Every finding on record at St Andrews Operator, LLC

Based on observations, interviews, and record review, the facility failed to provide evidence that alleged violations were thoroughly investigated for 1 of 7 incidents reviewed. Specifically, the facility failed to provide evidence of a through investigation related to a residents fall, including interviews with involved staff, relevant documentation review, identification of contributing factors, and determination of corrective actions. This failure has the potential to limit the facility's ability to identify root causes and prevent recurrence of similar incidents.Findings include:Based on review of facility policy, observations, interviews, and record review, the facility failed to ensure allegations of accidents were thoroughly investigated, as required, for 1 of 7 incidents reviewed. Missing elements included interviews with involved staff, adequate documentation review, identification of contributing factors, and determination of corrective actions. This failure has the potential to limit the facility's ability to identify root causes and prevent recurrence of similar incidents.Review of the facility's policy, titled Abuse Investigation and Reporting, with a revised date of 07/17, revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; j. Review all events leading up to the alleged incident. 4. The investigator will consult daily with the administrator concerning the progress/findings of the investigation. 5. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator.Review of Resident (R)99's face sheet revealed she was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Review of R99's progress notes, dated 04/16/26, revealed R99 was sent out to a local hospital for observation for a fall that resulted in a small [sic]dash to her right side of her head. POA, NP and DON were notified of resident being sent out. Review of the facilities 24-Hour investigation report of the accident/incident did not reveal the following information: Resident (R)99's face sheet, care plan, Minimum Data Set (MDS), hospital records, discharge summary to hospital, post-fall assessment, and witness statements.During an interview with the DON on 08/24/26 at approximately 11:23 AM, the surveyor requested information and documentation regarding R99's incident/accident at the facility. The DON stated that she would provide the requested materials as soon as possible. The DON did not return with the requested documents for the investigation report. Several reminders were requested for the investigation report.During an interview with the DON on 08/25/26 at approximately 10:00 AM, the surveyor requested information and documentation from the DON regarding R99's incident/accident at the facility pertaining to R99's incident/accident at the facility. The DON stated that she was going to retrieve the documents from the office. The DON did not return with the requested documents for the investigation report. Several reminders were requested for the investigation report.During an interview with the DON on 08/26/26 at approximately 09:15 AM, the surveyor requested information and documentation from the DON pertaining to R99's incident/accident at the facility. The DON stated that she was going to retrieve the documents from the office. The DON did not return with the requested documents for the investigation report. Several reminders were requested for the investigation report.

Based on observation, interview, document review, and facility policy review, the facility's quality assurance and performance improvement (QAPI) committee failed to implement effective corrective actions to ensure previously identified deficient practices were corrected and sustained. This deficient practice had the potential to affect all 91 residents who resided in the facility.Cross Reference: F693, F761, and F812.Findings included:Review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership Policy Statement, revised on 03/2020, revealed, 2. The governing body is responsible for ensuring that the QAPI program: a. Is implemented and maintained to address identified priorities; b. Is sustained through transitions of leadership and staffing; c. Is adequately resourced and funded, including the provision of money, time, equipment, training and staff coverage sufficient to conduct the activities of the program; d. Is based on data, resident and staff input, and other information that measures performance; and e. Focuses on problems and opportunities that reflect processes, functions and services provided to the residents.According to the Centers for Medicare & Medicaid Services (CMS) - 2567, during a Recertification and Complaint Survey conducted from 07/15/25 to 07/17/25, the facility was cited at F693 for a failure to label and date a tube feeding bag, F761 for a failure to label and date opened medications, and F812 for a failure to ensure food stored was sealed, labeled and dated with a use-by date.During observations conducted on 08/23/25, R502's tube feeding bag was not labeled; two medication carts had opened vials of insulin that were not labeled with an opened date; and food items in the kitchen were opened, unsealed and not labeled with an opened and/or use-by date. Review of the facility QAPI meeting minutes dated 08/15/25 revealed, Review of the Annual survey results. Discussion of the POC [plan of correction] and audit tools; see attached. The only reference to the plan of correction was a copy of the CMS-2567 attached to the meeting minutes.During an interview on 08/23/25 at 4:47 PM, the Administrator stated the QAPI committee discussed the plan of correction, and during the discussion, everyone reported the audits were effective. The Administrator stated he felt the audits were effective, and he did not understand why there were continued failures.

Based on observation, interview, and review of facility policy, the facility failed to ensure foods that are stored in the freezer, refrigerator and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date in 1 of 1 kitchen.Findings include:Review of the facility's undated policy, titled, Labeling and Dating, revealed Importance of Labeling and Dating Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Food labels must include: The food item name, the date of preparation/receipt/removal from freezer, the use by date. Leftovers must be labeled and dated with the date they are prepared and the use by date.During an initial observation of the kitchen on 07/15/25 at 9:51 AM, the Dry Food Storage revealed the following:Boxes on the floor.1 - 10-pound (lb) bag of macaroni noodles was opened with no open date and no use-by date.1 - 25 lb box of semi-sweet mini morsels was opened and not sealed, with no open date and no use-by date.3 - 28 ounce (oz) diced tomatoes with green chiles with a use-by date of August 28, 2024.Multiple cans were covered with a white powdery substance.1 - 25 lb box of instant food thicker with an open not properly sealed, no open date, no use-by date,During an initial observation of the walk-in cooler/refrigerator, the following was revealed:Rusted shelves.1 - 8-quart (qt) container not labelled with food contents.1 - 1-gallon (gal) container of mayonnaise with no open date and no use-by date.1 - Cut onion wrapped with a prep date of 07/06/25 and a use-by date of 06/09/25.1 bag baby spinach was opened with no open date and no use-by date; the spinach was brown and wilted.During an initial observation, the walk-in freezer revealed the following:1 opened bag of frozen corn placed in a box that was labelled broccoli, not properly sealed, with no open date and no use-by date.1 30 lb box of cut green beans was opened and not sealed properly, with no open date and no use-by date.During a follow up observation of the kitchen on 07/17/25 at 11:45 AM, the bottom shelf of one prep table was lined with multiple sheets of aluminium foil. The following items were opened with no open date or use-by date and were being stored on this shelf:1 - 18 oz container of granulated onion.1 - 24 oz container of blackened seasoning.1 - 16 oz container of turmeric1 - 16 oz container of ground cinnamon.1 - 18 oz container of ground cinnamon.1 - 16 oz container of black pepper.1 - 16 oz container of Italian seasoning.1 - 42 oz container of Quick Oats marked with the following dates: 06/16/25, 06/20/25 and 06/25/25.1 - 5.3 lb container of mashed potatoes.During an interview on 07/17/25 at 8:57 AM, the Dietary Manager (DM) revealed that Healthcare Services took over the kitchen services in July 2024 and that he has been with the company for about 6 or 7 months. The DM states that his expectations for food storage are for items to be used first in/first out; any items that have been removed from it's original packaging should be rewrapped or repacked, sealed and labelled with a prep/open date and a use by date in the dry food storage, refrigerators and freezers. The DM states that any ready-to-eat food/leftovers should be discarded after 3 days. The DM explains that any items past the manufacturer expiration date or marked use by date should be discarded. The DM further explains that he conducts rounds/walks through the kitchen daily.During an interview on 07/17/25 at 3:51 PM, the Administrator revealed that the kitchen services are contracted out and managed by Healthcare services. The Administrator explains that he tries to conduct weekly or monthly walkthroughs of the kitchen. The Administrator explains that his expectation is that food items be stored with labels that include an open date, a use-by date or product manufacturer expiration date. The Administrator continues to explain that his expectation are that open items be in a container and sealed and that no food items be exposed.

F880Based on review of facility policy, observation, record review and interview, 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. Specifically, the facility failed to produce documentation of a surveillance plan, based on a facility assessment, for tracking, and/monitoring infections, communicable diseases and outbreaks among residents and staff for the entire year 2024 and the months of January 2025 and February 2025.Findings include:Review of the facility policy titled Monitoring Compliance with Infection Control states, Policy Statement: Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices.Policy Interpretation and Implementation: 1. The infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and practices.2. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies, and the availability of personal protective equipment and its appropriate use.3. The infection preventionist conducts compliance surveillance at least quarterly or at a frequency determined by the Infection Prevention and Control Committee (IPCC) or the Quality Assurance and Performance Improvement (QAPI) committee.4. Compliance surveillance is unannounced.5. Compliance surveillance includes the use of standardized assessment and observation tools.6. The infection preventionist and/or the IPC committee provides reports to the QAPI committee that reflect:Staff adherence to infection prevention processes (hand hygiene, use of personal protective equipment, etc.);Incidents of employee exposure to blood/body fluids (including a description of the precipitating events and outcomes);Adherence to the facility's antibiotic stewardship program; andAll infection surveillance data7. The QAPI committee reviews and acts upon, as necessary, surveillance and monitoring records.8. Gaps identified in infection prevention and control processes are addressed promptly.During an interview on 07/16/25 at 8:45 AM, the Infection Preventionist revealed, I identify infections by symptoms the resident is having. I talk to the doctor about the resident's symptoms. I talk to the doctor about drawing labs that could identify a potential infection. The doctor may order a broad-spectrum antibiotic if he chooses to cover the resident until the lab results are back. I complete the infection line tracking and any contact tracing. I have not needed to perform any contact tracing since I have been the infection preventionist.During an interview on 07/16/25 at 8:50 AM, the Director of Nursing (DON) revealed antibiotic stewardship is reviewed monthly in QAPI. During a follow-up interview on 07/17/25 at 11:20 AM, the Director of Nursing revealed the previous Assistant Director of Nursing (ADON) was also the infection preventionist. She left on March 3, 2025, and she took her infection control book with her. So there is no infection control data available before April 2025. We have a clinical meeting every morning, and we review all new antibiotics. The current ADON/ Infection Preventionist presents the number of Infections in QAPI each month. She has not presented any infection tracking in QAPI. During an interview on 07/17/25 at 1:30 PM, the Regional Clinical Nurse revealed all antibiotics are reviewed in the morning clinical meeting to make sure that we have an appropriate diagnosis and rationale. The line listing report is completed by the IP daily and the monthly infection rate report is completed monthly and presented in QAPI. There is no infection tracking or trending that I can produce before April 2025. The previous DON and ADON quit abruptly and took that information with them and we have not been able to get that information from them. We have made phone calls and sent letters with no response.

