 at approximately 5:30 PM and provided it. Additionally, Administrator and DON stated they were aware of the concerns of CMT #1 but did not consider it an allegation of misappropriation concerning pain medications and had looked at it and saw that it was signed out by RN #1 and it was discussed with UM and RN #1 so DON stated she did not feel it warranted any follow-up and that was basically I; and pharmacy had done an audit on 08/22/19 ( approximately 20 days after the allegation was made by CMT #1). Administrator and DON stated they felt they had followed their policies related to these allegations, but did not feel they were allegations. Interview on 08/23/19 at 1:45 PM with Medical Records revealed she would have all of Resident #1's medical records and there were no oxycodone records. However, two narcotic sheets were found belonging to Resident #1 for Oxycodone 5 milligrams (mg) to be given PRN. Review of document dated 08/01/19 and provided by DON on 08/23/19 at approximately 5:00 PM, revealed she was notified that CMT #1 would not accept narcotic cart keys from RN #1 because he felt the narcotic count was off with a prior count conducted by LPN #4 and RN #1 with no discrepancy found in the count with another cart counted with no discrepancy and signed by RN #1, LPN #4 and CMT #1. Document is summarized as CMT#1 stated narcotic cards were missing from the cart for Resident #1 and after discussion by Unit Manager and DON there is no evidence of any missing medications or sheets. Interview on 08/26/19 at 1:23 PM with (HR) human resources revealed, if see someone take a resident medications from a medication cart and they don't receive the medication then the staff is to go to the DON and the second thing is go to the administrator. Additionally, HR stated that if go in the room and resident states did not get pain pill and past time and the resident is alert and oriented and if the nurse says gave to them then report to the Administrative staff as well and there should be an investigation. HR stated that she would consider if someone said a residents' meds are missing it would be misappropriation. Interview on 08/25/19 at 1:18 AM with LPN #3 revealed if narcotic count is during the count an oncoming nurse does not take the keys, (DON) Director of Nursing is called and whoever else, and they are to come to the facility and do whatever they do. Additionally, LPN #3 stated that she is sure if narcotics are mission they everyone would be drug tested and no nurse can leave till the medication is accounted for, and RN #1 was at the facility working. Review of times sheet revealed RN #1 continued to work 08/02/19, 08/03/19, 08/04/19 without suspension during an investigation. Interview on 08/26/19 at 12:06 PM with LPN #4 revealed she had looked at the pills in the cards when counted with CMT #1 because he had left at 6PM on 08/01/19 Registered Nurse #1 did not get come on shift till 7:00 PM on 08/01/19, LPN #4 stated she could not remember if Resident #1 had a count of 60 pills and had counted looked at the sheets and counted them on 08/01/19 with RN #1; ust remember the count was correct both times. LPN #4 stated she had come in to work on 08/02/19 and found CMT #1 and RN #1 arguing over the carts with CMT #1 stating that he thought there was more pills and another sheet in the book that was not there at the count; but the count was correct according to the amount of sheets at that time and the amount of pills at that time of that count. CMT #1 handed the keys back to RN #1 until someone checked it out. RN #1 got mad and went outside and called the Unit Manager or the ADON--whatever one the RN#1 was on the phone with said that if the count was right she could leave and it was correct according to the count at that time. RN #1 came back in and handed LPN #4 the keys because they had told her she could leave and the CMT#1 would not take them from the RN #1. Additionally, LPN #4 stated she did not think any of the administrative staff was at the facility at the time, but she counted with the CMT #1 afterwards and then gave the keys to the CMT #1. LPN #4 stated she did not have to write out a witness statement and was not asked too, was not drug tested , do not know if anyone else was, and if there is an allegation of medication or a sheet missing staff is to inform the DON and they investigate it. Additionally, LPN stated that facility policy is to contact DON during an allegation of abuse, remove resident from harm, start an investigation, the perpetrator is placed on administrative leave pending an investigation. Interview on 08/25/19 at 6:52 AM with Registered Nurse #1 revealed she had not had a narcotic count off or any missing sheets, and that a Certified Medication Technician (CMT) #1 had come in and counted with her, took the keys started walking away then turned around and came back to her and stated a card of narcotics was missing. RN #1 state they had counted all the cards and the sheets and the CMT #1 kept saying the sheets were missing. RN #1 states she had walked off and called the Unit Manager told her of the situation and that the count was right and she asked another nurse of the count and the nurse verified the count and that she did not remember another card of Oxycodone or of a white card sheet missing and Resident #1 only used the pain medication for breakthrough pain and was a (PRN) as needed pain medication. RN #1 stated she recounted the cart with LPN #4 and the count was correct with LPN #4 informing the Unit Manager the count was correct and RN #1 stated she was then told to go home, and did not get a call from the DON or anyone after she went home. Interview on 08/23/19 at 3:22 PM with Assistant Director of Nursing (ADON) revealed she had just caught the tail end of the situation being discussed by the DON, concerning narcotics and sheet count of Resident #1 missing, that had transpired between CMT #1 and RN #1. Interview on 08/23/19 at 3:20 PM with Pharmacist #1 revealed she had been at the facility the day before (08?22?1(0 and does not review all resident charts but looked at the control narcotic sheet on 200 hall and everything looked ok. Additionally, Pharmacist #1 stated that look at all the control sheets on 200 hall and to see if everything looked ok and had taken random patients to see what was administered, documented on four (4) patients, and usually looks at the PRN' s. Interview on 08/23/19 at 3:57 PM with Pharmacist #2 stated that Resident #1 had only (60) 5 (Mg) milligrams of Oxycodone dispensed on 03/20/19 and the narcotic was requested again on 08/09/19 but the script had run out with pharmacy placing the medication in-que until another script was sent. Pharmacist #2 then stated that Advanced Registered Nurse Practitioner (ARNP) #1 discontinued the medication on 08/09/19 via a verbal order.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop a comprehensive care plan for one (1) of four (4) sampled residents (Resident #2). Resident #2 was admitted on [DATE] and an Admission Minimum Data Set (MDS) assessment was completed on 04/01/19; however, there was no documented evidence a Comprehensive Care Plan was developed as of 05/06/19. The findings include: Review of facility policy titled, Care Plan, last revised 11/20/17, revealed; it was the facility policy that residents will have a person centered plan of care that supports the resident in making their own choices, having control of their daily lives, and addresses their assessed needs. A person centered care plan will be developed by the Interdisciplinary team with respect to the resident's choice of participants which encompasses resident choices and assessed needs. The care plan will be developed within (7) seven days after completion of the comprehensive assessment. Review of facility policy titled, Minimum Data Set (MDS), last revised 10/21/16, revealed upon completion of the mandated clinical OBRA assessments, a comprehensive care plan should be developed or reviewed/revised, by the appropriate Interdisciplinary team member. The initial plan of care is developed within seven (7) days of the MDS completion and no more than twenty-one (21) days from the resident's admission. Record review revealed the facility admitted Resident #2 on 03/25/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 04/01/19 revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Further review revealed the resident required limited assistance with activities of daily living. Review of Resident #2's Chart revealed there was a Baseline Care Plan dated 03/25/19; however, there was no documented evidence of a Comprehensive Care Plans to include measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. Interviews with the MDS Coordinator on 05/06/19 at 2:30 PM and 4:45 PM revealed all care plans were in the residents' charts and Resident #2's Comprehensive Care Plans should be in the chart. She stated she was behind on care plans, as she was the only one who completed care plans for all the residents. She further revealed she had not had time to complete Resident #2's Comprehensive Care Plans. Interview with the Director of Nursing (DON) on 05/06/19 at approximately 3:35 PM revealed the Comprehensive Care Plans should be completed by the twenty-first (21st) day and that Resident #2's Comprehensive Care Plans should have been done by the MDS Coordinator. Interview with Administrator on 05/06/19 at 4:00 PM revealed he expected the comprehensive care plans to be completed in twenty-one (21) days. He stated Resident #2's Comprehensive Care Plan should have already been completed.

Based on observation, interview and review of the facility policy and procedure, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Dietary Aide #2 was observed using contaminated gloves to serve food with her hands and not washing her hands. Review of the Census and Condition dated 06/27/18 revealed fifty-seven (57) of fifty-eight (58) residents received their food from the kitchen. The findings include: Review of the facility's policy and procedure titled Dietary Sanitation, last revised 11/20/17, revealed the facility would store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food service staff would follow the procedures that reduce the potential for food borne pathogens, in storing, preparing and serving food. Observation of a lunch meal, on 06/26/18 at 11:08 AM, revealed Dietary Cook #2 picking meat up with gloved hands rather than using tongs, after she had contaminated the gloves by touching cabinet drawers and oven handles that others had touched. She was observed tugging at the bottom of the top she was wearing and at one time took hold of her name badge and tucked it in her top pocket all the while wearing the same pair of gloves and not washing her hands. Interview with Dietary Cook #2, on 06/27/18 at 3:42 PM, revealed she was not aware of the things she was doing during meal service and after she thought about it she knew she should have changed her gloves and washed her hands as well as used tongs to serve the meat and bread. She stated she had been educated some but not a lot. Observation on 06/26/18 at approximately 11:15 AM, revealed Dietary Aide #1 left the kitchen area with gloves on and returned to the kitchen without washing her hands or changing gloves before filling drinks for the residents. Interview with Dietary Aide #1, on 06/27/18 at 3:29 PM, revealed she knew when she left the kitchen area and returned to the kitchen she should have washed her hands and she had been educated to do that. She stated she realized what she had done but it was too late. Interview with Dietary Cook #1, on 06/27/18 at 3:25 PM, revealed she knew to use utensils to serve food when wearing gloves or not and if her hands became contaminated she would wash her hands and change gloves. Interview with the Dietary Manager on 06/27/18 at 3:16 PM, revealed the staff were aware of the need to use utensils such as tongs when serving food and if gloves became contaminated during food service, they knew to change their gloves and wash their hands. She stated staff were educated on this monthly by her and the Registered Dietitian (RD). Interview with the RD on 06/27/18 at 3:20 PM, revealed dietary staff were trained to change their gloves and wash their hands after they leave the kitchen area and return and after contaminating their gloves. She stated they were educated at least monthly and they must have been nervous.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure medication was administered according to the professional standards addressing the five (5) rights of medication administration for two (2) of four (4) sampled residents (Resident #1 and Resident #2). On 10/28/14, Registered Nurse (RN) #1 prepared several insulin doses in advance. RN #1 entered Resident #2's room with Resident #2 and Resident #3's insulin in her hand. RN #1 administered Resident #3's insulin ([MEDICATION NAME] 30 units) to Resident #2 instead of the 10 units of the physician ordered [MEDICATION NAME]. (Refer to F333) On 11/17/14, RN #1 entered the dining room with a syringe of insulin and approached Resident #1 (who does not receive insulin) to administer the insulin. Resident #1's family member stopped RN #1 and informed her that the resident did not take insulin. The facility's failure to ensure medication was administered according to the nursing standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/10/14 and was determined to exist on 10/28/14. The facility was notified of the Immediate Jeopardy on 12/10/14. The findings include: Review of the Nursing 2007 Drug Handbook, (2007) Lippincott Williams & Wilkins: Philadelphia, Pennsylvania revealed the overwhelming talk of ensuring medication safety can be managed by consistently using the five (5) rights of drug administration: The right drug, right route, right dose, right time and right patient. Further review revealed the right patient should be confirmed by checking the patient's identification, and asking the resident's their name. Review of the facility's policy and procedure titled, "General Dose Preparation and Medication Administration", last revised 01/01/13 revealed facility staff should only prepare medications for one resident at a time. Further review revealed facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time and for the correct resident. Review of the facility's policy and procedure titled, "Resident Identification", dated 01/01/07, revealed its policy was to maintain a resident identification system to assure prescribed treatments were administered to the correct resident. Further review revealed the facility had adopted two (2) resident identification systems which were to be implemented upon admission to assist in assuring that drugs, medications, and treatments prescribed for one resident were not administered to another. The resident identification systems included the resident's photograph and/or wristband identification. The policy stated if pictures were utilized, the location of the resident's photograph would be on the Medication Administration Record [REDACTED] 1. Record review revealed the facility admitted Resident #2 on 07/10/14 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 06/04/14, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of 99, which indicated the resident was not interviewable. Review of the facility's Medication Error Log, dated 10/28/14, revealed Resident #2 had received the wrong insulin. Interview with RN #1, on 12/09/14 at 3:40 PM, revealed she had prepared several insulin doses in syringes in advance on 10/28/14. RN #1 stated she entered Resident #2's room with Resident #2's and another resident's insulin in her hand. She stated she mistakenly picked up the other resident's insulin syringe and administered the insulin, [MEDICATION NAME] 30 units, to Resident #2 instead of his/her 10 units of the physician ordered [MEDICATION NAME]. RN #2 stated she immediately realized she had administered the wrong medication to Resident #2 and notified the Director of Nursing (DON) and the resident's physician. RN #1 stated Resident #2 was monitored throughout the night, as ordered by the physician, and no known adverse outcome was noted. Furthermore, RN #1 stated she had pre-filled the insulin syringes for residents frequently and did not realize it was an unsafe practice. 2. Record review revealed the facility admitted Resident #1 on 04/30/11 with [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident did not have a physician's orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/30/14, revealed the facility had assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was not interviewable. Review of the facility's Medication Error Logs for 11/2014, revealed no documented evidence of a medication error for Resident #1. Interview with RN #1, on 12/09/14 at 3:40 PM, revealed she had prepared several doses of insulin in advance on 10/28/14. RN #1 stated she had Resident #2 and Resident #3's insulin in her hand when she entered Resident #2's room. She stated she mistakenly picked up Resident #3's insulin ([MEDICATION NAME] 30 units) and administered it to Resident #2 instead of the [MEDICATION NAME] 10 units as ordered by the physician. She stated she immediately realized she had administered the wrong medication to Resident #2 and notified the Director of Nursing (DON) and the resident's physician. RN #1 stated she had pre-filled insulin syringes for residents frequently in the past and did not realize it was an unsafe practice. Further interview with RN #1 revealed she also had an incident with Resident #1 on 11/17/14. She stated she entered the dining room to administer the insulin and was told by the resident's family member that the resident did not take insulin. She stated she should have looked in the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON), on 12/09/14 at 9:43 AM and 12/10/14 at 5:43 PM, revealed she had talked with RN #1 after the medication error with Resident #2 and instructed her in the future to prepare the residents' insulin per policy and procedure, one resident at a time. The DON stated the facility did not have any documented evidence an investigation was conducted related to the incident with Resident #1 to determine the root cause, as she did not consider this to be a medication error because the medication was not administered to the resident. The DON stated that no action had been taken to prevent the incident from happening again. In addition, the DON stated the facility did not provide any re-education to the licensed nurses and had not developed an action plan or conducted any monitoring. Interview with the Administrator on 12/10/14 at 6:00 PM, revealed it was her expectation for staff to follow the facility's policy and procedures. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 12/10/14, RN #1 was re-educated to prepare medication for one resident at a time and was instructed never to pre-fill insulin syringes for multiple residents. In addition, RN #1 was re-educated on following the "Six Rights of Medication Administration" and to review the resident's photo in the MAR prior to administering medications. RN #1 was observed by the Regional Resource Nurse during administration of insulin to verify competency. Additionally, RN #1 was suspended without pay for three (3)days. 2. The DON and the Unit Managers (UM) were trained by the Regional Recourse Nurse on preparation of medication for only one resident at a time on 12/10/14, and on 12/11/14. 3. The facility provided education to all licensed nurses and Certified Medication Technicians (CMTs) on the "Six Rights of Medication Administration" and re-educated on the preparation of medication for only one resident at a time. This was done by the DON, UMs, and Regional Resource Nurse on 12/10/14, 12/11/14 and 12/12/14. In addition, the training has been incorporated into the orientation of all licensed nurse hires and CMT hires. 4. The DON was educated regarding the need to thoroughly investigate medication errors and to identify the root cause of the error. This education was conducted on 12/11/14 by the Administrator and the Regional Recourse Nurse. 5. The facility developed a process to ensure staff members were provided education/counseling to address the root cause of the error to prevent re-occurrence. The facility's Department Leaders consisting of the DON, Unit Managers, Dietary Supervisor, Activity Director, Social Service Director, Human Resource Director, and the Minimum Data Set (MDS) Coordinators were educated on the process on 12/11/14 and 12/12/14 by the Administrator. 6. Medication Administration observations for all nurses and CMTs were completed by the Regional Resource Nurse, DON and Unit Managers on 12/10/14 through 12/13/14. 7. Medication errors previously identified for 2014 were audited to verify that appropriate actions had been taken. The audit was completed on 12/12/14 by the Administrator, Regional Director of Operations and the Human Recourse Director. 8. On 12/11/14, the Regional Resource Nurse conducted training for the Quality Assurance (QA) Team Members which included the Administrator, Director of Nursing, Unit Managers, MDS Coordinators, Social Service Director, Activity Director, Maintenance Director, Human Resources Director and the Medical Records Director regarding Root Cause Analysis. 9. The QA committee, which includes the Administrator, Director of Nursing, Unit Managers, MDS Coordinators, Social Service Director, Activity Director, Maintenance Director, Human Resources Director and the Medical Records Director will track medication pass observation findings for six (6) months to verify that proper administration technique is being followed. The QA Committee will also confirm that measurable goals are presented on all medication error counseling to create follow up monitoring to evaluate the ongoing compliance with policies. Trends will also be reviewed in the monthly QA meeting in conjunction with the Medical Director. 10. The facility modified the process for responding and recording Medication Errors to include implementation of corrective measures based on the root cause analysis findings. The facility will maintain a record of education and performance correction actions conducted with employees involved with medication errors. Employees involved in medication errors will be subject to progressive disciplinary actions. 11. The facility modified the new employee orientation education to include the proper way to prepare and administer medication and the six (6) rights of medication administration. In addition, all new medication errors are now brought to the daily QA meetings Monday-Friday to discuss the root cause analysis and ensure employee follow up. The Administrator and DON or, the On Call Administrative Nurse will be notified when a medication error occurs. Additionally, on 12/12/14, a checklist was implemented to guide the staff through the appropriate steps following a medication error. 12. The facility developed and implemented a log on 12/15/14 to assist in monitoring the implementation of corrective actions and to assist in trending errors identified which will be reviewed as part of the Abbreviated Quality Assurance Meeting. 13. The QA Committee will review medication errors/performance correction to identify trends conduct root cause analysis and ensure appropriate interventions added to prevent re-occurrence. 14. The DON, Unit Managers, and the Resource Nurses will conduct medication pass observations on all nurses and CMTs each month for six (6) months and then quarterly. Results of the observations will be reviewed at the monthly QA Committee meeting. 15. Monthly post testing on the six (6) rights of medication administration, preparation of medication for one resident at a time, and resident identification will be completed for six (6) months and then reduced to quarterly. The State Survey Agency validated the Corrective Action taken by the facility as follows: 1. Interview with RN #1 on 12/23/14 at 10:55 AM, revealed she was re-educated to prepare medication for one resident at a time and was instructed never to pre-fill insulin syringes for multiple residents. In addition, RN #1 stated she was re-educated on following the "Six Rights of Medication Administration" and to review the resident's photo in the MAR prior to administering medications. RN #1 stated she was observed by the Regional Resource Nurse during administration of insulin to verify competency and was suspended for three (3) days. Review of a "Staff Development Attendance Record" dated 12/10/14 validated RN #1 received the education. 2. Interview with the DON on 12/23/14 at 11:05 AM, revealed she was trained by the Regional Recourse Nurse on preparation of medication for only one resident at a time. Interviews on 12/23/14 with Unit Manager, LPN #3 at 9:35 AM and Unit Manager, LPN #4 at 10:09 AM, revealed they were trained by the Regional Recourse Nurse on preparation of medication for only one resident at a time on 12/10/14 and on 12/11/14. Review of the facility's attendance records dated 12/10/14 and 12/11/14 verified training was conducted. 3. Interview on 12/23/14 with LPN #2 at 10:00 AM, LPN #5 at 7:39 AM, LPN #6 at 7:29 AM, LPN #7 at 11:02 AM, and LPN #8 at 10:55 AM revealed they had been re-educated on the "Six Rights of Medication Administration" and preparation of medication for only one resident at a time. Interviews on 12/23/14 with CMT #2 at 9:18 AM and CMT #3 at 10:35 AM, revealed they had been re-educated on the "Six Rights of Medication Administration" and preparation of medication for only one resident at a time. 4. Interview with the DON, on 12/23/14 at 11:05 AM, revealed she was educated by the Regional Resource Nurse regarding the need to thoroughly investigate medication errors and to identify the root cause of the error. 5. Interview on 12/23/14, with the Dietary Manager at 6:55 AM, the Activity Director at 9:30 AM, and the Social Service Director at 9:12 AM, revealed they had received education on the facility's new process to address the root cause of medication errors to prevent re-occurrence. The facility's Department Leaders were educated on the process on 12/11/14 and 12/12/14 by the Administrator. 6. Interviews on 12/23/14, with LPN #2 at 10:00 AM, LPN #5 at 7:39 AM, LPN #6 at 7:29 AM, LPN #7 at 11:02 AM, and LPN #8 at 10:55, revealed they had been observed during medication administration and received a check off for competency. 7. Interview with the Administrator on 12/23/14 at 9:40 AM, revealed the facility reviewed all medication errors previously identified for 2014 and performed an audit to verify appropriate actions were taken. 8. Interview on 12/23/14, with the Dietary Manager at 6:55 AM, the Activity Director at 9:30 AM, and the Social Service Director at 9:12 AM, revealed they received training conducted by the Regional Resource regarding Root Cause Analysis. 9. Interview with the DON on 12/23/14 at 11:05 AM revealed the facility was performing audits and competency testing to confirm that proper medication administration techniques were followed. She stated that competencies audits were done randomly and included all nursing staff. Interview with the Administrator on 12/23/14 at 9:40 AM, revealed the QA committee continues to meet monthly and the facility was evaluating for potential trends. Interview with the Medical Director on 12/23/14 at 12:00 PM revealed medication errors were a big concern for him. He stated the facility had implemented new processes to better determine the root cause of all medication errors and the QA committee will continue to evaluate for any potential trends. 10. Interview with the Administrator on 12/23/14 at 9:40 AM, revealed the facility modified the process for responding and recording Medication Errors to include implementation of corrective measures based on the root cause analysis findings. 11. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed education regarding the proper way to prepare and administer medication and the six (6) rights of medication administration was now included in the New Employee Orientation. Further interview revealed the facility had a daily Abbreviated Quality Assurance meeting Monday-Friday to determine the root cause for all medication errors. The DON stated that both she and the Administrator were notified immediately when a medication error occurred. 12. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed they each keep a log to monitor medication errors and ensure implementation of appropriate corrective actions. 13. Interview on 12/23/14, with the Dietary Manager at 6:55 AM; the Activity Director at 9:30 AM; and, the Social Service Director at 9:12 AM, revealed as part of the QA Committee they now review medication errors/performance corrections each month during the QA meetings to identify trends, conduct root cause analysis, and ensure appropriate interventions were added to prevent further errors. 14. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed they will continue to conduct Medication Pass Observations on all nurses and CMTs each month for six (6) months and then quarterly. 15. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed they will continue to conduct monthly post testing on the six (6) rights of medication administration, preparation of medication for one resident at a time, and resident identification for all nurses and CMTs for six (6) months and then reduce to quarterly.