Based on review of the facility policy, observations, record review and interviews, the facility failed to remove expired and discontinued medications from storage and failed to label and date open medications in 3 of 6 medication carts. Findings include:Review of the facility policy titled Medication Labeling and Storage last revised on 02/23 revealed the nursing staff is responsible for maintaining medication storage and preparation in a sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologic pharmacy is contacted for instructions regarding returning or destroying these items. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: expiration date, when applicable.On 07/16/25 at 11:38 AM, observation of the 200 Back Hall medication cart with Licensed Practical Nurse (LPN)4 revealed one box of Nutren 2.0 tube feeding formula with an expiration date of 06/27/25; one opened Novolog FlexPen injector with no open or expiration date; and one unidentified loose oblong white pill. LPN4 confirmed the findings and stated that the nurse who opened the insulin pen should have documented the open and expiration dates. She also explained that Novolog pens are typically only viable for 28 days after opening. LPN4 then disposed of the tube feeding formula and the loose pill.On 07/16/25 at 4:28 PM, observation of the 300 Hall medication cart with LPN3 revealed one opened bottle of Sorbitol 70% solution with an expiration date of 10/11/24 and one opened bottle of Robitussin DM with an expiration date of 11/29/24. LPN3 confirmed the medications were expired and stated they had been previously discontinued. However, she was unsure how to properly dispose of the medications and stated she would need to check with someone for that.During an interview on 07/17/25 at 8:46 AM, the Director of Nursing (DON) stated that all nurses have the authority to dispose of expired or discontinued medications on the medication carts using a [Drug Buster], which is kept on each cart. The DON further stated that Unit Managers are responsible for auditing the medication carts weekly, expired medications should be removed from medication carts.

Based on review of facility policy, record review and interviews, the facility failed to ensure resident assessments accurately reflected the resident's status for pressure ulcers for 1 of 2 residents, Resident (R)10, reviewed for pressure ulcers. Specifically, R10 was readmitted to the facility on [DATE] with a sacral pressure ulcer that was not documented on his skin assessment or Minimum Data Set (MDS). Findings include:Review of the facility policy titled Resident Assessments last revised on 03/22 revealed, 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews.Review of the facility policy titled Functional Impairment - Clinical Protocol last revised 03/18 revealed, Upon admission to the facility, whenever a significant change of condition occurs, and periodically during a resident/patient's stay, the physician and staff will assess the resident/patient's function along with their physical condition.Review of R10's Face Sheet revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including but not limited to malignant neoplasm of lateral wall of the bladder, malignant neoplasm of left kidney, hemiplegia and hemiparesis, acute cystitis with hematuria and diabetes mellitus type two. R10's sacral pressure ulcer was not listed. Review of R10's re-admission Head to Toe Skin Check dated 06/21/25 revealed, Skin Integrity, New Other Issue, Resident returned from hospital with new open area to coccyx, noted under type as pressure no further documentation of the wound was noted.Review of R10's Weekly Head to Toe Skin Check dated 06/28/25 noted R10's skin to be intact with no documentation of any wounds. Review of R10's Weekly Head to Toe Skin Check dated 07/05/25 revealed, Skin Integrity, Existing Pressure Ulcer, open area noted to sacrum. No additional wounds documentation was noted. Review of R10's Weekly Head to Toe Skin Check dated 07/12/25 revealed, Skin Integrity, New Pressure Ulcer, Sacrum Wound, Under wound care DR.Review of a document titled Provider Communication Log revealed, on 06/21/25, R10 had a concern noted as New open area to coccyx, 9.5 [centimeters] cm [by] x 10.3 cm, Wound [doctor] DR aware. Review of R10's Physician Orders revealed Apply Santyl and Alginate to sacrum wound bed. Cover with border dressing. every shift for Wound Care with a start date of 07/02/25. Review of R10's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R10 was cognitively intact. Review of Section M - Skin Conditions noted R10 was at risk of pressure ulcers but did not have any pressure ulcers. During an interview on 07/16/25 at 4:35 PM, Licensed Practical Nurse (LPN) 3 stated the facility does not have a dedicated wound care nurse. LPN3 stated the facility nurses perform wound care and assessments. The wound care provider and the Nurse Practitioner (NP) make weekly rounds at the facility to assess residents with wounds.During an interview on 07/17/25 at 8:40 AM, the MDS Coordinator stated that she is responsible for completing MDS assessments. She then stated that she uses the assessments/evaluations completed by the nursing staff and placed in the Electronic Medical Record (EMR) to complete the necessary MDS. The MDS Coordinator also noted that when completing a Significant Change in Status MDS for R10, she did a seven-day lookback at his skin assessment, and it showed that his skin was intact. The MDS Coordinator confirmed that R10 did indeed have a sacral pressure ulcer that was not accurately documented in the resident skin/wound assessments. During an interview on 07/17/25 at 8:54 AM, the Director of Nursing (DON) stated the Unit Managers (UM) on the floor are responsible for completing admission assessments for the residents; however, the floor nurses complete ongoing skin assessments and should notate if there are any skin issues. The DON also stated she expects assessments to be complete and accurate.

Based on interview, record review, and facility policy review, the facility failed to timely develop a baseline care plan for 1 (Resident (R)502) of 7 sampled residents.Findings include:Review of an undated facility policy titled Care Plans-Baseline revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.Review of an admission Record revealed the facility admitted R502 on 07/16/25. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of cerebral infarction, hyperglycemia, aphasia, and gastrostomy status.Review of R502's medical record revealed a care plan report for an admission date of 07/16/25. The care plan report initiated on 08/06/25 indicated the resident was admitted to the facility with pressure areas to several areas of their body and non-pressure areas to the back and left ear.During an interview on 08/23/25 at 3:30 PM, the Minimum Data Set (MDS) Coordinator stated R502's baseline care plan was not completed for the resident's admission on [DATE] until 08/06/25, and it did not include the resident's need to be fed by way of a tube. The MDS Coordinator stated the baseline care plan should include all interventions the resident needed so the staff could manage the resident's care until completion of the comprehensive care plan.

Based on review of facility policy, record review, observations and interviews, the facility failed to ensure a resident with continuous tube feed received the correct ordered amount and rate of tube feed. The facility also failed to label and date a tube feed bag for 1 of 1 resident, Resident (R)9 reviewed for tube feedings. Specifically, R9's tube feed was infusing at 45 milliliters (ml) per hour (hr) instead of the physician's ordered rate of 50 ml per hour.Review of the facility policy titled Enteral Tube Feeding via Continuous Pump last revised on 11/18, states, The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings. General Guidelines. 3. Check the enteral nutrition label against the order before administration. Check the following information: Resident name, ID and room number; Type of formula; Date and time formula was prepared; and Rate of administration mL/hour. Initiate Feeding. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.Review of R9's Face Sheet revealed R9 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including but not limited to: gastrostomy status, dysphagia and adult failure to thrive. Review of R9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/25 revealed a Brief Interview for Mental Status (BIMS) score was unable to be conducted. Review of Section K - Swallowing/Nutritional Status noted R9 received 51% or more of nutritional intake through a Feeding Tube.Review of R9's Physician Orders documented the following: Order Date, 05/03/25: Enteral Feed Order two times a day related to Gastrostomy status. Jevity 1.5 at 50 mL/hr x 20 hours. 1000 mL total infused. Order Date, 05/19/25: Start Jevity 1.5 @ 50 ml at 8 pm. at bedtime start Jevity 1.5 @ 50 ml total feed 1000 ml. Order Date, 05/03/25: Turn feeding off at 4pm daily in the afternoon turn feeding off at 4pm daily.Review of a Nutrition Progress Note dated 07/10/25 revealed, Enteral: Jevity 1.5 at 50 mL x 20 hours, total infused 1000 mL. Run 8pm-4pm. This will provide 1500 [kilocalories] kcals, 63 [grams] gm [protein] PRO, and 750 mL of free water. Flush 250 mL [four times a day] QID (+1000 mL) = 1750 mL.During an observation on 07/16/25 at 9:59 AM, R9's tube feed was observed without a label or date, the feed was running at a rate of 45 ml/hr.During an observation on 07/16/25 at 11:58 AM, R9's tube feed was again observed at a rate of 45 ml/hr.During an interview on 07/16/25 at 12:06 PM, Licensed Practical Nurse (LPN)1, confirmed R9's tube feed orders of 50 ml/hr, and when notified that R9's current rate was not the ordered rate, LPN1 stated, Let me guess, it's at 45. LPN1 was asked if she verified the correct rate with the off-going nurse, LPN1 replied, She just told me she started it, no verification was done. LPN1 then entered R9's room and confirmed the incorrect rate of 45 ml/hr.During an interview on 07/17/25 at 8:54 AM, the Director of Nursing (DON) stated, the off-going nurse and the incoming nurse must verify and check residents' tube feed orders during change of shift, residents should receive tube feed as ordered.

Based on review of facility policy, record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure one nebulizer machine, one oxygen mask and one medication chamber were clean and/or bagged when not in use for 1 of 2 residents (Resident (R)82), reviewed for respiratory care.Findings include:Review of the facility's policy titled Nebulizer Therapy, with a revision date of October 2024, revealed, Purpose: The purpose of this procedure is to safely administer aerosolized particles of medication into the resident's airway. Steps in the Procedure: 1. Obtain equipment (i.e., administration set up, plastic bag, gauze sponge). 2. Wash hands. 3. After completion of therapy: a. Remove the nebulizer container; b. Rinse the container with fresh tap water; and c. Dry on a clean paper towel or gauze sponge. 4. Reconnect to the administration setup when air dried. 5. Take care not to contaminate internal nebulizer tubes. 6. Wipe the mouthpiece with a damp paper towel or gauze sponge. 7. Store the circuit in a plastic bag, marked with the date and resident's name, between uses. 8. Wash hands. 9. Discard the administration set up every seven days. Review of the facility's policy titled Oxygen Administration, revision date of 01/23/25, revealed, Policy: Licensed clinicians with the demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer. Procedure: 1. Verify provider order. Administration Via Nasal Cannula: 5. Set flow rate as prescribed or to obtain desired SpO2. Standard nasal cannulas provide flow rates up to 6L/min. >6L/min use high flow nasal cannula device.Review of R82's Face Sheet, located in the Electronic Medical Record (EMR) under the Clinical tab, revealed R82 was admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, pneumonia and dementia. Review of R82's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R82 has moderate cognitive impairment. Review of R82's Care Plan documented a focus: has oxygen therapy to relieve hypoxia r/t End Stage COPD, recent Flu, Hypoxia, respiratory distress, Chronic Hypoxemic respiratory failure. The goal documented, Will have no s/sx of poor oxygen absorption through the review date. Intervention directed staff to OXYGEN SETTINGS: O2 via nasal cannula as ordered.Review of R82's Medication Administration Record (MAR) for 07/01/25 - 07/17/25 revealed an order for O2 AT 2L-3L Continuous VIA NC every shift for to relieve hypoxia related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation; Acute and Chronic Respiratory Failure with an order date of 07/10/25. Review of R82's Physician Orders located in the EMR under the Orders tab and dated start date 07/10/25 with a revision date of 07/15/25 revealed an order for Budesonide Inhalation Susp 0.5 MG/2ML 2 cc inhale orally two times a day related to Acute and Chronic Respiratory Failure and Pneumonia, Pulmicort Suspension 0.5 MG/2ML (Budesonide) 2 ml inhale orally via nebulizer every 12 hours related to Chronic Obstructive Pulmonary Disease. Further review of the Physician Orders revealed O2 AT 2L-3L Continuous VIA NC every shift to relieve hypoxia related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Acute and Chronic Respiratory Failure . with a start date of 07/11/25.During an observation and interview on 07/15/25 at 11:25 AM, R82's nebulizer mask lying in the middle of the resident's bed face down. The oxygen mask was attached to the medication chamber and the tubing. The mask was not bagged. There was a clear liquid in the medication chamber. The medication chamber was attached to the mask and the oxygen tubing. The medication chamber was not bagged. R82 states she does not know how much oxygen she is on. Further observation revealed oxygen noted running via concentrator. Nasal cannula noted in the resident's nose, and the oxygen rate was at 4 litres per minute (LPM).During an observation on 07/15/25 at 4:00 PM, revealed resident was sitting on the side of her bed, the oxygen concentrator was set at 4.0 liters per minute (LPM). The nebulizer was on the resident's bedside table. Black writing on the nebulizer mask reads 07/14/25. The oxygen mask was face down in the middle of the resident's bed. The mask was attached to the medication chamber and the tubing. The mask was not bagged. There was a clear liquid in the medication chamber. The medication chamber was attached to the mask and the oxygen tubing. The medication chamber was not bagged.During an interview on 07/15/25 at 4:10 PM, LPN1 verified the nebulizer mask was face down in the middle of the resident's bed. The mask was attached to the medication chamber and the tubing. The mask was not bagged. There was a clear liquid in the medication chamber. The medication chamber was attached to the mask and the oxygen tubing. LPN1 revealed that the nebulizer mask should be cleaned and placed in a bag. LPN1 confirmed that the nebulizer mask was dated 07/14/25. LPN1 revealed that the day and time to change the mask and tubing pops up on the MAR every two to three days. The resident's order reads to change mask and tubing every Sunday. The nurse verified that the date on the mask was a Monday. LPN1 verified that the oxygen was on 4 LPM and it should be on 2 to 3 liters per minute. Oxygen was adjusted to 3 liters per minute as per order by LPN1.During an interview with the Unit Manager on 07/15/25 at 4:27 PM, the resident's oxygen order of O2 at 2-3 liters per minute via nasal cannula.During an interview on 07/17/24 at 9:00 AM, revealed oxygen rates should be verified by each nurse assigned to a resident receiving oxygen at the beginning of every shift and as need.