Based on observation, interview, record review, and review of the facility's policy and procedures it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #2) was free of any significant medication errors. The facility failed to ensure licensed staff followed the facility's policy and procedure related to ensuring medication was administered to the right resident. Registered Nurse (RN) #1 prepared several insulin doses, for different residents on 10/28/14, before it was time for the medication to be administrated. RN #1 entered Resident #2's room with Resident #2 and Resident #3's insulin in her hand. The RN administered Resident #3's insulin ([MEDICATION NAME] 30 units) to Resident #2 instead of giving the resident the 10 units of physician ordered [MEDICATION NAME]. The facility's failure to ensure residents remained free of any significant medication errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/10/14 and was determined to exist on 10/28/14. The facility was notified of the Immediate Jeopardy on 12/10/14. The findings include: Review of the facility's policy and procedure titled, "General Dose Preparation and Medication Administration", revised 01/01/13 revealed facility staff should only prepare medications for one resident at a time. Further review revealed facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and for the correct resident. Review of the facility's policy and procedure titled, "Resident Identification", dated 01/01/07, revealed its policy was to maintain a resident identification system to assure prescribed treatments were administered to the correct resident. Further review revealed the facility had adopted two (2) resident identification systems which were to be implemented upon admission to assist in assuring that drugs, medications, and treatments prescribed for one resident were not administered to another. Additionally, the resident identification systems included Resident's photograph and/or wristband identification. The policy stated if pictures were utilized the location of the resident's photograph would be on the Medication Administration Record [REDACTED] Record review revealed the facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed physician's orders [REDACTED]. Review of the facility's Medication Error Log, dated 10/28/14, revealed Resident #2 had received the wrong insulin. Interview with RN #1 on 12/09/14 at 3:40 PM, revealed she had prepared several insulin doses in syringes in advance on 10/28/14. RN #1 stated she had Resident #2's and another resident's insulin in her hand when she entered Resident #2's room. She stated she mistakenly picked up the other resident's insulin syringe and administered the insulin, [MEDICATION NAME] 30 units, to Resident #2 instead of his/her 10 units of the physician ordered [MEDICATION NAME]. She further stated she immediately realized she had administered the wrong medication to Resident #2 and notified the Director of Nursing (DON) and the resident's physician. RN #1 stated Resident #2 was monitored throughout the night, as ordered by the physician, and no known adverse outcome was noted. Furthermore, RN #1 stated she had pre-filled the insulin syringes for residents frequently and did not realize it was an unsafe practice. However, the facility's policy entitled "General Dose Preparation and Medication Administration", revised 01/01/13 revealed facility staff should only prepare medications for one resident at a time. Interview with the DON, on 12/09/14 at 9:43 AM and 12/10/14 at 5:43 PM, revealed she had talked with RN #1 after the medication error and instructed her in the future to prepare the residents' insulin per policy and procedure, one resident at a time. Additionally, the DON stated the facility did not have any documented evidence that an investigation had been conducted to determine the root cause. There was also no documented evidence that any action(s) had been taken to prevent the incident from happening again. Furthermore, she stated the facility did not consider the medication error significant because Resident #2 did not experience an adverse outcome. Thus, the facility did not provide any re-education to the licensed nurses and had not developed an action plan. The DON stated she was made aware of a second incident involving medication administration with RN #1 by an upset family member. The DON stated but no action had been taken because a medication error had not occurred. Interview with the Administrator on 12/10/14 at 6:00 PM, revealed it was her expectation for staff to follow the policy and procedures. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 12/10/14, RN #1 was re-educated to prepare medication for one resident at a time and was instructed never to pre-fill insulin syringes for multiple residents. In addition, RN #1 was re-educated on following the "Six Rights of Medication Administration" and to review the resident's photo in the MAR prior to administering medications. RN #1 was observed by the Regional Resource Nurse during administration of insulin to verify competency. Additionally, RN #1 was suspended without pay for three (3)days. 2. The DON and the Unit Managers (UM) were trained by the Regional Recourse Nurse on preparation of medication for only one resident at a time on 12/10/14, and on 12/11/14. 3. The facility provided education to all licensed nurses and Certified Medication Technicians (CMTs) on the "Six Rights of Medication Administration" and re-educated on the preparation of medication for only one resident at a time. This was done by the DON, UMs, and Regional Resource Nurse on 12/10/14, 12/11/14 and 12/12/14. In addition, the training has been incorporated into the orientation of all licensed nurse hires and CMT hires. 4. The DON was educated regarding the need to thoroughly investigate medication errors and to identify the root cause of the error. This education was conducted on 12/11/14 by the Administrator and the Regional Recourse Nurse. 5. The facility developed a process to ensure staff members were provided education/counseling to address the root cause of the error to prevent re-occurrence. The facility's Department Leaders consisting of the DON, Unit Managers, Dietary Supervisor, Activity Director, Social Service Director, Human Resource Director, and the Minimum Data Set (MDS) Coordinators were educated on the process on 12/11/14 and 12/12/14 by the Administrator. 6. Medication Administration observations for all nurses and CMTs were completed by the Regional Resource Nurse, DON and Unit Managers on 12/10/14 through 12/13/14. 7. Medication errors previously identified for 2014 were audited to verify that appropriate actions had been taken. The audit was completed on 12/12/14 by the Administrator, Regional Director of Operations and the Human Recourse Director. 8. On 12/11/14, the Regional Resource Nurse conducted training for the Quality Assurance (QA) Team Members which included the Administrator, Director of Nursing, Unit Managers, MDS Coordinators, Social Service Director, Activity Director, Maintenance Director, Human Resources Director and the Medical Records Director regarding Root Cause Analysis. 9. The QA committee, which includes the Administrator, Director of Nursing, Unit Managers, MDS Coordinators, Social Service Director, Activity Director, Maintenance Director, Human Resources Director and the Medical Records Director will track medication pass observation findings for six (6) months to verify that proper administration technique is being followed. The QA Committee will also confirm that measurable goals are presented on all medication error counseling to create follow up monitoring to evaluate the ongoing compliance with policies. Trends will also be reviewed in the monthly QA meeting in conjunction with the Medical Director. 10. The facility modified the process for responding and recording Medication Errors to include implementation of corrective measures based on the root cause analysis findings. The facility will maintain a record of education and performance correction actions conducted with employees involved with medication errors. Employees involved in medication errors will be subject to progressive disciplinary actions. 11. The facility modified the new employee orientation education to included the proper way to prepare and administer medication and the six (6) rights of medication administration. In addition, all new medication errors are now brought to the daily QA meetings Monday-Friday to discuss the root cause analysis and ensure employee follow up. The Administrator and DON or, the On Call Administrative Nurse will be notified when a medication error occurs. Additionally, on 12/12/14, a checklist was implemented to guide the staff through the appropriate steps following a medication error. 12. The facility developed and implemented a log on 12/15/14 to assist in monitoring the implementation of corrective actions and to assist in trending errors identified which will be reviewed as part of the Abbreviated Quality Assurance Meeting. 13. The QA Committee will review medication errors/performance correction to identify trends conduct root cause analysis and ensure appropriate interventions added to prevent re-occurrence. 14. The DON, Unit Managers, and the Resource Nurses will conduct medication pass observations on all nurses and CMTs each month for six (6) months and then quarterly. Results of the observations will be reviewed at the monthly QA Committee meeting. 15. Monthly post testing on the six (6) rights of medication administration, preparation of medication for one resident at a time, and resident identification will be completed for six (6) months and then reduced to quarterly. The State Survey Agency validated the Corrective Action taken by the facility as follows: 1. Interview with RN #1 on 12/23/14 at 10:55 AM, revealed she was re-educated to prepare medication for one resident at a time and was instructed never to pre-fill insulin syringes for multiple residents. In addition, RN #1 stated she was re-educated on following the "Six Rights of Medication Administration" and to review the resident's photo in the MAR prior to administering medications. RN #1 stated she was observed by the Regional Resource Nurse during administration of insulin to verify competency and was suspended for three (3) days. Review of a "Staff Development Attendance Record" dated 12/10/14 validated RN #1 received the education. 2. Interview with the DON on 12/23/14 at 11:05 AM, revealed she was trained by the Regional Recourse Nurse on preparation of medication for only one resident at a time. Interviews on 12/23/14 with Unit Manager, LPN #3 at 9:35 AM and Unit Manager, LPN #4 at 10:09 AM, revealed they were trained by the Regional Recourse Nurse on preparation of medication for only one resident at a time on 12/10/14 and on 12/11/14. Review of the facility's attendance records dated 12/10/14 and 12/11/14 verified training was conducted. 3. Interview on 12/23/14 with LPN #2 at 10:00 AM, LPN #5 at 7:39 AM, LPN #6 at 7:29 AM, LPN #7 at 11:02 AM, and LPN #8 at 10:55 AM revealed they had been re-educated on the "Six Rights of Medication Administration" and preparation of medication for only one resident at a time. Interviews on 12/23/14 with CMT #2 at 9:18 AM and CMT #3 at 10:35 AM, revealed they had been re-educated on the "Six Rights of Medication Administration" and preparation of medication for only one resident at a time. 4. Interview with the DON, on 12/23/14 at 11:05 AM, revealed she was educated by the Regional Resource Nurse regarding the need to thoroughly investigate medication errors and to identify the root cause of the error. 5. Interview on 12/23/14, with the Dietary Manager at 6:55 AM, the Activity Director at 9:30 AM, and the Social Service Director at 9:12 AM, revealed they had received education on the facility's new process to address the root cause of medication errors to prevent re-occurrence. The facility's Department Leaders were educated on the process on 12/11/14 and 12/12/14 by the Administrator. 6. Interviews on 12/23/14, with LPN #2 at 10:00 AM, LPN #5 at 7:39 AM, LPN #6 at 7:29 AM, LPN #7 at 11:02 AM, and LPN #8 at 10:55, revealed they had been observed during medication administration and received a check off for competency. 7. Interview with the Administrator on 12/23/14 at 9:40 AM, revealed the facility reviewed all medication errors previously identified for 2014 and performed an audit to verify appropriate actions were taken. 8. Interview on 12/23/14, with the Dietary Manager at 6:55 AM, the Activity Director at 9:30 AM, and the Social Service Director at 9:12 AM, revealed they received training conducted by the Regional Resource regarding Root Cause Analysis. 9. Interview with the DON on 12/23/14 at 11:05 AM revealed the facility was performing audits and competency testing to confirm that proper medication administration techniques were followed. She stated that competencies audits were done randomly and included all nursing staff. Interview with the Administrator on 12/23/14 at 9:40 AM, revealed the QA committee continues to meet monthly and the facility was evaluating for potential trends. Interview with the Medical Director on 12/23/14 at 12:00 PM revealed medication errors were a big concern for him. He stated the facility had implemented new processes to better determine the root cause of all medication errors and the QA committee will continue to evaluate for any potential trends. 10. Interview with the Administrator on 12/23/14 at 9:40 AM, revealed the facility modified the process for responding and recording Medication Errors to include implementation of corrective measures based on the root cause analysis findings. 11. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed education regarding the proper way to prepare and administer medication and the six (6) rights of medication administration was now included in the New Employee Orientation. Further interview revealed the facility had a daily Abbreviated Quality Assurance meeting Monday-Friday to determine the root cause for all medication errors. The DON stated that both she and the Administrator were notified immediately when a medication error occurred. 12. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed they each keep a log to monitor medication errors and ensure implementation of appropriate corrective actions. 13. Interview on 12/23/14, with the Dietary Manager at 6:55 AM; the Activity Director at 9:30 AM; and, the Social Service Director at 9:12 AM, revealed as part of the QA Committee they now review medication errors/performance corrections each month during the QA meetings to identify trends, conduct root cause analysis, and ensure appropriate interventions were added to prevent further errors. 14. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed they will continue to conduct Medication Pass Observations on all nurses and CMTs each month for six (6) months and then quarterly. 15. Interview with the Administrator on 12/23/14 at 9:40 AM and the DON at 11:05 AM, revealed they will continue to conduct monthly post testing on the six (6) rights of medication administration, preparation of medication for one resident at a time, and resident identification for all nurses and CMTs for six (6) months and then reduce to quarterly.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure each resident had the right to be free from mental, physical and sexual abuse. The facility failed to assess and implement effective interventions to prevent sexual abuse for four residents (#7, #14, #18 and #ZZ), in the selected sample of five. On 06/09/10, the facility identified Resident #16 as having behaviors of a sexual nature and became aware of Resident #16's history of sexual behaviors in other facilities on 06/15/10. While the facility implemented care plan interventions to address Resident #16's sexually aggressive behaviors, the facility failed to ensure those interventions were effective in managing the resident's behaviors and failed to identify and implement interventions to prevent potential abuse of other residents. Resident #16 began having sexually aggressive behaviors, which impacted other residents of the facility, on 07/10/10 and continued on 07/12/10, 07/15/10, 07/19/10 and 07/22/10. Furthermore, the facility while aware of these incidents, failed to ensure interventions implemented were effective in managing Resident #16's repetitive sexual behaviors and failed to provide appropriate supervision to prevent Resident #16 from abusing residents of the facility. Resident #16 touched Resident #7's pubic area while he/she was sitting on a sofa in the common area of the facility. Resident #16 had his/her hand in Resident #14's pants touching Resident #14's pubic area and Resident #14 was yelling for help. Resident #18 was in bed, during the night, when Resident #16 entered Resident #18's room and demanded sex from Resident #18. Resident #ZZ reported to staff that Resident #16 had stood in his/her doorway and demanded sex. It was identified that the facility's failure to intervene to prevent abuse had placed residents at risk for serious injury, harm, impairment, or death to a resident receiving care in this facility. The findings include: A review of the facility Abuse/Neglect policy, dated 01/01/07 and revised 08/20/08, revealed sexual abuse defined as "an act of a sexual nature committed for the sexual gratification of the abuser and in the presence of a disabled adult or elderly person without the disabled adult's or elderly person's informed consent." Sexual abuse can include, but is not limited to fondling. Under the Identification section, the policy stated as part of the assessment process, residents will be reviewed to determine if the resident displays inappropriate behavior that could result in a catastrophic behavior incident. Interventions will be care planned as appropriate. Review of Resident #16's closed record revealed the facility admitted Resident #16, on 06/07/10, with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#16. Review of the nurse's notes revealed Resident #16 began exhibiting verbally aggressive sexual behaviors towards staff, on 06/09/10 at 2:00 PM, when Resident #16 stated to a Certified Nurse Aide (CNA) while she was providing assistance with toileting, "You like to shake it don't you" and "Let me see your boobs, come on let me see them". These behaviors continued on 06/15/10 at 12:00 PM, per the nurses' notes, which revealed Resident #16 remarked to another CNA during care, "Put it up (his penis)" and asked if the CNA was "Scared of it". Additionally, Resident #16 asked the CNA if she had "Ever been touched". The facility requested additional information about Resident #16's behavior history due to the behaviors exhibited on 06/09/10 and 06/15/10. On 06/15/10, the facility received information from a previous facility's History and Physical and signed as received by the Administrator, which revealed Resident #16 had a history of [REDACTED]. The facility developed a "Behavioral symptoms" care plan dated 06/15/10 which revealed the following interventions: 1. Explain that such behavior will not be tolerated; 2. Provide opportunities to vent aggressive feelings; 3. Always have 2 CNAs present when care provided; and, 4. Notify Social Services (SS) and Physician of any change in frequency of behaviors exhibited. There was no documented evidence the facility identified that Resident #16's sexual behaviors could potentially impact other residents of the facility and there was no documented evidence the facility implemented interventions requiring supervision to ensure other residents of the facility would not be impacted by these behaviors. Furthermore, there was no documented evidence the facility followed up with psychiatric services for Resident #16. On 06/20/10, the facility assessed, through the Resident Assessment Protocol (RAP), Resident #16 as having moderately impaired cognitive skills for daily decision making and socially inappropriate behaviors on the RAP. No additional interventions were added to the resident's care plan dated 06/15/10. A nurse's note, dated 07/10/10 at 9:30 PM revealed Resident #16 was wandering in other residents' rooms and made the statement, "I want some pussy, go ask her to give me some pussy" and than called the staff "Sluts" when facility staff redirected. The note detailed the facility intervened by redirecting the resident. There was no other evidence of action the facility took to address this resident's behavior in order to prevent potential abuse of other residents. Nurse's notes, dated 07/12/10 at 9:30 AM, revealed, "Resident noted in 212 A, female bed, masturbating and ejaculated on bed; 212 A resident not in room". On 07/15/10 at 10:40 AM, a nurse's note entry revealed the resident had "Pants down fondling self". Interview on 08/20/10 at 8:30 AM revealed this behavior occurred in view of Resident #16's roommate. The nurse's note additionally revealed Resident #16 stated all the female staff were "Whores". Review of the "Behavior symptoms" care plan revealed the facility added the following interventions on 07/15/10: an alarm to Resident #16 top of door; to be monitored every 15 minutes; and pharmacist review meds. A phone interview on 08/20/10 ar 4:55 PM with Resident #18 revealed Resident #16 had entered his/her room during the night and said, "Give me some" two times. Resident #18 yelled for the staff and nobody came but Resident #16 left the room when he/she yelled for staff. Resident #18 reported what had happened to the day shift nurse the next morning. Additionally, Resident #18 stated he/she had heard from "a lot of work-hands that Resident #16 had done it to others" and said "the lady next door to me said Resident #16 had done it to her". Resident #18 did not know the resident's name. Resident #18 said what happened "Didn't make me feel very good" and "I'd put him/her in a cage". A review of a MDS assessment, dated 7/15/10, revealed Resident #18 was independent and had no cognitive impairment. On 08/20/10 at 9:45 AM, interview with LPN #2 confirmed that Resident #16 had entered Resident #18's room one night demanding sex and scared him/her. An interview with the Social Service Director (SSD), on 08/20/10 at 11:45 AM, revealed she was called, on 07/11/10 (Sunday), at home due to Resident #18 reporting to the day shift nurse that Resident #16 had entered his/her room demanding he/she "Give him/her