Based on interview, record review, and facility policy review, the facility failed to protect one non-interviewable, cognitively impaired Resident (R2) from a non-consensual sexual encounter with R1. Despite prior documentation of R1's inappropriate and unsafe behaviors toward female residents, the facility did not implement timely or adequate interventions to prevent further incidents. On April 25, 2025 at 5:26 PM, the Administrator and Director of Nursing (DON) were notified that the failure to protect Resident (R)2 from a non-consensual sexual encounter with R1 constituted Immediate Jeopardy (IJ) at F600. On April 25, 2025 at 5:26 PM, the survey team provided the Administrator and DON with a copy of the CMS IJ Template and informed the facility the IJ existed as of April 16, 2025. The IJ was related to §483.12 - Freedom from Abuse, Neglect, and Exploitation. On April 28, 2025, the facility provided an acceptable IJ Removal Plan. On April 28, 2025 at 12:00 PM, the survey team validated the facility's corrective action and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled Abuse Prevention Program last revised December 2016, revealed, Our residents have the right to be free from abuse . This includes but is not limited . sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including but necessarily limited to facility staff, other residents . Protect residents during abuse investigations. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Review of R1's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: frontal lobe and executive function deficit, impulse disorder, dementia with behaviors, and psychoactive substance dependence in remission. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/25, revealed he had a Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicates that he had severe cognitive impairment. Review of R1's Electronic Medical Record (EMR) Nurses Note revealed a note dated 04/16/25 at 9:25 AM, which revealed, Resident was seen going into a female resident's room [R2] while Certified Nursing Assistant (CNA) was performing Activities of Daily Living (ADL) care. [R1] was directed to leave the room and not return. Female resident next door [R5] also stated that he went into the same resident's room last night and was attempting to come into her room as well. Female resident asked [R1] to leave and not come back. Management was notified of the behavior for possible room change. Review of R1's EMR Nurses Note dated 04/16/25 at 12:57 PM, revealed, Writer educated resident about entering another resident's room without their consent. Resident understood to not enter another resident's room. Plan of care is ongoing. Review of R1's Nurses Notes revealed a note dated 04/16/25 at 3:22 PM, which revealed 15-minute check was initiated at noon. Resident has been redirected out of female's rooms three times. Review of R1's EMR Situation Background Assessment Recommendation (SBAR) Summary dated 04/17/25 at 8:12 AM, revealed, Increased confusion . Resident is being sent to local hospital for evaluation and treatment, Resident Representative notified, primary care physician notified. Review of R1's EMR Nurses Note revealed a note dated 04/17/25 at 12:45 PM, 15-minute check reinitiated since return from hospital. Review of R1's EMR Nurses Note revealed a note dated 04/18/25 at 6:06 AM, 15-minute checks remain in place resident at rest with no behaviors noted plan of care ongoing. Review of R1's EMR Nurses Note revealed a note dated 04/18/25 at 1:02 PM, Resident remains on 1:1 monitoring, Medical Director (MD) and Resident Representative (RR) made aware, plan of care is ongoing. Review of R1's EMR Nurses Note revealed a note dated 04/18/25 at 6:04 PM, [R1] doing well has had 1:1 sitter all day no complaints voiced. Review of R1's EMR Physician Progress Notes dated 04/17/25 at 1:30 PM, revealed, [R1] seen today for management of acute or chronic conditions to avoid decline while in Skilled Nursing Facility (SNF), per staff patient altered mental status now wandering into opposite sexes room two days. Per Nurse Practitioner sent to emergency room (ER). No pain noted, no skin issues reported, staff has no concerns at this time. Assessment/Plan - altered mental status increased for two day and now wandering into opposite sex rooms, sent out for evaluation. Review of R1's EMR Physician Progress Note dated 04/18/25 at 1:30 PM, revealed [R1] being seen today for management of acute or chronic conditions to avoid decline while in SNF. Patient being seen for follow up from ED visit, per staff, no new orders or findings from ED report. No pain noted, no skin issues reported, staff has no concerns at this time. Assessment/Plan - altered mental status increased for two days and now wandering into opposite sexes rooms, sent out for evaluation . Facility made [R1] 1:1 supervision until resident seen by psychiatric services. Review of R1's EMR Psychiatry Initial Consult dated 04/18/25, revealed, Assessment and Plan - dementia, BIMS 15 out of 15, moderate symptoms of cognitive impairment, sexual inappropriate behaviors reported, intrusive behavior, symptoms will progress as dementia progress. Start Divalproex ER 250mg tablet extended related 24 hours, take one tablet by mouth once a day. Review of R1'S Care Plan revised on 04/24/25 (during survey) revealed, [R1] exhibits severe cognitive impairment and memory loss. He is alert and oriented to self only. R1 has a diagnosis of frontal lobe and executive deficit following cerebral infraction and diagnosis of dementia with behaviors. Damage to the frontal lobe can cause executive dysfunction affecting ability to perform everyday tasks. R1 has trouble with planning, starting tasks, remembering things, and shifting plans. He may also experience behavioral changes, mood swings, and loss of interest in activities. He also has a history of psychoactive substance abuse in remission. Strengths include [R1] appears to understand what is said to him, answers simple questions and make needs/wants known, and is pleasantly confused and cooperative with staff. He was poor hygiene and poor safety awareness at times. Toilets in inappropriate areas, wanders on unit at times. Interventions include 1:1 due to increased confusion/wandering; explain all procedure to [R1]; give [R1] simple choices to increase sense of autonomy and reduce the stress of decision making; monitor for any changes or decline in [R1] cognitive status; notify nurse/MD of any changes in mental status. Review of R1's Notification of Room Change/Notification of Roommate document dated 04/25/25 revealed, Staff reported that [R1's] roommate watches adult entertainment on his phone/tablet and plays it out loud. To avoid any triggers for [R1] he is being moved to another unit. [R1] agreed to the room change. He is familiar with 300 Hall and was previously in a room on that unit. Said he'd be glad to move back to the 300 Unit. Review of R2's Face Sheet revealed that she was readmitted to the facility on [DATE], with diagnoses including but not limited to: muscle wasting atrophy, weakness, contracture of muscle, cognitive communication deficit, and paraplegia. Review of R2's Quarterly MDS with and an ARD of 03/12/25, revealed that R2 is in a vegetative state, no BIMS score was record. Further review of the Quarterly MDS revealed that R2 is dependent on staff for all ADLs. Review of R2's EMR Nurses Notes for April 2025, revealed no notes related to this incident. Review of R2's EMR Assessments revealed a Head-to-Toe Skin Check dated 04/17/25 at 7:05 AM, status was still in progress on 04/24/25 at 1:53 PM. Further review of the Head-to-Toe Skin Check revealed that it was incomplete/blank. During an observation and an attempted interview on 04/24/25 at 10:17 AM, with R1 was unsuccessful. The resident at this time was asleep. Further observation and interview revealed Certified Nursing Assistant (CNA)1 sitting outside of R1's door and providing 1:1 supervision for R1. During an observation and attempted interview on 04/24/25 at 10:17 AM, with R2 was unsuccessful, as R2 is in a vegetative state. During an observation and interview on 04/24/25 at 11:44 AM, R2's Resident Representative (RR) in R2's room revealed, On Easter Sunday (04/20/25) I was informed by a resident that they overheard on 04/17/25 a staff member yelling at [R1], What are you doing in here . you should not be in [R2's] room with the door closed. The staff member escorted [R1] out of [R2's] room and was yelling about [R1] touching [R2] inappropriately in her room to other staff and attempting to get other staff to call law enforcement. R2's RR further stated that when this resident reported this information to her she was in shock because they were not informed by the facility staff of any incident occurring with R2 and was told by the resident that law enforcement never came to the facility and R2 was never sent out to the hospital for evaluation, only R1. R2's RR was also informed by the resident that this was the third time that he witnessed/overheard R1 entering R2's room without consent and having to be redirected by staff out of her room and this has been happening ever since R2's former/more cognitively intact roommate discharged from the facility a few weeks ago. The resident told R2's RR that R1 was sent to the hospital but returned to the facility the same day and was placed back in the same room [ROOM NUMBER] doors down from R2. During interview with R2's RR they stated that a staff member/nurse (unable to recall name) also informed them that something inappropriate occurred to R2 by R1. This staff member explained to her that they wanted to call law enforcement and report this incident to the appropriate authorities, but they were told (by Administration) to change their documentation in the EMR/Nurses Notes to make the incident appear like R1 did not have a non-consensual encounter with R2. Further interview with R2's RR revealed that they visit R2 daily and visited the resident on 04/19/25 (day before R3 reported incident to RR) but could tell something was off with R2 on that Saturday because of her facial expressions, specifically R2 appeared to have a worried grimace. R2's RR additionally stated that they are disappointed and upset with the facility for not informing her of this incident and does not feel like R2 is safe because R1 is still 2 doors down from her. Although R1 has a sitter with him for now, I feel like after the state agency leaves/in a few weeks when things settle down, he (R1) will be back wandering the facility again and in other resident rooms. During a follow up interview on 04/24/25 at 12:05 PM, CNA1 revealed they were assigned to R1 for 1:1 supervision last week but could not recall which specific date. CNA1 stated the reason they have to provide R1 with 1:1 supervision is because R1 sexually assaulted another resident at the facility and was informed of this by another CNA that works at the facility. CNA1 stated that they haven't personally witnessed R1 touching other resident's inappropriately but have seen him wandering out of female resident rooms and other staff in the past had to redirect him out. Review of R3's Face Sheet revealed that he was admitted to the facility on [DATE], with diagnoses including but not limited to cerebral palsy, muscle weakness, pain, abnormalities of gait and mobility, and major depressive disorder recurrent (mild). Review of R3's Quarterly MDS with an ARD of 03/19/25, revealed that R3 had a BIMS score of 15 out of 15, which indicates that he is cognitively intact. During an interview with R3 on 04/24/25 at 2:10 PM, revealed on 04/17/25 around 7:00 AM I overheard a staff member yelling at R1 from R2's room, What are you doing in [R2's] room with the door closed? R3 stated they heard a staff member yelling out to other staff to help assist her with removing R1 out of R2's room. R3 stated that this was not the first time that R1 wandered into R2's room and he has observed R1 close the door while alone with R2 and could recall this incident happening two times prior. R3 stated that R1 was sent out to the hospital after being found in R2's room that morning but returned to the facility a few hours later and was returned to his room. R3 stated that they did not observe R2 being sent for evaluation. When R1 returned to the facility he was then placed on 1:1 supervision. R3 stated facility staff did not report this incident to R2's RR or call law enforcement but they could not allow this situation to go unreported out of fear for R2's safety because she is vulnerable due to her vegetative state. R3 revealed that they have had conversations with R1 about the incident with R2 while outside smoking with staff and R1 stated, I wanted to touch some pussy. Review of R4's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: type 2 diabetes with diabetic neuropathy, acquired absence of left and right leg below knee, abnormalities of gait and mobility, major depressive disorder recurrent severe without psychotic features, and congestive heart failure. Review of R4's Quarterly MDS with an ARD date of 03/13/25, revealed that R4 had a BIMS score of 15 out of 15, which indicates that he is cognitively intact. During an observation and interview with R4 on 04/24/25 at 2:42 PM, revealed that they are currently roommates with R1 and overheard CNA2 yelling at R1 to get out of R2's room. R4 further stated that they witnessed CNA2 bring R1 back into the room and yelling at other staff to call law enforcement because R1 was touching R2 in a non-consensual and sexually inappropriate manner. R4 further revealed, He has been living with me for a few weeks prior to the incident with R2, but R1 has always wandered and taken other resident's food/snacks. R1 would also at times relieve (defecate/urinate) in public areas. There have been times in the past when R1 eats others meal trays that have been left for clean up in the dining area. I always keep my foods/snacks on me and on the back of my wheelchair because I don't want R1 to take my food. During the daytime I stay out of my room because I don't feel comfortable being in the room with R1 and I also don't like now that it has to always have a sitter with him because the incident with R2. R4 he stated that staff have been retaliative towards him because of this incident. R4 revealed that he was outside smoking with R1 after the incident on 04/17/25, and R1 was bragging about, touching [R2's] pussy to [R4], [R3], other residents and staff. One staff member even told R1 that he was being bad but R1 laughed it off. Review of R5's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: muscle weakness, need for assistance with personal care, major depressive disorder recurrent, and generalized anxiety disorder. Review of R5's Quarterly MDS with an ARD of 04/17/25, revealed R5 had a BIMS score of 13 out of 15, which indicates that she is cognitively intact. During an interview on 04/24/25 at 3:30 PM, R5 revealed that R1 attempted to enter her room on 04/16/25 around midday. R5 stated that she yelled at R1, If you come in here, I will gouge out your eyes. R1 ran next door into R2's room and was in there for several minutes. R1 was then observed by a staff member in R2's room and ran out of R2's and back into his room and closed his door. R5 stated that this was not the first incident of R1 attempting to enter female resident's room, and they have witnessed R1 enter R2's room at night over the last few weeks. R5 stated that they reported this to a nurse (unsure of name), but nothing was done about the situation/it was brushed off. R5 further stated that she does not feel safe at the facility because R1 is still located on the same hall, R5 also stated that she is frustrated that R1 is still 2 doors away from R1 as well. R5 finally stated that she has informed her family about the incident in the event anything should happen. R5 feels the facility is not protecting R2 by allowing this behavior to continue. During an interview on 04/24/25 at 4:30 PM, R1 revealed I was sent to the hospital on [DATE], because I went in the room next door and touched [R2]. I touched her leg. R1 stated he viewed R2 in bed with one leg hanging out of the covers. R1 begin to demonstrate how he touched R2. R1 beginning to rub his own leg starting at his knee and moving up towards the body. When asked why did you touch R2's leg, R1 replied, Because I'm a man and I have urges. That was the first time I touched another resident and the last time. I realized it was wrong, and someone told me I'm not supposed to do that. I was punished for what I did. The day after the incident I was required to always have a sitter as a punishment. During an interview with CNA2 on 04/25/25 at 9:06 AM, revealed that they did not witness R1 in R2's room on 04/17/25 and that she was providing ADL care to another resident but heard a commotion and someone yelling, What are you doing in here? to R1 while in R2's room. CNA2 stated that when they made it to R2's room, the Unit Manager and a nurse (unable to recall name) assisted the resident back to the room. CNA2 stated that law enforcement was not notified of the incident but R1 was sent to the hospital for an altered mental state. CNA2 stated she was unsure if R2 was assessed or sent out for evaluation for a potential non-consensual sexual encounter. During an interview on 04/25/25 at 9:58 AM, Licensed Practical Nurse (LPN)1 revealed at approximately 6:45 AM on 4/17/25, during med pass she heard a male voice yell out, What are you doing? and upon inspection, she noted her supervisor, standing in R2's doorway while R1 was sitting in his wheelchair outside the room. LPN1 reports that R1 stated, He wanted to see her pussy and that he has needs. LPN1 reports R1 was sent out for a psych evaluation and that no police were called, nor was R2 sent out to be evaluated. LPN1 further stated she reported her concerns to the Administrator and Director of Nursing (DON) and gave them her written statement. LPN1 stated, She felt like they should have done more by calling the police and having [R2] evaluated after an alleged assumption of sexual abuse, but she was told to follow her higher-up's instruction. During an interview on 04/25/25 at 11:51 AM, CNA3 revealed that R1 was placed on 1:1 observation due to wandering into R2's room without her consent. CNA3 revealed that R1 does not have a history of behaviors, and they have never witnessed R1 wandering into other residents' room or exhibiting inappropriate behaviors. CNA3 stated [R1] used to relieve himself in sinks at the facility but does not currently have that behavior. CNA3 stated that they are aware of the facilities abuse policy and that, If you see something then you should report it immediately to the nurse or supervisor then stop talking about the incident. During an interview on 04/25/25 at 12:54 PM, LPN2 stated on 04/16/25 between approximately 10:00 and 10:30 AM, R5 reported to her, That white man [R1], kept coming in [R2's] room last night and tried to come into my room. LPN2 stated not even 1 hour later, a CNA was screaming that R1 had entered R2's room and pulled her curtains back while she was performing ADL care. R1 was told to leave R2's room. LPN2 then notified the unit manager (UM) about her concerns who replied with OK. LPN2 further states that after she documented in R1's progress notes the UM stated they were placing R1 on 15-minute checks. LPN2 had to redirect R1 from entering female residents' room three more times afterwards. LPN2 stated the potential was there for R1 to abuse residents and expected that the facility would move R1 from the hall and from around female residents and wanted to prevent anything further from happening. During an interview on 04/25/25 at 12:36 PM, the Social Worker (SW) revealed that R1 often sleeps during the day but does not have any significant behaviors. R1 recently began wandering into other resident's rooms which is a new behavior for R1. The SW revealed that R4 reported to them that they witnessed R1 being brought back into the room on 04/17/25, after being observed near R2's room and staff were questioning R1 about what he was doing in front of R2's room. The SW revealed they were not at the facility yet for the day for work when this incident occurred and doesn't know the full details, but they reported what R4 told them to the Administrator and was told the administrative staff was handling this incident. The SW stated that the last abuse training/in-service they received was about two months ago. During an interview with the Unit Manager (UM) on 04/25/25 at 1:40 PM, revealed that they were not at work yet for the day on 04/17/25, but it was reported to them that R1 was observed outside of R2's door and has had an increase of wandering behavior which is new behavior for R1. The UM further stated that because R1 was observed near R2's door he was sent to the hospital due to altered mental status and was placed on 1:1 supervision, when R1 returned from the hospital. The UM stated that a body audit was completed for R2. During an interview on 04/25/25 at 2:29 PM, the Assistant Director of Nursing (ADON) and Administrator, when asked what interventions were implemented after R1 was redirected 3 times from entering female residents' room after being on 15-minute checks, no answer was provided. The Administrator stated he was unaware of R1's documented behavioral concerns on 4/16/25 the day prior to the incident. During a phone interview on 04/25/25 at 2:58 PM, CNA4 revealed that they work the night shift at the facility and is often assigned to R1 and R2. CNA4 stated that most nights R1 wanders the unit and mostly goes to the nurse's station to ask for snacks and to the main dining area. CNA4 states that R1 looks/enters into the female resident's room. CNA4 stated that in the last few weeks (could not recall specific date) they observed R1 wandering into R2's room at night, and they observed at least three separate occasions. On the first two incidents CNA4 stated that they observed R1 in the room but not close to R2 and they observed R2's sheets on her bed were disheveled each time and they had to redirect R1 out of the room and tuck R2's sheet back in place. On the third observation CNA4 stated that she observed R1 in his wheelchair next to R2's bed. CNA4 stated that she did not observe R1 touching R2 but observed that R2's sheets were disheveled again and realized that R1 must have been the reason why the resident's sheets were displaced because he was the only other person in R2's room and she is not able to transfer/move without staff assistance. CNA4 stated that they reported this 3rd incident to LPN1. CNA4 stated that the morning of 04/17/25 at approximately 7:00 AM, CNA2 observed R1 in R2's room and had to redirect him out of her room as well. CNA4 revealed that it has been about one month are longer since the last time they received abuse/neglect training. Review of a Hospital Transfer Form dated 04/25/25 at 3:14 PM, revealed, Key Clinical Information reason for transfer: other: hospital given report. Resident Representative notified on 04/25/25 at 3:22 PM Review of a Hospital Discharge summary dated [DATE] revealed, [R2] has a past medial history of Anoxic brain injury, sacral decubitus ulcer, seizure disorder, functional quadriplegia who presents to the Emergency Department (ED) for evaluation of potential reported sexual assault per patient's mother. Patient is resident at Skilled Nursing Facility, history obtained from the Emergency Medial Services (EMS) and patient's mother. Patient's mother states that she heard from another resident at the facility that another patient (R1) was seen in [R2] room a week ago (04/17/25). According to the mother (R2 Resident Representative) there was no visualization of any sexual activity. EMS sates that the facility did a full physical exam including external genitalia exam and did not see any evidence of infection . During a phone interview on 04/28/25 at 11:19 AM, the Psychiatric Nurse Practitioner (PNP) revealed that they first evaluated R1 on 04/18/25 due to a change in R1's mental status specifically that the resident was exhibiting verbal aggression and sexually inappropriate behaviors towards female residents by wandering into their rooms without their consent. After the initial consult on 04/18/25 a recommendation was made to start Divalproex 250 mg tablet for a diagnosis of dementia with behavioral disturbances. A second evaluation of R1 was conducted by the PNP on 04/25/25 and a recommendation was made to start Seroquel 50 mg tablet for a diagnosis of dementia with behavioral disturbance. During a phone interview on 04/28/25 at 1:10 PM, the Medical Director (MD) revealed that they were not formally informed by the facilities Administration of the potential non-consensual sexual abuse. The MD revealed that they had spoken with other residents and were informed by a potential incident with R1 and R2 during their last visit to the facility on [DATE] but was unaware of the extent of the situation. The MD revealed that the resident has a history of inappropriate behaviors such as urinating in public areas but wandering into other resident rooms is a new behavior for R1. The MD also stated that the only facility staff member that was spoken to regarding the potential incident was the Social Worker and was told that the facility was investigating the matter. The MD stated that he was not notified on the Immediate Jeopardy that is ongoing at this time related to R1 and R2 and the potential non-consensual sexual abuse. On April 28, 2025, the facility provided an acceptable IJ Removal Plan, which included the following: On 04/17/25 at approximately 7:00 AM R1 was placed on one-to-one supervision; on 04/17/25 at 8:12 AM R1 was sent to the hospital for evaluation; on 04/17/25 R2 has a skin check performed by a licensed nurse state post the event to check for apparent injuries without findings; on 04/17/25 at approximately 9:15 AM R2 was assessed by the Nurse Practitioner (NP) status post event to check for apparent injuries without findings; on 04/17/25 at 9:45 PM R1 returned from the hospital without orders and was placed on one-to-one staff supervision; on 04/17/25 at approximately 1:30 PM R1 was assessed by the NP post the event without further orders R1 remained on one-to-one staff supervision; on 04/18/25 at 1:30 PM R1 continued on one-to-one staff supervision and was assessed by the NP post event without orders; on 04/18/25 R1 was assessed by the facilities Psychiatric Nurse Practitioner (PNP) post the event with the new medications orders R1 remained on one-to-one staff supervision; on 04/25/25 room change for R1 remains on one-to-one supervision; on 04/25/25 at approximately 3:15 PM R2 was transferred to the hospital for evaluation; on 04/26/25 the Social Services Director (SSD) completed interviews with residents with Brief Interview of Mental Status (BIMS) score of 13 or above were interviewed to ensure no abuse or neglect; on 04/26/25 all current residents had skin checks by licensed nurse and documented in the facility Electronic Medical Report to ensure no suspicious injuries or indication of abuse or neglect. On 04/26/25 current residents with targeted physical behaviors of wandering into other resident room potentially becoming sexually inappropriate towards others were identified by the Interdisciplinary Team (IDT) to include the Administrator, DON, Medical Director (MD), SSD, Therapy Director, Unit Managers, and Regional Clinical Director (RCD). On 04/26/25 current residents with targeted physical behaviors care plans and behavior monitoring tools were reviewed and updated as needed by the IDT to ensure interventions are in place for safety. On 04/26/25 the RCD reviewed the policy with and completed re-education of the facility's policies and procedures for abuse and neglect with the Administrator and DON to ensure understanding with a verbal return demonstration as to the types of abuse and neglect, dealing with disruptive behaviors including dementia care sexually acting out, to include but not limited to what to do if staff witness abuse and neglect, when to report abuse and neglect, to whom to report abuse and neglect and the designated facility abuse coordinator, who is the facility administrator. On 04/26/25 the DON and Unit Managers completed re-education with all current staff, including Dietary, Housekeeping, Laundry, Administration, Maintenance, Social Services, Therapy, Activities, Department Managers, Nursing including Licensed Nurses and Certified Nursing Assistants (CNA) including agency staff on the facility's policy and procedure for abuse and neglect, Dealing with Disruptive Behaviors including Dementia Care Sexually Acting Out, to ensure understanding with a verbal return demonstration as to the types of abuse and neglect to include but not limited to what to do if staff witness abuse and neglect, to whom to report abuse and neglect and the designated facility abuse coordinator. This education for staff will be the responsibility of the DON/ Licensed Nurse Manager for current staff. Staff who were not educated on 04/26/25 either in person or by telephone will be educated prior to the start of their next shift. The DON and Licensed Nurse Managers were notified of this responsibility on 04/26/25. A Quality Assurance Performance Improvement (QAPI) Committee was held on 04/25/25 to formulate and approve a plan of correction for the deficient practice. The Administrator will be responsible for the completion of the corrective action plan. The DON/Designee will review the 24-hour report five times a week for 12 weeks to ensure wandering behaviors are addressed timely and without incident; the DON/Designee will be reviewing five residents skin assessments weekly for 12 weeks to ensure no signs of abuse/neglect; the SSD will interview five cognitively intact residents for 12 weeks to ensure no signs of abuse/neglect. The DON/Designee and the SSD will be responsible for reporting the results of these audits to the facility's monthly QAPI committee will make recommendations and changes as indicated based upon the findings of the audits.