some". The SSD thought Resident #16 was asking for sex. No incident report was completed because there was "no contact, no injury and the nurse would have done an incident report". The SSD stated she did not document anything in the Social Service Notes and had not implemented any new interventions. The facility was unable to provide evidence of action taken to prevent Resident #16 from exhibiting aggressive verbal sexual behaviors towards other residents. Nurse's note, dated 07/19/10 at 8:30 AM, revealed Resident #16 was found in another resident's bed and when redirected by the staff, he/she became aggressive and slapped at them. There was no evidence the facility implemented any further intervention other than redirection. An interview with Housekeeping Staff #1, on 08/18/10 at approximately 11:45 AM, revealed she saw Resident #16, on 07/22/10 in Resident #14's room. She observed Resident #16 standing over Resident #14's bed with his/her hand in the front of Resident #14's pants using his/her hand to "rub" Resident #14's pubic area inside Resident #14's pants. Resident #14 was yelling "help, help' and saying "Get off me". Housekeeper #1 yelled for help, entered the room and yelled "No, no, get off (him/her)". Resident #16 then "jerked" his/her hand out of Resident #14's pants. Resident #14 was "visibly upset and crying". Housekeeper #1 stated she "...almost started crying too. Resident #14 couldn't do anything". Additionally, the Housekeeper stated staff who entered the room to help (couldn't remember who) made the statement "Oh, that's what (he/she) has been yelling about". Record review revealed the facility had assessed Resident #14, MDS assessment dated [DATE], as having modified independence cognitively with some difficulty in new situations only. Interviews with Resident #14, on 08/20/10 at 3:45 PM and on 08/30/10 at 1:20 PM revealed Resident #16 had pulled the cover back and "...put (his/her) hand inside my pants and touched me". Resident #14 told Resident #16 to "Stop" and staff came and escorted him/her out of the room. Resident #14 stated "I'm scared when I get out and somebody looks at me now". Resident #14 spoke softly but became loud and pressured when describing how he/she told Resident #16 to get out. An interview on 08/19/10 at approximately 5:50 PM, with Nurse Aide (NA) #1, revealed he was aware of Resident #16's behaviors of wandering. NA #1 stated Resident #16 had a favorite room (Resident #14's) located across the hall from him/her and required frequent redirection out of that room. An interview on 08/20/10 at 4:00 PM with family member #1 (former resident of the facility) revealed he/she had witnessed on 07/22/10, Resident #16 rubbing Resident #7's leg and then moved his/her hand and began rubbing Resident #7's pubic area. Resident #7 was half asleep on the couch and did not know what was happening. The family member stated "It made me feel bad". Review of a nurse's note, dated 07/22/10 at 3:20 PM, revealed Resident#16 was observed pulling the cover off a female resident and told staff he/she was "up to meanness". On 08/31/10 at 3:15 PM, interview with Resident #ZZ (identified by the facility during the investigation of 07/22/10 incident), who the facility assessed as cognitively independent, revealed Resident #16 had been to the doorway of his/her room on two occasions and requested sex. Resident #ZZ stated he/she remembered telling a nurse but could not recall who and told the Social Service Director on 07/27/10. On 08/20/10 at 9:45 AM, an interview conducted with LPN #2 revealed Resident #16 had entered other residents' rooms several times and Resident #16 would wait for one resident to leave a room, leaving the other resident alone. Resident #16 knew what he/she was doing and at no time did she see him/her confused as he/she focused on female residents. LPN #2 stated Resident #16 made her feel "uneasy". An interview conducted with LPN #1, on 08/20/10 at approximately 8:30 AM, revealed Resident #16 had behaviors of staring at everybody's bottoms and entering other residents' rooms. LPN #1 stated she thought Resident #16 had a purpose for entering some rooms in particular and thought he/she "preyed on female residents". She also stated the last incident, on 07/22/10 with Resident #14 was a deliberate choice because Resident #14 was non-ambulatory and located directly across from Resident #16. Additionally, LPN #1 stated the facility had placed a door alarm on Resident #16's door because he/she had been in other residents' rooms touching him/herself. The facility had utilized 15 minute checks but "In 15 minutes Resident #16 could do what he/she did to Resident #14". LPN #1 stated, "I was scared of Resident #16 myself" and had told the administrative staff. An interview on 08/20/10 at 12:20 PM, with the Director of Nursing (DON), revealed nurses were responsible to ensure a resident's care plan was updated if an immediate intervention was needed. She thought Resident #16 had been on 15 minute checks but on 07/15/10 she had added "to be monitored every 15 minutes" with a date of 07/10/10. Additionally, on 07/15/10, "alarm to top of door" and Pharmacist reviewed meds" was added. The DON did not know if the 15 minute checks were placed on the Nurse Aide care plan. Interviews with LPN #2 on 08/20/10 at 8:30 AM, LPN #1 on 08/20/10 at 9:45 AM, the SSD on 08/20/10 at 11:45 AM, and CNA #3 on 08/20/10 at 3:10 PM, revealed they thought Resident #16 might have been on 15 minute checks off and on but no particular staff was assigned as responsible to ensure the checks were completed and no flow sheet was utilized to verify if checks were completed. A review of the Nurse Aide Data Sheet (not dated) revealed two assist with all care and door alarm for a safety device. The Nurse Aide Data Sheet did not indicate 15 minute checks. The Behavior Interventions sections was blank. The care plan titled "Behavioral symptoms (#6145) revealed 15 minute checks, dated 07/10/10 that the DON had stated she actually placed on the care plan on 07/15/10. No other documentation for 15 minute checks could be verified. An interview with the Administrator conducted 08/19/10 at approximately 6:35 PM, revealed Resident #16's behaviors had been discussed in the morning meetings and staff were told to present reality and that his/her behaviors were unacceptable. Resident #16 had been admitted with orders to follow up with psychiatric service and a psychiatric evaluation was discussed sometime during Resident #16's first week after admission; however, no behaviors were documented for about a month so the psychiatric evaluation was not obtained. The Administrator further revealed the facility had initiated 15 minute checks of Resident #16 due to inappropriate behaviors but the facility had no method utilized to determine who was completing the checks. Furthermore, the facility had no policy and procedure for 15 minute checks. The Administrator confirmed that the facility did not initiate 1:1 supervision of Resident #16 until 07/22/10, after the resident was observed by staff with his/her hand in Resident #14's pants, rubbing the resident's pubic area. The facility then initiated transfer of Resident #16 to a geriatric psychiatric facility on 07/23/10. An acceptable Allegation of Compliance (AoC) was received 09/02/10. On 07/22/10 Resident #16 was placed on 1:1 monitoring immediately after the incident and remained on 1:1 monitoring until 07/23/10 when he/she was discharged to a geriatric psychiatric facility. Resident #14 was assessed following the incident. The SSD visited with the resident on 07/22/10 following the incident and twice again on 07/23/10 to follow up and observe for signs and symptoms of distress as crying, tearfulness, fidgeting, facial expressions and changes in voice from normal. Resident #14 was discharged to a hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #7 was assessed by nursing staff following the incident and showed no signs and symptoms of pain or distress. The SSD and Administrator (a former Social Worker) visited Resident #7 eight times from 07/22/10 to 07/28/10. The resident did not show any changes in behavior as crying, tearfulness or unpleasantness which would have been abnormal for this resident. The actions taken to verify the removal of Immediate Jeopardy included review of the policy developed regarding Inappropriate Sexual Behavior Management on 08/30/10. Verified training was completed for the Administrator, SSD and staff were trained by Quality Management Specialist Nurses regarding this policy beginning on 08/30/10 and continuing with on-coming employees before they began work. A review was conducted of the Abuse Policy with an emphasis placed on recognizing sexual abuse and inappropriate behaviors and the need to report any suspected abuse of any kind. A review of the policy developed on 08/30/10 described the process to be followed when providing behavior monitoring including 1:1 monitoring and every 15 minute monitoring. The completion of the post test taken by the Administrator and staff to verify understanding was reviewed. The Director of Nursing, MDS Coordinator, Unit Managers, SSD, Activity Director, Dietary Director, Rehab Director and Administrator were provided training regarding updating the plan of care as conditions arise and monitoring the effectiveness of the approaches that were in place. The training was conducted by Quality Management Specialist Nurses on 08/31/10. A review of the new Inappropriate Sexual Behavior Management policy dated, 08/30/10, was conducted 08/31/10. Interviews with the Administrator and SSD confirmed they were in-serviced by the Quality Management Specialist Nurses on 08/30/10. Interviews were conducted with CNAs, LPNs and RNs to confirm they had received the in-service related to the new Inappropriate Sexual Behavior Management policy. The DON was responsible to maintain a list of employees not readily available for training and testing to ensure the training was completed prior to their return to duty. Additionally, education of the Abuse Policy was provided regarding the entire abuse policy and inappropriate behaviors and recognizing sexual abuse. This education was verified initiated on 08/30/10 and was continuing with on-coming employees before they began work. This training was conducted by the DON, Quality Management Nurse, MDS Coordinator and Nursing Services. The DON was to be responsible to provide the training to any remaining employees before their return to duty. Interviews on 09/01/10 and 09/02/10 conducted with CNAs, LPNs and RNs confirmed they had received the in-services and training related to the new Inappropriate Sexual Behavior Management policy. The staff were able to verbalize their knowledge of the new policy and review of the in-service sign in sheets verifying their attendance and their completion of the post tests. The Administrator and SSD were in-serviced and completed a post test with 100% accuracy. Extended reviews and interviews of facility residents revealed no concern. The Immediate Jeopardy was verified removed on 09/02/10, as alleged in the AoC, with the scope/severity lowered to a "D", based on the facility's need to continue to evaluate the implementation of systematic changes.

Based on interviews and record reviews, it was determined the facility failed to ensure appropriate and timely social services was provided for two residents (#16 & #18), in the selected sample of 5. The Social Service Director (SSD) failed to promote the general well being of each resident through identification of their emotional and psychosocial needs and failed to ensure effective interventions were developed and implemented when residents exhibited behaviors which resulted in negative outcomes to the resident or other residents of the facility. On 06/09/10, the facility identified Resident #16 as having behaviors of a sexual nature and became aware of Resident #16's history of sexual behaviors in other facilities on 06/15/10. While the facility implemented care plan interventions to address Resident #16's sexually aggressive behaviors, the facility failed to ensure those interventions were effective in managing the resident's behaviors and protecting other residents within the facility. Resident #16 began having sexually aggressive behaviors, which affected other residents of the facility on 07/10/10, and continued on 07/12/10, 07/15/10, 07/19/10, and 07/22/10. The failure to effectively address and manage Resident #16's sexually aggressive behaviors resulted in two residents (#7 and #14) being sexually abused by Resident #16. Additionally, the facility failed to ensure the emotional and psychosocial needs of Resident #18 were met after Resident #18 reported Resident #16 entered his/her room during the night and demanded sex. It was identified that the facility's failure to intervene, manage and supervise behavior's to prevent abuse had placed residents at risk for serious injury, harm, impairment, or death to a resident receiving care in this facility. The findings include: A review of the SSD Job Description, undated, included the SSD functions on behalf of the nursing home and its' residents by promoting the general well being of each resident through identification of their emotional and psychosocial needs and works with staff in developing a means to meet and sustain these needs. Additionally, assures timely progress notes on each resident in the facility. An interview with the Administrator, on 08/20/10 at 5:20 PM, revealed the SSD's duties included completing mood and behavior assessments and developing behavior care plan interventions, when behaviors were exhibited. 1. Review of Resident #16's closed record revealed the facility admitted Resident #16 on 06/07/10, with [DIAGNOSES REDACTED]. Review of the admission physician orders [REDACTED].#16. On 06/09/10, Resident #16 began exhibiting sexual behaviors toward staff and continued these behaviors on 06/15/10. On 06/15/10, the Administrator received a History and Physical from another facility, where Resident #16 resided in the past, which revealed Resident #16 had a history of [REDACTED]. The facility developed a "Behavioral Symptoms" care plan, dated 06/15/10, which revealed the following interventions: 1. Explain that such behavior will not be tolerated; 2. Provide opportunities to vent aggressive feelings; 3. Always have 2 CNAs present when care provided; and, 4. Notify Social Services (SS) and Physician of any change in frequency of behaviors exhibited. A review of the Minimum Data Set (MDS) Assessment, dated 06/20/10, revealed the facility assessed Resident #16 as having moderate cognitive impairment with supervision required. The facility identified Resident #16 as having socially inappropriate behaviors on the Resident Assessment Protocol (RAP), dated 06/20/10, and referred to sexual remarks made to staff but no additional interventions were implemented at that time. Record review revealed Resident #16 began exhibiting sexual behaviors impacting other residents of the facility by entering other residents' rooms and making sexual remarks, masturbating and ejaculating on a another resident's bed, fondling him/herself in front of another resident and slapping at staff when redirected, which began on 07/10/10 and continued on 07/12/10, 07/15/10, 07/19/10 and 07/22/10. On 07/22/10, per interview housekeeping staff observed Resident #16 rubbing Resident #14's pubic area inside the resident's pants. Interview with family member #1 (a former resident of the facility) on 08/20/10 at 4:00 PM, revealed the family member observed Resident #16 rubbing Resident #7's leg and then moved his/her hand and began rubbing Resident #7's pubic area. There was no evidence that social services addressed Resident #16's repetitive sexual behaviors since the implementation of the care plan on 06/15/10. 2. A review of a MDS assessment, dated 07/15/10, revealed the facility had assessed Resident #18 as independent and with no cognitive impairment. Resident #18 was admitted to the facility, on 07/09/10, for short term rehabilitation. Review of the nurse's notes, dated 07/11/10 at 9:00 AM, revealed Resident #18 reported to facility staff that Resident #16 was in his/her room during the night, demanded sex and left the room when Resident #18 yelled for the nurses. The nurse's note revealed Resident #18 was "upset" and requested that his/her room door be kept shut. An interview with Licensed Practical Nurse (LPN) #2, on 08/20/10 at 9:45 AM, revealed Resident #18 told her on the morning of 07/11/10, that Resident #16 came in his/her room the previous night and asked for sex. LPN #2 notified the on-call supervisor, who was the SSD. During an interview with Resident #18, on 08/20/10 at 4:55 PM, Resident #18 stated that the incident "didn't make me feel very good". Additionally, Resident #18 stated staff had told him/her that Resident #16 did it to others and it was not good for them. Further review of the record revealed no evidence the facility addressed the incident through Social Services with Resident #18. An interview with the SSD, on 08/20/10 at 11:45 AM, revealed she had been working as the SSD, since 07/01/10, with experience working in this position from 06/2009 through 03/2010. The SSD revealed she was called, on 07/11/10 (Sunday), at home, due to Resident #18 reporting to the day shift nurse that Resident #16 had entered his/her room demanding he/she "give him/her some". The SSD thought Resident #16 was asking for sex. The SSD stated that no incident report was completed because there was "no contact, no injury and the nurse would have done an incident report". The SSD stated after reading Resident #18's nurse's notes, dated 07/11/10 at 9:00 AM, the incident "looks like verbal sexual abuse". The SSD did not document anything in the Social Service Notes and stated she would "normally chart something like that" and did not know why she had not. She stated she was responsible to document when residents had behaviors and update the behavior care plans, but she had not implemented any new interventions for Resident #18 because he/she was not "upset" and she did not follow up with Resident #18. The SSD described her duties as "making sure residents were not abused, and care plan what they need". Additionally, she stated if the nurse contacted her, she was to take it to the Director of Nursing (DON) and Administrator. However, the SSD stated she did not personally take it to them, it was on the 24 hour report. Additionally, she remembered discussing the incident at the next day's (07/12/10) meeting but did not recall what was determined and could only speculate Resident #16 was "Put on alert and was watched". An interview with the Administrator, on 08/20/10 at 5:20 PM, revealed the SSD did not complete his/her assigned duties as it related to addressing Resident #16's persistent sexual behaviors to the incidents and confirmed that the SSD had totally forgotten about addressing the needs of Resident #18 after the incident of 07/10/10. An acceptable Allegation of Compliance (AoC) was received 09/02/10. The actions taken to verify the removal of Immediate Jeopardy included a policy developed regarding Inappropriate Sexual Behavior Management on 08/30/10. On 08/31/10, the SSD was re-educated regarding utilizing the admission history and assessment process to aide in identifying potential risks for inappropriate sexual behaviors. If potential risks were identified, the SSD was trained to notify the Administrator and/or DON or the on-call designee if both are not available. If immediate intervention was required she was trained to notify the charge nurse of the potential risk and assist in the development of the care plan and interventions to manage potential risk. Additional training was provided to the SSD, on 09/01/10, by the Quality Management Specialist. The training included recording in objective terms, noting specific observations that were described clearly using words to paint a visual picture, and observing for mood and behavior indicators to aide in assessing for changes in condition. The training also instructed to document situations and conditions that occurred between routine quarterly documentation that may have impact on the residents' psychosocial functioning. Social Services would be involved in the assessment of the residents' behaviors. Interview with the SSD, on 09/01/10, verified the re-education and she was able to verbalize understanding of the education regarding utilizing the admission history and assessment process to aide in identifying risks for behaviors. She verified she would notify the Administrator and/or DON or the on-call designee if both were not available. Training by the Quality Management Specialist was verified, 09/02/10, as completed 09/01/10. The training included documentation, observation of mood indicators to aide in assessing changes in behaviors that could impact a resident's psychosocial functioning. The Immediate Jeopardy was verified removed on 09/02/10, as alleged in the AoC, with the scope/severity lowered to a "D", based on the facility's need to continue to evaluate the implementation of systematic changes.

Based on interviews and record review, it was determined the facility failed to provide services in accordance with the care plan for two (2) residents (#5 and #16) in the selected sample of nineteen (19). On 06/19/10, the facility identified Resident #16 as having behaviors of a sexual nature and became aware of Resident #16's history of sexual behaviors in other facilities on 06/15/10. While the facility implemented care plan interventions to address Resident #16's sexual behaviors, the facility failed to ensure those interventions were effective in managing the resident's behaviors and failed to identify and implement interventions to prevent potential abuse of other residents. Resident #16 began having sexually aggressive behaviors, which impacted other residents of the facility, on 07/10/10 and continued on 07/12/10, 07/15/10, 07/19/10 and 07/22/10. Furthermore, the facility while aware of these incidents, failed to ensure interventions implemented were effective in managing Resident #16's repetitive sexual behaviors and failed to provide appropriate supervision to prevent Resident #16 from abusing residents in the facility. Resident #16 touched Resident #6's pubic area while he/she was sitting on a sofa in the common area of the facility. Resident #16 had his/her hand in Resident #14's pants touching Resident #14's pubic area and Resident #14 was yelling for help. Resident #18 was in bed, during the night, when Resident #16 entered Resident #18's room and demanded sex from Resident #18. Resident #ZZ reported to staff that Resident #16 had stood in his/her doorway and demanded sex. In addition, Resident #5 was transferred on 07/03/10 by one staff instead of two staff as per the resident's care plan, resulting in a fall. It was identified the facility's failure to develop and implement effective care plan interventions to manage resident's behaviors and prevent abuse placed residents at risk for serious injury, harm, impairment, or death to a resident receiving care in this facility. The findings include: 1. A review of the facility Abuse/Neglect policy, dated 01/01/07 and revised 08/20/08, revealed sexual abuse defined as "an act of a sexual nature committed for the sexual gratification of the abuser and in the presence of a disabled adult or elderly person without the disabled adult's or elderly person's informed consent." Sexual abuse can include, but is not limited to, fondling. Under the Identification section, the policy stated as part of the assessment process, residents will be reviewed to determine if the resident displays inappropriate behavior that could result in a catastrophic behavior incident. Interventions will be care planned as appropriate. A review of the facility policy and procedure titled "Comprehensive Care Plans", dated 04/16/08 and revised 03/25/09 and 09/17/09, included: a care plan will be developed based on assessed needs and the plan of care will be reviewed and revised when indicated, based on the resident's response. Review of a closed record revealed Resident #16 was admitted to the facility, on 06/07/10, with [DIAGNOSES REDACTED]. A nurse's note, dated 06/09/10 at 2:00 PM, revealed a Certified Nurse Aide (CNA) was assisting him/her with a urinal, when he/she stated, "You like to shake it don't you" and "Let me see your boobs, come on let me see them". No interventions were added to the care plan at this time. On 06/15/10, the facility received a History and Physical document which detailed Resident #16's sexually aggressive behavior history at other facilities. The History and Physical revealed Resident #16 had a history of [REDACTED]. Additionally, a review of a nurse's note entry, dated 06/15/10 at 12:00 PM, revealed Resident #16 remarked to a CNA, while she was providing care, "Put it up (his penis)" and asked if the CNA was "Scared of it". Resident #16 asked the CNA if she had "Ever been touched". The facility developed a "Behavioral symptoms" care plan, dated 06/15/10, which revealed