Based on review of facility policy, record review, and interview, the facility failed to report an allegation of potential non-consensual sexual abuse for Resident (R)2 by R1 to the proper authorities/state agency within the appropriate timeframes. On April 28, 2025 at 4:03 PM, the survey team notified the Administrator and DON that the failure to report an allegation of sexual abuse made by residents and staff constituted IJ at F609. On April 28, 2025 at 4:03 PM, the survey team provided the Administrator and DON with a copy of the CMS IJ Template and informed the facility the IJ existed as of April 16, 2025. The IJ was related to §483.12 - Freedom from Abuse, Neglect, and Exploitation. On April 28, 2025, the facility provided an acceptable IJ Removal Plan. On April 29, 2025 at 10:00 AM, the survey team validated the facility's corrective actions were in place as of April 28, 2025 and removed the IJ. The facility remained out of compliance at F609 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F609, constituting substandard quality of care. Findings include: Record Review of the facility policy titled Abuse Investigation and Reporting last revised July 2017 revealed All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or/ injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy interpretation and implementation include: .the administrator will keep the resident and his/her representative informed of the progress of the investigation; the administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented; the administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident .All alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; the local/state Ombudsman; The Resident's Representative (Sponsor) of Record; Law Enforcement officials; the resident's attending physician; and the facility Medical Director (MD). An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but not later than two hours if alleged violation involves abuse or has resulted in serious bodily injury; or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The administrator or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident. Record review of R1's Electronic Medical Record (EMR) Nurses Note revealed a note dated 04/16/25 at 9:25 AM revealed, Resident was seen going into a female resident's room (R2) while Certified Nursing Assistant (CNA) was performing Activities of Daily Living (ADL) care. R1 was directed to leave the room and not return. Female resident next door (R5) also stated that he went into the same resident's room last night and was attempting to come into her room as well. Female resident asked R1 to leave and not come back. Management was notified of the behavior for possible room change. Record review of R1's EMR Nurses Note dated 04/16/25 at 12:57 PM revealed Writer educated resident about entering another resident's room without their consent. Resident understood to not enter another resident's room. Plan of care is ongoing. Record review of R1's Nurses Notes revealed a note dated 04/16/25 at 3:22 PM, revealed 15-minute check was initiated at noon. Resident has been redirected out of female's rooms three times. Record review of R1's EMR Situation Background Assessment Recommendation (SBAR) Summary dated 04/17/25 at 8:12 AM revealed Increased confusion . Resident is being sent to local hospital for evaluation and treatment, Resident Representative notified, primary care physician notified. Record review of R1 EMR Physician Progress Notes dated 04/17/25 at 1:30 PM revealed R1 seen today for management of acute or chronic conditions to avoid decline while in Skilled Nursing Facility (SNF), per staff patient altered mental status now wandering into opposite sexes room two days. Per Nurse Practitioner sent to emergency room (ER). No pain noted, no skin issues reported, staff has no concerns at this time. Assessment/Plan - altered mental status increased for two day and now wandering into opposite sex rooms, sent out for evaluation. Record review of R1 EMR Physician Progress Note dated 04/18/25 at 1:30 PM, revealed R1 being seen today for management of acute or chronic conditions to avoid decline while in SNF. Patient being seen for follow up from ED visit, per staff, no new orders or findings from ED report. No pain noted, no skin issues reported, staff has no concerns at this time. Assessment/Plan - altered mental status increased for two days and now wandering into opposite sexes rooms, sent out for evaluation . Facility made R1 1:1 supervision until resident seen by psychiatric services. Record review of R1 EMR Psychiatry Initial Consult dated 04/18/25, revealed, Assessment and Plan - dementia, BIMS 15 out of 15, moderate symptoms of cognitive impairment, sexual inappropriate behaviors reported, intrusive behavior, symptoms will progress as dementia progress. Start Divalproex ER 250mg tablet extended related 24 hours, take one tablet by mouth once a day. Record review of R2's EMR Nurses Notes for April 2025 revealed no notes related to this incident. Record review of R2's EMR Assessments revealed a Head-to-Toe Skin Check dated 04/17/25 at 7:05 AM, that status was still in progress on 04/24/25 at 1:53 PM. Further review of the Head-to-Toe Skin Check revealed that it was incomplete/blank. An observation and interview on 04/24/25 at 11:44 AM with R2's Resident Representative (RR) in R2's room revealed that they were informed by another resident at the facility that R2 may have potentially been sexual abused by R1 and that the facility staff were attempting to hide/cover up the incident. R2's RR revealed that a staff member also reported to them off the record that they had concerns with R2 potentially being sexually assaulted by R1 as well. This staff member explained to her that they wanted to call law enforcement and report this incident to the appropriate authorities, but they were told (by Administration) to change their documentation in the EMR/Nurses Notes to make the incident appear like R1 did not have a non-consensual encounter with R2. R2's RR stated that no one from the facility administration has formally on the record notified her of any incident regarding R2 potentially being sexually abused by R1. An interview with R3 on 04/24/25 at 2:10 PM revealed that that they recall R1 being sent out to the hospital after that incident but R2 remained in the facility and law enforcement was not notified and never came to the facility regarding this incident. An interview on 04/25/25 at 9:58 AM, Licensed Practical Nurse (LPN)1 revealed R1 stated, He wanted to see her pussy and that he has needs. LPN1 further stated she reported her concerns to the Administrator and Director of Nursing (DON) and gave them her written statement. LPN1 stated she felt like they should have done more by calling police and having R2 evaluated after an alleged assumption of sexual abuse, but she was told to follow her higher-up's instruction. An interview on 04/25/25 at 12:36 PM, the Social Worker (SW) revealed R4 told the Administrator and was told by the administrative staff that they were handling this incident. An interview with the Unit Manager (UM) on 04/25/25 at 1:40 PM the UM questions were asked about how the facility ensured a thorough investigation was completed to ensure that no harm/potential occurred with R2, and they stated that a body audit was completed. During the interview the surveyor revealed that the body audit dated for 04/17/25, was still marked in progress on the EMR. Further interview with the UM revealed that the facility did not notify R2's Resident Representative of the potential for harm related to this incident, and no other residents', specifically female residents, that are in close contact to R1, were interviewed. Final interview with the UM revealed that they were unaware of other incidents' of R1 being reported in R2 and other female resident's rooms. An interview on 04/25/25 at 2:29 PM, the Assistant Director of Nursing (ADON) and Administrator, revealed no residents were interviewed regarding safety concerns, after the alleged incident occurred with R1 and R2. When asked how they ensured that no additional residents were impacted and all residents remained safe, there was no answer given. When asked what interventions were implemented after R1 was redirected 3 times from entering female's room after being on 15-minute checks, no answer was provided. The Administrator stated he was unaware of R1's documented behavioral concerns on 04/16/25 the day prior to the incident. An observation on 04/25/24 at 4:33 PM, the Administrator and Law Enforcement Officer revealed that the facility is having this alleged incident investigated by law enforcement (8) days after the potential sexual abuse incident. A follow-up interview with the Administrator on 04/25/25 at 4:48 PM, they provided the case number for the law enforcement investigation, Administrator stated that the official report will be ready in a few days. A phone interview on 04/24/25 at 10:23 AM, the local Ombudsman revealed that they were unaware of any allegations of potential non-consensual sexual abuse and was not notified by the facility. During interview with the Ombudsman state surveyor that complaint was received anonymously and that this was not a facility reported investigation. An in-person follow-up interview on 04/28/25 at 10:30 AM with the local Ombudsman revealed that they still have not been formally notified of the allegation of potential non-consensual sexual incident by R1 with R2 by the facility. Further interview with Ombudsman revealed that they spoke with the facility and explained that their expectation and state regulation require for facilities to report abuse which includes allegation of potential abuse. A follow-up phone interview on 04/28/25 at 12:39 PM with R2's RR revealed that they have still not been formally notified of the potential non-consensual sexual incident regarding R1 and R2. R2's RR stated that the Administrator and Unit Manager spoke with her on 04/25/25 and stated that they were sending R2 to the hospital even though nothing happened but the Administrator and Unit Manager never went into detail about incident/ complete reason for transfer. Record review of a Hospital Transfer Form dated 04/25/25 at 3:14 PM revealed Key Clinical Information reason for transfer: other: hospital given report. Resident Representative notified on 04/25/25 at 3:22 PM Record review of a Hospital Discharge summary dated [DATE] revealed R2 has a past medial history of Anoxic brain injury, sacral decubitus ulcer, seizure disorder, functional quadriplegia who presents to the Emergency Department (ED) for evaluation of potential reported sexual assault per patient's mother. Patient is resident at Skilled Nursing Facility, history obtained from the Emergency Medial Services (EMS) and patient's mother. Patient's mother states that she heard from another resident at the facility that another patient (R1) was seen in R2 room a week ago (*04/17/25). According to the mother (R2 Resident Representative) there was no visualization of any sexual activity. EMS sates that the facility did a full physical exam including external genitalia exam and did not see any evidence of infection . A phone interview on 04/28/25 at 1:10 PM with the Medical Director revealed that they were not formally informed by the facilities Administration of the potential non-consensual sexual abuse. During interview with the MD, they revealed that they had spoken with other residents and were informed by a potential incident with R1 and R2 during their last visit to the facility on [DATE] but was unaware of the extent of the situation. MD revealed that the resident has a history of inappropriate behaviors such as urinating in public areas but wandering into other resident rooms is a new behavior for R1. MD also stated that the only facility staff member that spoke with regarding the potential incident was the Social Worker and was told that the facility was investigating the matter. MD finally stated that he was not notified on the Immediate Jeopardy that is ongoing at this time related to R1 and R2 and the potential non-consensual sexual abuse. On April 28, 2025, the facility provided an acceptable IJ Removal Plan, which included: On 04/25/25 the facility completed an initial report with the state agency and the property authorities for allegation of potential sexual abuse for R2 by R1; on 04/26/25 the DON notified the responsible party of R2 of investigation by the facility and proper authorities; on 04/26/25 the Medical Director (MD) was notified of the facility failure to report potential sexual abuse for R2 by R1; on 04/26/25 the Social Services Director (SSD) completed interviews with residents of Brief Interview of Mental Status (BIMS) score 13 or above were interviewed to ensure no potential abuse and neglect needed to be self-reported to the stated agency and proper authorities; on 04/26/25 all current residents had skins check performed by licensed nurse and documented in the facility Electronic Medical Report, to ensure no suspicious injuries or indication of abuse or neglect that needed to be reported to the state agency and proper authorities; on 04/26/25 the Regional Clinical Director (RCD) and Unit Manager reviewed the incident log for the past 30 days for any other potential abuse allegations needing to be self-reported to the state agency and the proper authorities without further instances; on 04/28/25 the Ombudsman was notified by the Administrator of failure to report an allegation of potential sexual abuse for R2 by R1; on 04/26/25 the RCD reviewed the policy with and completed re-education of the facility's policy and procedures for abuse and neglect with the Administrator and DON to ensure understanding with verbal return demonstration as to the types of abuse and neglect, dealing with dealing with disruptive behaviors including dementia care sexually acting out, to include but not limited to what to do if staff witness abuse and neglect, when to report abuse and neglect, to whom to report abuse and neglect and the designated facility abuse coordinator, who is the facility administrator. The RCD will review all reports for 12 weeks to ensure proper notification to the state agency/proper authorities and the facility Medical Director is completed timely. A Quality Assurance Performance Improvement (QAPI) Committee was held on 04/28/25 to formulate and approve a plan of correction for the deficient practice. The Administrator will be responsible for the completion of the corrective action plan. The Administrator/Designee will be responsible for reporting the results of these audits to the QAPI committee meeting for three months. The QAPI committee will make recommendations and changes as indicated based upon the findings of the audits.

Based on review of the facility policy and procedures, observations and interviews, the facility failed to maintain water temperatures within safe limits. This failure placed residents with access to hand sinks/showers at a potential risk for scalding injuries for three of three halls reviewed. Findings include: Review of the facility policy titled Water Temperatures, Safety of last revised December 2009, states, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation, Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120° [Fahrenheit] F or 48.88°[Celsius] C, or the maximum allowable temperature per state regulation . If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor . Review of an undated facility procedure guide titled F-689 Accidents- Water Temperatures revealed, Common Causes of tap-water burns to the elderly include . Residents may also not check the water temperature . Task Instructions, as the temperature of the water is taken hold your hand under the running water at about the same time assess how the water feels on your skin. 1. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit . Check resident rooms at the end of each wing on a rotating basis or per facility policy. During observation and interview on 04/28/25 at 2:58 PM with the Plant Operations Director (POD), the following room temperatures was observed: room [ROOM NUMBER]: 122.1°F room [ROOM NUMBER]: 132°F room [ROOM NUMBER]: 128.8°F room [ROOM NUMBER]: 124°F room [ROOM NUMBER]: 123°F room [ROOM NUMBER]: 125.6°F room [ROOM NUMBER]: 128°F 100 Hall Shower Room: 131.1°F While checking the room temperatures, the POD placed his hand under the running water and said, this water is way too hot, it shouldn't be this hot, I'll have to turn it down. POD further stated that over the winter period residents made complaints stating the water was too cold, so he turned it up. Lastly, he said, they have not turned the water temperatures down since then, nor after the facility installed boosters around the units. During an interview on 04/28/25 at 3:13 PM, Licensed Practical Nurse (LPN)3, stated, No residents had formally complained about the water temperature. However, she noted that when washing hands, the sinks became really hot. During a follow up interview on 04/29/25 at 10:35 AM, the POD stated that he turned the temperature down at the mixing valve from 137°F to 110°F. POD also noted the facility was replacing the mixing valve as a precaution. During an interview on 04/29/25 at 10:41 AM, the Facility Administrator (FA) stated, Maintenance usually checks the temperatures in rooms and around he facility every couple of days. When asked if he knew the process on how the POD check the temperatures, he stated he was unaware. FA noted the temps are usually set around 120°F and he believes the temperatures were checked after the facility installed booster. When asked if the mixing valve being set at 137°F met the facility's threshold, FA said it was set above their threshold. Lastly, he stated his expectations for temperatures is that it should between 110°F-120°F.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure 3 of 5 residents reviewed for dignity (Resident (R)3, R4, and R5) were treated in a manner that maintained and promoted their dignity and sense of safety after reporting or witnessing a potential non-consensual sexual encounter involving a non-interviewable resident (R2). Cross-Reference: F600 §483.12 Freedom from Abuse, Neglect, and Exploitation. Findings include: Record review of facility policy titled Quality of Life Dignity last revised February 2020 revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Policy interpretation and implementation include residents are treated with dignity and respect at all times. The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Resident's private space and property are respected at all times. Staff inform and orient residents to their environment. Procedures are explained before they are performed, and residents will be told in advance if they are going to be taken out their usual or familiar surroundings. Review of R3's Face Sheet revealed that he was admitted to the facility on [DATE], with diagnoses including but not limited to: cerebral palsy, muscle weakness, pain, abnormalities of gait and mobility, and major depressive disorder recurrent (mild). Review of R3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/25, revealed that R3 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates that he is cognitively intact. During an interview with R3 on 04/24/25 at 2:10 PM, revealed on 04/17/25 around 7:00 AM, I overheard a staff member yelling at R] from R2's room; What are you doing in [R2's] room with the door closed? [R3] stated they heard a staff member yelling out to other staff to help assist her with removing R1 out of R2's room. During interview with R3 he stated that this was not the first time that R1 wandered into R2's room and he has observed R1 close the door while alone with R2 and could recall this incident happening two times prior. R3 stated that R1 was sent out to the hospital after being found in R2's room that morning but returned to the facility a few hours later and was returned to his room. R3 stated that they did not observe R2 being sent for evaluation. When R1 returned to the facility he was then placed on 1:1 supervision. R3 stated facility staff did not report this incident to R2's RR or call law enforcement but they could not allow this situation to go unreported out of fear for R2's safety because she is vulnerable due to her vegetative state. Further interview with R3 revealed that they have had conversations with R1 about the incident with R2 while outside smoking with staff and R1 stated, I wanted to touch some pussy. R3 stated that staff members have been retaliative towards him, and he has some fear of his future treatment/care by staff, I have had a staff member tell me that I shouldn't spread false rumors and that I should shut my mouth because I don't know what I am talking about. R3 did not feel comfortable identifying a specific staff member that had been retaliative towards him. Review of R4's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: type 2 diabetes with diabetic neuropathy, acquired absence of left and right leg below knee, abnormalities of gait and mobility, major depressive disorder recurrent severe without psychotic features, and congestive heart failure. Review of R4's Quarterly MDS with an ARD date of 03/13/25, revealed that R4 had a BIMS score of 15 out of 15, which indicates that he is cognitively intact. During an observation and interview with R4 on 04/24/25 at 2:42 PM, revealed that they are currently roommates with R1 and overheard Certified Nursing Assistant (CNA)2 yelling at R1 to get out of R2's room. R4 further stated that they witnessed CNA2 bring R1 back into the room and yelling at other staff to call law enforcement because R1 was touching R2 in a non-consensual and sexually inappropriate manner. R4 further revealed, He has been living with me for a few weeks prior to the incident with R2, but R1 has always wandered and taken other resident's food/snacks. R1 would also at times relieve (defecate/urinate) in public areas. There have been times in the past when R1 eats others meal trays that have been left for clean up in the dining area. I always keep my foods/snacks on me and on the back of my wheelchair because I don't want R1 to take my food. During the daytime I stay out of my room because I don't feel comfortable being in the room with R1 and I also don't like now that it has to always have a sitter with him because the incident with R2. R4 stated that staff have been retaliative towards him because of this incident. Observation of R4 revealed several bags attached to the back of his wheelchair with food/snack items. R4 revealed that he was outside smoking with R1 after the incident on 04/17/25 and R1 was bragging about touching R2's vagina to R4, R3, and other residents and staff. One staff member even told R1 that he was being bad but R1 laughed it off. Review of R5's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: muscle weakness, need for assistance with personal care, major depressive disorder recurrent, and generalized anxiety disorder. Review of R5's Quarterly MDS with an ARD of 04/17/25, revealed R5 had a BIMS score of 13 out of 15, which indicates that she is cognitively intact. During an interview on 04/24/25 at 3:30 PM, R5 revealed that R1 attempted to enter on 04/16/25 around midday. R5 stated that she yelled at R1, if you come in here, I will gouge out your eyes. R1 ran next door into R2's room and was in there for several minutes. R1 was then observed by a staff member in R2's room and ran out of R2's room and back into his room and closed his door. R5 stated that this was not the first incident of R1 attempting to enter female resident's room, and they have witnessed R1 enter R2's room at night over the last few weeks. R5 stated that they reported this to a nurse (unsure of name), but nothing was done about the situation, it was brushed off. R5 further stated that she does not feel safe at the facility because R1 is still located on the same hall, R5 also stated that she's frustrated that R1 is still 2 doors away from R2 as well. R5 finally stated that she has informed her family about the incident in the event anything should happen. R5 feels the facility is protecting R1 by allowing this behavior to continue.