the following interventions: 1. Explain that such behavior will not be tolerated; 2. Provide opportunities to vent aggressive feelings; 3. Always have 2 CNAs present when care provided; and, 4. Notify Social Services (SS) and Physician of any change in frequency of behaviors exhibited. There was no documented evidence the facility identified that Resident #16's sexual behaviors could potentially impact other residents in the facility and there was no documented evidence the facility implemented interventions requiring supervision to ensure other residents in the facility would not be impacted by these behaviors. The facility assessed the resident as having moderately impaired cognitive skills for daily decision making and socially inappropriate behaviors on the Resident Assessment Protocol (RAP), dated 06/20/10. Further review revealed no evidence of changes made to the care plan addressing Resident #16's sexually aggressive behaviors. A nurse's note, dated 07/10/10 at 9:30 PM, revealed Resident #16 was wandering in other residents' rooms and made the statement, "I want some pussy, go ask her to give me some pussy" and then called the staff "Sluts", when redirected. Review of the care plan revealed no new interventions were implemented at this time. Documentation on a nurse's note, dated 07/12/10 at 9:30 AM, revealed "Resident noted in 212 A, female bed, masturbating and ejaculated on bed; 212 A resident not in room". Review of the care plan revealed no new interventions were implemented at this time. On 07/15/10 at 10:40 AM, a nurse's note entry revealed the resident had "Pants down fondling self" and was in full view of the roommate. The nurse's note revealed Resident #16 stated all the female staff were "Whores". Review of the care plan revealed the facility added an intervention to monitor every 15 minutes, placed an alarm at the top of the resident's door and pharmacy reviewed Resident #16's medications. The pharmacy review recommended hormone therapy and an increase in [MEDICATION NAME]. Furthermore, there was no documented evidence the 15 minute checks were implemented and completed by staff on 07/15/10. Nurse's note, dated 07/19/10 at 8:30 AM, revealed Resident #16 was found in another resident's bed and when redirected by the staff, he/she became aggressive and slapped at them. There continued to be no documented evidence the 15 minute checks were implemented and completed by staff on 07/19/10. Further review revealed, the physician increased the [MEDICATION NAME] from 5 milligrams (mg) to 10 mg on 07/20/10. On 07/22/10, per the nurse's note at 3:20 PM, Resident #16 was observed pulling the cover off a female resident and told staff he/she was "Up to meanness". Additionally, that same day, an interview with Housekeeping Staff #1, on 08/18/10 at approximately 11:45 AM, revealed she observed Resident #16 in Resident #14's room on 07/22/10. Resident #16 was standing over Resident #14, who was in bed, and Resident #16's hand was inside the pants of Resident #14 rubbing his/her pubic area. Furthermore, an interview with family member #1 (on 08/20/10 at 4:00 PM, former resident of the facility) revealed, on 07/22/10, he/she had witnessed Resident #16 rubbing Resident #7's leg and then moved his/her hand and began rubbing Resident #7's pubic area. Resident #7 was half asleep on the couch and did not know what was happening. The family member stated, "It made me feel bad". The facility was unable to provide any documented evidence the 15 minute monitoring of Resident #16 was implemented. While the pharmacy review recommended hormone therapy and an increase in [MEDICATION NAME], the [MEDICATION NAME] order was not received until 07/20/10. The hormone therapy was not initiated until 07/23/10, the day after the incident with Residents #14 and #7. Furthermore, the facility was unable to provide evidence interventions were re-evaluated for effectiveness. On 08/19/10 at 5:50 PM, an interview was conducted with Nurse Aide (NA) #1. NA #1 revealed Resident #16 wandered and had a favorite room (Resident #14's) and required frequent redirection out of that room. NA #1 stated, "We all tried to watch Resident #16", but was not aware of any process for implementing every 15 minute monitoring. On 08/20/10 at 9:45 AM, an interview conducted with LPN #2 revealed Resident #16 entered other residents' rooms several times and Resident #16 waited for one resident to leave a room, leaving the other resident alone. Resident #16 knew what he/she was doing and at no time did she see him/her confused. Resident #16 entered another resident's (#18) room one night demanding sex and scared him/her. LPN #2 stated Resident #16 did not bother male residents and said, "He/she made me feel uneasy". An interview conducted with LPN #1, on 08/20/10 at approximately 8:30 AM, revealed Resident #16 had behaviors of staring at everybody's bottoms and entering other residents' rooms. LPN #1 stated she thought Resident #16 had a purpose for entering some rooms in particular and thought he/she "prayed on female residents". The facility placed a door alarm on Resident #16's door because he/she had been in other residents' rooms touching him/herself, but it was not effective if Resident #16 was not in his/her room. LPN #1 stated she wasn't sure if Resident #16 was or was not on 15 minute checks but "In 15 minutes Resident #16 could do what he/she did to Resident #14". Additionally, the LPN did not know if there was a policy or procedure for 15 minute monitoring. LPN #1 stated, "I was scared of this guy myself" and had told the administrative staff at the morning meeting when the door alarm was implemented 07/15/10. An interview with the Social Services Director (SSD), on 08/20/10 at 11:45 AM, revealed she was responsible to update the behavior care plan when residents had behaviors but she had not implemented any new interventions for Resident #16. Interviews with LPN #2 on 08/20/10 at 8:30 AM, LPN #1 on 08/20/10 at 9:45 AM, the SSD on 08/20/10 at 11:45 AM, and CNA #3 on 08/20/10 at 3:10 PM, revealed they thought Resident #16 had been on 15 minute checks off and on but no particular staff had been assigned as responsible to ensure the checks were completed and no flow sheet was utilized to verify if checks were completed. Additionally, the staff interviewed were not sure if 15 minute checks were on Resident #16's care plan. A review of the Nurse Aide Data Sheet (not dated) revealed two assist with all care and door alarm for a safety device. The Behavior Interventions sections was blank. The care plan titled "Behavioral symptoms revealed 15 minute checks, dated 07/10/10, that the DON had stated she actually placed on the care plan on 07/15/10. Additionally, the DON stated she was not sure if 15 minute checks had been put on the Nurse Aide Data Sheet. No other documentation for 15 minute checks could be verified. An interview on 08/20/10 at 12:20 PM, with the Director of Nursing (DON), revealed nurses were responsible to ensure a resident's care plan was updated if an immediate intervention was needed. She thought Resident #16 had been on 15 minute checks but on 07/15/10 she had added "to be monitored every 15 minutes" with a date of 07/11/10. Additionally, on 07/15/10, "alarm to top of door" and "pharmacist reviewed meds" was added. An interview with the Administrator, conducted 08/19/10 at approximately 6:35 PM, revealed Resident #16 had been placed on 1:1 observation, after 07/22/10, when he/she was observed by staff with his/her hand in the front of Resident #14's pants. The Administrator stated the facility had previously initiated 15 minute checks due to Resident #16's inappropriate behaviors; however, there was no documented evidence that the checks were completed. The Administrator further revealed the facility had not developed a policy and procedure for 15 minute monitoring. Resident #16's behaviors had been discussed in the morning meetings and staff were told to present reality and that his/her behaviors were unacceptable. An acceptable Allegation of Compliance (AoC) was received 09/02/10. The actions taken to verify the removal of Immediate Jeopardy included a policy developed regarding Inappropriate Sexual Behavior Management on 08/30/10. The Administrator and staff were trained regarding this policy beginning on 08/30/10 and continuing with on-coming employees before they began work. A review of the Abuse Policy with an emphasis placed on recognizing sexual abuse and inappropriate behaviors and the need to report any suspected abuse of any kind was reviewed. A policy was developed on 08/30/10, describing the process to be followed when providing behavior monitoring including 1:1 monitoring and every 15 minute monitoring. Review of the 24 hour Nursing reports will be conducted daily, by the Director of Nursing or Unit Managers in her absence, to identify the onset of or changes in, behaviors that are sexually inappropriate. On weekends and holidays the on call nurse would verbally review the 24 hour reports by phone to identify a new onset of sexually inappropriate behaviors. If sexually inappropriate behaviors are identified, the on call nurse would come in to review interventions and report to the Director of Nursing (DON) and/or Administrator. Additional interventions would be based on the assessment of contributing/causative factors. A post test was given to the Administrator and staff to verify understanding. The Care Plan team including the DON, MDS Coordinator, Unit Managers, Social Service Director, Activity Director, Dietary Director, Rehab Director and the Administrator, were provided training regarding updating the plan of care as conditions arise and monitoring the effectiveness of the approaches that were in place. The training was conducted by Quality Management Specialist Nurses on 08/31/10. The new Sexual Behavior Management policy, dated 08/30/10, was reviewed on 08/31/10. The Administrator, SSD and staff were trained regarding this policy beginning 08/30/10. The Administrator and SSD were trained by the Quality Management Specialist Nurses on 08/30/10 and continued with on-coming employees before they began work and post tests were completed. The sign in sheets and post tests were verified and interviews conducted with the Administrator, SSD and staff on 09/01/10 and 09/02/10 verified their understanding. A new policy, dated 08/30/10, for the process to be followed for every 15 minute monitoring was reviewed 09/01/10 and the Administrator, SSD and staff were able to verify understanding through interviews conducted 09/01/10 through 09/02/10. The Care Plan team including the Administrator, DON, MDS Coordinator, Unit Managers, SSD, Activity Director, Dietary Director and the Rehab Director were provided training regarding updating the plan of care as conditions arise and monitoring the effectiveness of the approaches that were in place. The training was verified conducted by Quality Management Specialist Nurses on 08/31/10. The Immediate Jeopardy was verified removed on 09/02/10, as alleged in the AoC, with the scope/severity lowered to a "D", based on the facility's need to continue to evaluate the implementation of systematic changes. 2. Record review revealed Resident #5 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, dated 02/08/10, revealed the facility identified Resident #5 as moderately cognitively impaired and required extensive assistance of two or more staff for transfers. A review of the Comprehensive Care Plan, dated 02/07/10, revealed interventions included extensive assistance of two staff with transfers. Further review of the Nurse Aide Data Sheet, dated 04/08/10 through 08/13/10, identified the resident as non-ambulatory, at risk for falls, two staff assist at times for mobility, and two staff assist for transferring. An interview, on 08/19/10 at 10:50 AM, with Certified Nurse Aide (CNA) #1 revealed she was aware Resident #5 required extensive assist of two staff for transfers. An interview, on 08/19/10 at 10:55 AM, with CNA #2 revealed she was aware Resident #5 was care planned for two staff assist with toileting and transfers. She revealed on occasion she transferred him/her alone. She stated, "He does pretty good with grabbing hold of something to help with the transfer". An interview, on 08/19/10 at 11:30 AM, with Licensed Practical Nurse (LPN)/MDS #3 revealed Resident #5 had always been assessed as in need of two assist for transfers and the CNA transferring him/her at the time of the fall on 07/03/10, "did not follow the CNA care plan". A telephone interview, on 08/20/10 at 9:40 AM, with CNA #3 revealed, on 07/03/10, she was attempting to transfer Resident #5 alone to bed from the resident's wheelchair when the resident began to slide. She eased the resident to the floor. She stated she was aware the resident was care planned for two staff assist with transferring; however, she did not get help. An interview, on 08/20/10 at 7:05 PM, with LPN #4, the unit nurse on 07/03/10, revealed she was called into Resident #5's room by CNA #3. She observed Resident #5 on the floor. She assisted CNA #3 to assist the resident off the floor and to bed. She stated the resident was care planned, on that date, for two staff assist but CNA #3 did not seek assistance before attempting to transfer the resident alone. An interview, on 08/20/10 at 10:55 AM, with LPN #5, Unit Manager for the unit on which Resident #5 resided, revealed there had been no changes made to the care plan related to transfers. She stated, on 07/03/10, Resident #5 required extensive assistance of two staff for transfers. An interview, on 08/20/10 at 11:05 AM, with CNA Manager #4, revealed orientation of new CNAs to Nurse Aide Data Sheets included review of the forms and explanation of each area addressed on the forms. New employees were instructed to review the forms daily for changes or updates and to follow the care plans for care of the residents.