Based on interview, record review, and review of facility policy, the facility failed to ensure Resident (R)1 was being monitored for the use of Psychotropic Medication, for 1 of 3 residents reviewed for chemical restraints. Findings include: Review of the undated facility policy titled Psychotropic Medication Use revealed, Residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics; anti-depressants; anti-anxiety medications; and hypnotics. Residents, families, and or/or the representative are involved in the medication management process. Psychotropic medication management include indications for use; dose (including duplicate therapy); duration; adequate monitoring for efficacy and adverse consequences; and preventing, identifying, and responding to adverse consequences. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Use of psychotropic (other than antipsychotics) are not increased when efforts to decreased antipsychotic medications are being implemented. Medications not classified as anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medication are not prescribed or administered as a substitution for another psychotropic medication unless there is a documented clinical indication consistent with clinical standard of practice. Consideration of the use of psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Residents receiving psychotropic medications are monitored for adverse consequences including anticholinergic effects; cardiovascular effects; metabolic effects; neurologic effects; and or psychosocial effects. Review of R1's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: frontal lobe and executive function deficit, impulse disorder, dementia with behaviors, and psychoactive substance dependence in remission. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/25, revealed that that he had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicates that he had severe cognitive impairment. Review of R1's April 2025 Physician Orders revealed an order for Depakote Oral Tablet 250 MG related to a diagnosis of dementia with behavioral disturbance with an order date of 04/18/25 and start date of 04/19/25. Review of R1's Medication Administration Record (MAR) for April 2025 revealed R1 received the medication Depakote Oral Tablet 250 MG related to a diagnosis of dementia with behavioral disturbance daily one time each day from 04/19/25 - 04/28/25. Review of R1's April 2025 Physician Orders revealed an order for Seroquel Oral Tablet 50 MG related to a diagnosis of impulse disorder and dementia with behavioral disturbance with an order date of 04/27/25 and start date of 04/27/25. Review of R1's MAR for April 2025 revealed R1 received the medication Seroquel Oral Tablet 50 MG related to a diagnosis of impulse disorder and dementia with behavioral disturbance daily one time each day from 04/27/25 - 04/28/25. Review of R1's Physician Orders for April 2025 revealed an order for Antipsychotic Medication Monitoring with a start date of 04/27/25, R1 had no antipsychotic monitoring for his Seroquel from 04/19/25 - 04/26/25. During a phone interview on 04/28/25 at 10:07 AM, the Consultant Pharmacist revealed that R1's antipsychotic monitoring should have behavior monitoring when the resident was started on Depakote on 04/19/25. Review of R1's Care Plan revealed R1 receives antipsychotic medications (Seroquel) related to Impulse Disorder interventions include administer antipsychotic medications as ordered by physician observe for side effects and effectiveness; Abnormal Involuntary Movement Scale (AIMS) every six months and as needed; observed/document/report as needed any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, frequent falls, social isolation, behavioral symptoms not usual to the person, etc. During a phone interview on 04/28/25 at 11:19 AM, the Psychiatric Nurse Practitioner (PNP) revealed that they first evaluated R1 on 04/18/25 due to a change in R1's mental status specifically that the resident was exhibiting verbal aggression and sexually inappropriate behaviors towards female residents by wandering into their rooms without their consent. After the initial consult on 04/18/25 a recommendation was made to start Divalproex 250 mg tablet for a diagnosis of dementia with behavioral disturbances. A second evaluation of R1 was conducted by the PNP on 04/25/25 and a recommendation was made to start Seroquel 50 mg tablet for a diagnosis of dementia with behavioral disturbance. During a phone interview on 04/28/25 at 1:10 PM, the Medical Director revealed that the resident should have had an order for antipsychotic monitoring when the resident was started on Depakote on 04/19/25.

Based on review of facility policy, interview, and record review, the facility failed to implement their abuse policies Abuse Investigation and Reporting and Abuse Prevention Program regarding an allegation of sexual abuse for 2 of 5 residents (Resident (R)1 and R2) reviewed for abuse. Specifically, the facility failed to investigate, report, prevent and or protect allegations of sexual abuse. Findings Include: Review of facility policy titled Abuse Investigation and Reporting last revised July 2017 revealed .5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: g. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. interview the resident's roommate, family members, and visitors j. review all events leading up to the alleged incident. Review of facility policy titled Abuse Prevention Program last revised December 2016, revealed, As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including .residents . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. 8. Protect residents during abuse investigations. Review of R1's Nurses Notes dated 04/16/25 at 9:25 AM, revealed, Resident was seen going into a female resident's room [R2] while Certified Nursing Assistant (CNA) was performing Activities of Daily Living (ADL) care. [R1] was directed to leave the room and not return. Female resident next door [R5] also stated that he went into the same resident's room last night and was attempting to come into her room as well. Female resident asked [R1] to leave and not come back. Management was notified of the behavior for possible room change. Review of R1's Nurses Note dated 04/16/25 at 12:57 PM, revealed, Writer educated resident about entering another resident's room without their consent. Resident understood to not enter another resident's room. Plan of care is ongoing. Review of R2's Nurses Notes for April 2025, did not reveal any notes related to this incident. During an interview on 04/24/25 at 12:05 PM, CNA1 revealed they were assigned to R1 for 1:1 supervision last week but could not recall which specific date because R1 sexually assaulted another resident at the facility. CNA1 stated they have previously seen R1 wandering out of female resident rooms in the past. During an interview on 04/25/25 at 9:06 AM, CNA2 stated, on 04/17/25, she heard a commotion and someone yelling, What are you doing in here? to R1 while in R2's room. CNA2 stated when they made it to R2's room, the Unit Manager (UM) and a nurse assisted R1 back to his room. CNA2 further stated law enforcement was not notified of the incident but R1 was sent to the hospital for an altered mental state. CNA2 stated she was unsure if R2 was assessed or sent out for evaluation for a potential non-consensual sexual encounter. During an interview on 04/25/25 at 9:58 AM, Licensed Practical Nurse (LPN)1 stated, at approximately 6:45 AM on 4/17/25, during med pass she heard a male voice yell out What are you doing? and upon inspection, she noted her supervisor, standing in R2's doorway while R1 was sitting in his wheelchair outside the room. LPN1 reports that R1 stated, He wanted to see her pussy and that he has needs. LPN1 reports R1 was sent out for a psych evaluation and that the police were not called, nor was R2 sent out to be evaluated. LPN1 further stated she reported her concerns to the Facility Administrator (FA) and Director of Nursing (DON) and gave them her written statement. LPN1 stated, She felt like they should have done more by calling police and having R2 evaluated after an alleged assumption of sexual abuse, but she was told to follow her higher-up's instruction. During an interview on 04/25/25 at 12:54 PM, LPN2 stated, on 04/16/25 between approximately 10:00 and 10:30 AM, R5 reported to her, That white man [R1], kept coming in R2's room last night and tried to come into my room. LPN2 stated not even 1 hour later, a CNA was screaming that R1 had entered R2's room and pulled her curtains back while she was performing ADL care. R1 was told to leave R2's room. LPN2 then notified the unit manager about her concerns who replied with OK. LPN2 further reports that after she documented in R1's progress notes the UM stated they were placing R1 on 15-minute checks. LPN2 had to redirect R1 from entering female residents' room three more times afterwards. LPN2 stated the potential was there for R1 to abuse residents and expected that the facility would move R1 from the hall and from around female residents and wanted to prevent anything further from happening. During an interview on 04/25/25 at 12:36 PM, the Social Worker (SW) stated they reported what R4 told them to the FA and was told the administrative staff was handling this incident. During an interview on 04/25/25 at 1:40 PM, the UM stated they were not at work yet for the day on 04/17/25, but it was reported to them that R1 was observed outside of R2's door and has had an increase of wandering behavior which is new behavior for R1. UM further stated that because R1 was observed near R2's door he was sent to the hospital due to altered mental status and was placed on 1:1 supervision when R1 returned to the hospital. When asked about how the facility ensured a thorough investigation was completed to ensure that no harm/potential occurred with R2, and the UM stated, a body audit was completed. Further interview with the UM revealed that the facility did not notify R2's Resident Representative of the potential for harm related to this incident, and no other resident's, specifically female residents were interviewed. Lastly, the UM noted they are aware of the facilities abuse/neglect polices and how the investigation process should be handled but the UM was unsure about the facilities polices for potential abuse/allegations of abuse. During an interview on 04/25/25 at 2:29 PM, the ADON and FA, revealed, no residents were interviewed regarding safety concerns, after the alleged incident occurred with R1 and R2. When asked how they ensured that no additional residents were impacted and all residents remained safe, there was no answer given. When asked what interventions were implemented after R1 was redirected 3 times from entering female's room after being on 15-minute checks, no answer was provided. Administrator stated he was unaware of R1's documented behavioral concerns on 04/16/25 the day prior to the incident. During an interview on 04/25/25 at 2:58 PM, CNA4 revealed that R1 looks/enters the female residents' room. CNA4 stated that in the last few weeks (could not recall specific date) they observed three separate occasions of R1 wandering into R2's room at night. On the first two incidents CNA4 stated she observed R1 in the room but not close to R2 and she observed R2's sheets on her bed were disheveled each time and they had to redirect R1 out of the room and tuck R2's sheet back in place. On the third observation CNA4 stated that she observed R1 in his wheelchair next to R2's bed. CNA4 stated that she did not observe R1 touching R2 but observed that R2's sheets were disheveled again and realized that R1 must have been the reason why the residents' sheets were displaced because he was the only other person in R2's room. CNA4 stated that they reported this third incident to LPN1. CNA4 stated that the morning of 04/17/25 at approximately 7:00 AM CNA2 observed R1 in R2's room and had to redirect him out of her room as well.