Based on interviews and record reviews, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Resident #16 displayed sexually aggressive behaviors that affected four (4) residents (#7, #14, #18 and #ZZ), in the selected sample of five and resulted in reported sexual abuse. The facility was aware of Resident #16's behavior and failed to implement effective interventions to manage the sexual behaviors of Resident #16 and provide appropriate supervision to prevent abuse. While the facility implemented interventions to address the resident's behaviors, the facility failed to ensure the interventions were effective, resulting in continued sexual behaviors towards staff and residents and sexual abuse of Residents #7 and #14. Therefore, the facility failed to ensure residents were free from abuse. It was identified that the facility's failure to intervene to prevent abuse placed residents at risk for serious injury, harm, impairment, or death to a resident receiving care in this facility. The findings include: Refer to F223 Based on observations, interviews and record reviews, it was determined the facility failed to ensure each resident had the right to be free from mental, physical and sexual abuse. The facility failed to assess and implement effective interventions to prevent sexual abuse for four residents (#7, #14, #18 and #ZZ) in the selected sample of five. On 06/09/10, the facility identified Resident #16 as having behaviors of a sexual nature and became aware of Resident #16's history of sexual behaviors in other facilities on 06/15/10. While the facility implemented care plan interventions to address Resident #16's sexually aggressive behaviors, the facility failed to ensure those interventions were effective in managing the resident's behaviors and failed to identify and implement interventions to prevent potential abuse of other residents. Resident #16 began having sexually aggressive behaviors, which impacted other residents of the facility, on 07/10/10 and continued on 07/12/10, 07/15/10, 07/19/10 and 07/22/10. Furthermore, the facility while aware of these incidents, failed to ensure interventions implemented were effective in managing Resident #16's repetitive sexual behaviors and failed to provide appropriate supervision to prevent Resident #16 from abusing residents in the facility. Resident #16 touched Resident #7's pubic area while he/she was sitting on a sofa in the common area of the facility. Resident #16 had his/her hand in Resident #14's pants touching Resident #14's pubic area and Resident #14 was yelling for help. Resident #18 was in bed, during the night, when Resident #16 entered Resident #18's room and demanded sex from Resident #18. Resident #ZZ reported to staff that Resident #16 stood in his/her doorway and demanded sex. Refer to F250 Based on interviews and record reviews, it was determined the facility failed to ensure appropriate and timely social services were provided for two residents (#16 and #18) in the selected sample of 5. The Social Service Director (SSD) failed to promote the general well being of each resident through identification of their emotional and psychosocial needs and failed to ensure effective interventions were developed and implemented when residents exhibited behaviors, which resulted in negative outcomes to the resident or other residents of the facility. On 06/09/10, the facility identified Resident #16 as having behaviors of a sexual nature and became aware of Resident #16's history of sexual behaviors in other facilities on 06/15/10. While the facility implemented care plan interventions to address Resident #16's sexually aggressive behaviors, the facility failed to ensure those interventions were effective in managing the resident's behaviors and protecting other residents within the facility. Resident #16 began having sexually aggressive behaviors, which affected other residents of the facility, on 07/10/10 and continued on 07/12/10, 07/15/10, 07/19/10, and 07/22/10. The failure to effectively address and manage Resident #16's sexually aggressive behaviors resulted in two residents (#7 and #14) being sexually abused by Resident #16. Additionally, the facility failed to ensure the emotional and psychosocial needs of Resident #18 were met after Resident #18 reported Resident #16 entered his/her room during the night and demanded sex. Refer to F282 Based on record review and interviews, it was determined the facility failed to ensure services provided or arranged by the facility by qualified persons in accordance with each resident's written plan of care for one resident (#16) in the selected sample of five. On 06/09/10, the facility identified Resident #16 as having behaviors of a sexual nature and became aware of Resident #16's history of sexual behaviors in other facilities on 06/15/10. While the facility implemented care plan interventions to address Resident #16's sexually aggressive behaviors, the facility failed to ensure those interventions were effective in managing the resident's behaviors and failed to identify and implement interventions to prevent potential abuse of other residents. Resident #16 began having sexually aggressive behaviors, which impacted other residents in the facility, on 07/10/10 and continued on 07/12/10, 07/15/10, 07/19/10 and 07/22/10. Furthermore, the facility while aware of these incidents, failed to ensure interventions implemented were effective in managing Resident #16's repetitive sexual behaviors and failed to provide appropriate supervision to prevent Resident #16 from abusing residents in the facility. Resident #16 touched Resident #7's pubic area while he/she was sitting on a sofa in the common area of the facility. Resident #16 had his/her hand in Resident #14's pants touching Resident #14's pubic area and Resident #14 was yelling for help. Resident #18 was in bed, during the night, when Resident #16 entered Resident #18's room and demanded sex from Resident #18. Resident #ZZ reported to staff that Resident #16 stood in his/her doorway and demanded sex. A review of a closed record revealed the facility admitted Resident #16 on 06/07/10. On 06/09/10, the facility became aware Resident #16 began exhibiting sexually aggressive behaviors towards staff. On 06/15/10, the facility received documentation, per a History and Physical, which detailed Resident #16 had a history of [REDACTED]. While the facility developed a care plan on 06/15/10, the facility was unable to provide documented evidence of interventions that had been implemented to ensure the safety of other residents due to Resident #16's sexually aggressive behaviors. Resident Assessment Protocol (RAP), dated 06/20/10, revealed Resident #16 had moderately impaired cognitive skills for daily decision making and socially inappropriate behaviors. Care plan interventions to notify the Social Services staff, when Resident #16's behaviors were exhibited more frequently, were unable to be verified through review of documentation. Interview with the SSD, on 08/20/10 at 11:45 AM, revealed she had been made aware of one incident on 07/11/10; however, had not made any changes to the resident's behavior care plan. On 07/11/10, Resident #18 reported to the facility staff the he/she was in bed, during the night, when Resident #16 entered Resident #18's room and demanded sex from Resident #18. Resident #ZZ reported to staff (unable to remember who) that Resident #16 stood in his/her doorway and demanded sex. An interview, on 08/20/10 at 4:00 PM, with family member #1, revealed he/she observed Resident #16 touch Resident #7's pubic area, on 07/22/10, while he/she was sitting on a sofa in the common area of the facility. An interview, on 08/18/10 at 11:45 AM, with housekeeping staff #1, revealed she observed Resident #16 with his/her hand in Resident #14's pants touching Resident #14's pubic area on 07/22/10 and Resident #14 was yelling for help. Interviews with facility staff, conducted on 08/18/10 through 08/20/10 with Housekeeper #1, Licensed Practical Nurse (LPN) #1 and Nurse Aide (NA) #1, revealed Resident #16 wandered in other residents' rooms. Resident #16 had a favorite room (Resident #14's) and required frequent redirection out of that room. The staff revealed Resident #16 stared at "everybody's bottoms" and "prayed on female residents". Resident #16 had been in other residents' rooms touching him/herself sexually. Resident #16 was on 15 minute checks but none of the staff could verify who was responsible to implement the 15 minute checks and there was no procedure for documenting if the checks had been completed. Interviews with the Administrator, on 08/19/10 at 6:35 PM and on 08/31/10 at 4:30 PM, revealed she failed to talk with the Medical Director prior to 07/22/10 and was aware of Resident #16's history of behaviors on 06/15/10, when she requested information from a former facility. There was not a policy or procedure for management of residents with sexual behaviors and staff had not been trained related to management of such behaviors. Resident #16's behaviors had been discussed in the morning meetings and staff were told to present reality that his/her behaviors were unacceptable. A psychiatric evaluation was discussed sometime during Resident #16's first week after admission, but then no behaviors were documented for about a month so the psychiatric evaluation was not obtained. The Administrator stated she did not realize, until the investigation of the 07/22/10 incident involving Resident #14, that Resident #16 was admitted with orders to follow up with psychiatric services. The Administrator stated Resident #16 had been on 15 minute checks due to inappropriate behaviors but no system was in place to verify completion of the checks or who was completing them. Additionally, there was no facility policy or procedure for 15 minute checks. The facility was unable to provide documented evidence that they provided necessary supervision and implemented effective interventions to manage the sexually aggressive behaviors of Resident #16 and protected the other residents in the facility from abuse. An acceptable Allegation of Compliance (AoC) was received 09/02/10. The actions taken to verify the removal of Immediate Jeopardy included a policy developed regarding Inappropriate Sexual Behavior Management on 08/30/10. The Administrator and staff were trained regarding this policy beginning on 08/30/10 and continuing with on-coming employees before they began work. A review of the Abuse Policy revealed an emphasis was placed on recognizing sexual abuse and inappropriate behaviors and the need to report any suspected abuse of any kind. A policy was developed, on 08/30/10, describing the process to be followed when providing behavior monitoring including 1:1 monitoring and every 15 minute monitoring. A post test was given to the Administrator and staff to verify understanding. The Immediate Jeopardy was verified removed on 09/02/10, as alleged in the AoC, with the scope/severity lowered to a "D", based on the facility's need to continue to evaluate the implementation of systematic changes.