Based on observation, interview, record review, and facility policy review, the facility failed to serve foods palatable, safe, and at an appetizing temperature for six residents (Resident (R) 88, R1, R3, R6, R7, and R18) out of 31 sample residents. Findings include: Review of the facility's policy titled, Meal Distribution, dated August 2022 and provided by the facility administrator, revealed that hot foods should be held at a temperature of equal to or greater than 136 degrees F [Fahrenheit] until served. During an interview on 01/22/24 at 9:52 AM, R88 stated that he received cold breakfast food when he received breakfast in his room. Review of the Resident Council meeting minutes, dated 12/29/23, indicated the breakfast grits were cold when served. During a resident group meeting conducted on 01/23/24, at 12:43 PM, five residents (R1, R3, R6, R7, and R18) in attendance agreed that food served in the dining room was hot but residents that ate in their room received cold food, and that the breakfast biscuits with gravy and grits were always cold. A test tray was reviewed alongside the Dietary Manager (DM) on 01/24/24 at 7:47 AM. The DM assisted in taking the temperature of each breakfast item. The temperature of the scrambled eggs was 113 degrees F. The sausage gravy temperature was 112 degrees F. The grits temperature was 109 degrees F. During an interview 01/24/24 at 9:30 AM, the DM stated that she was not aware the residents were receiving cold breakfast food in their room. She stated that she would request serving carts that would help to contain heat for food transported to individual resident rooms. During an interview on 01/24/24 at 5:15 PM, the Administrator stated he was aware that the food served to residents in their room was cold. He stated that his expectation for food service was to make sure the residents received a hot breakfast, at the desired preference for the residents, and at the required serving temperatures.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL) assistance received fingernail care services for one of three residents (Resident (R) R58) of 31 sample residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues. Findings include: Review of the facility's policy titled, Activities of Daily Living (ADL), dated November 2017, documented: The objective of the Activities of Daily Living Policy is to ensure that residents maintain their highest practicable level . A resident who is unable to carry out activities of daily living will received the necessary services to maintain good nutrition, grooming, and personal care, and oral hygiene. Review of R58's Face Sheet located under the Resident Profile tab located in the electronic medical record (EMR) revealed R58 was admitted to the facility on [DATE] with diagnoses of history of a stroke, contracture of left hand, major depression, and need for assistance with personal care. Review of R58's quarterly Minimum Data Set (MDS) assessment located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 01/07/23, revealed R58's Brief Interview for Mental Status (BIMS) was 15 out of 15 which indicated R58 had intact cognition. R58 was coded for maximum staff assistance with personal care. Review of R58's Care Plan located under the Care Plan tab in the EMR, dated 01/01/22, revealed: Resident requires assistance for mobility, transfers, dressing, grooming, toileting and bathing related to weakness, left sided Hemiplegia. Interventions included: assist with Activity of Daily Living (ADLs). Observations on 01/22/04 at 9:36 AM and 3:06 PM, on 01/23/24 at 9:23 AM, 12:57 PM, and 3:28 PM and on 01/24/24 at 9:26 AM and 10:55 AM, revealed R58 had dark brown debris under all of his nails, his nails were long, and needed to be trimmed and cleaned. During an interview on 01/22/24 at 09:36 AM, R58 stated the staff did not always have time to trim and clean his nails. He stated sometimes he asked the staff to trim his nails, they said they would come back to do that, and never did. R58 stated sometimes when he asked to have his nails trimmed, they told him they would do it in the shower. He stated sometimes they did and sometimes they did not. R58 stated the staff gave him a shower three times a week but some days, they were busy, and they washed him in bed. During an interview on 01/23/24 at 11:15 AM, Certified Nursing Assistant (CNA) 7 stated R58 was alert and oriented and agreeable to personal care. CNA7 stated fingernail care was provided to all residents during the day shift on Sunday. CNA7 stated sometimes the unit was short staffed and not all the residents received fingernail care. She stated if they had time, the evening shift CNAs provided nail care to the residents, who did not receive nail care. CNA7 stated the staff also did nail care on the days the residents were assigned a shower. She stated R58 received his showers on Tuesday, Thursday, and Saturday during the evening shift. CNA7 stated sometimes R58 asked to have his fingernails trimmed and she tried to trim the nails if she had time. During an interview on 01/24/24 at 9:00 AM, R58 stated the staff told him they would trim his nails today during his shower. During an observation on 01/24/24 at 9:26 AM, CNA7 and CNA6 gave a shower to R58. Neither CNAs provided nail care to R58 nor ask him if he wanted his fingernails trimmed and cleaned. During an interview on 01/24/24 at 10:55 AM, CNA7 stated although she gave R58 a shower on 01/24/24 in the morning, she was not aware R58 needed fingernail care and confirmed she did not ask R58 if he wanted nail care and did not trim or clean his nails during or after his shower. She confirmed R58's fingernails were long and had brown material under the nails and said she would immediately clean his nails. R58 was agreeable to this. During an interview on 01/24/24 at 11:04 AM, Registered Nurse (RN)1 stated R58 was compliant with personal care and fingernail care. She assessed R58's fingernails and stated his nails were too long and needed cleaning. During an interview on 01/24/24 at 12:31 PM, the Director of Nurses (DON) stated fingernail care was to be done with showers and as needed.

Based on observation, interview, record review, and facility policy review, the facility failed to serve meals to the residents eating at the same table, at the same time, promoting dignity and well-being for three of four residents (Resident (R) 29, R4, and R88) of 31 sample residents. Findings include: During an observation of meal service in the dining room on 01/23/24 at 12:11 PM, R29 received her meal tray at 12:11 PM with three other residents seated at the same table without food. R4 was seated next to R29 and did not receive her meal tray. R4 appeared to be anxious while waiting to receive her meal tray. During an interview on 01/23/24 at 12:13 PM, R29 stated that she would not eat her meal until the other residents at the table received their meal. She said, it is rude to eat in front of others that didn't have their food. Observation of meal service on 01/23/24 at 12:26 PM, R4 received her meal tray at 12:26 PM. The other two residents seated at the same table received a meal tray at 12:32 PM and 12:36 PM. During an interview on 01/23/24 at 12:15 PM, the Dietary Manager (DM) stated that she did not have a system in place that would serve all residents seated at the same table at the same time. She stated the residents seated together always ate at the same table, but they did not all eat every day in the dining room. During an interview on 01/23/24, at 12:15 PM, the Regional Nurse Consultant stated her expectation for meal service was to serve all residents while they were seated together at the table.

Based on interview, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed for dementia for one of two residents (Residents (R) 28) sampled for dementia care. Findings include: Review of the facility policy titled, Care Planning, dated 07/17, revealed The purpose of the Care Planning . is to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care and resident desires. Review of R28's Face Sheet located in the electronic medical record (EMR) under the Resident Profile tab, revealed an admitted [DATE] and readmitted [DATE] with medical diagnoses that included adult failure to thrive and dementia. Review of R28's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/23 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severe cognitive impairment. During an observation on 01/22/24 at 2:29 PM, R28 was in bed, eyes open, and responded to being greeted, smiled, and said hello. During an observation on 01/23/24 at 1:36 PM, R28 was in bed, covered up to her chin, following commands to turn on side for brief to be checked. During an interview on 01/23/24 at 1:38 PM, Registered Nurse (RN)1 explained R28 stayed in bed most of the time. Review of the Care Plan located under the Care Plan tab in the EMR for R28 lacked documentation for a plan of care for dementia. During an interview on 01/24/24 at 12:08 PM, RN1 confirmed the medical record for R28 lacked a care plan for dementia and there should be a plan of care for dementia for R28. During an interview on 01/24/24 at 12:04 PM, the Social Services Director (SSD) reviewed the care plan for R28 and confirmed there was no plan of care or interventions for dementia for R28 and verified there should be a dementia care plan. During an interview on 01/24/24 at 5:08 PM, the Director of Nursing (DON) confirmed the expectation for resident R28, with a diagnosis of dementia, should have had a care plan for dementia.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that one of three residents (Resident (R)13) reviewed for splinting of 31 sample residents received the orthotic devices ordered by the Physician. This practice has the potential for other residents to be at risk for decreased range of motion and/or worsening of their contracture. Findings include: Review of the facility policy titled, Resident Mobility and Range of Motion (ROM), dated December 2017, documented: The purpose of the Resident Mobility and ROM policy is to ensure each resident maintains their highest level of function in regards to range of motion and mobility .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Review of R13's Face Sheet located under the Resident Profile tab located in the electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE] with diagnoses of anoxic brain damage, contracture of muscles multiple sites, and paraplegia. Review of R13's quarterly Minimum Data Set (MDS) assessment located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/24/23, revealed R13's Brief Interview for Mental Status (BIMS) was not completed because of the resident's anoxic brain injury and aphasia. The assessment indicated she had impairment of both upper and lower extremities. Review of R13's Physician Orders located under the Orders tab in the EMR, dated 05/08/23, revealed a physician's order for Patient to wear bilateral palm protectors 9:00 AM to 5:00 PM. Review of R13's Care Plan located under the Care Plan tab in the EMR, dated 11/14/23, revealed the following: resident to remain free from further skin breakdown On 04/27/23, R13 had an Occupational Therapy (OT) evaluation, and plan was for resident to wear bilateral palm protectors 9:00 AM to 5:00 PM and assist with activity of daily living (ADL). During observations on 01/22/24 at 8:51 AM, 12:00 PM, 1:42 PM, and 3:03 PM and on 01/23/24 at 8:56 AM, 12:30 PM, and 3:19 PM, R13 was observed in her bed with both hands closed into a fist, and there were no palm protectors or washcloths in her hands. During an interview on 01/22/24 at 3:04 PM, the Family Member said the staff were to place splints (palm protectors) on R13's hands everyday per the therapy recommendations. She stated she visited R13 daily and on several occasions, there were no splints in her hands. She stated sometimes she told the staff, and they placed the splints on R13. Review R13's OT progress notes provided by the Rehabilitation Director documented the following: 10/12/23 to 11/06/23: rolled up washcloth placed in bilateral hands to decrease risk for skin breakdown. Review of the Training and Education Log provided by the Director of Rehabilitation, dated 10/19/2,3 documented Application of bilateral palm protectors for R13. Also, hand hygiene and use of washcloth if unable to use palm protectors. The education was provided to five staff members that included the Staff Scheduler, and four Certified Nursing Assistants (CNA)s. During an interview on 01/23/24 at 4:45 PM, the Rehabilitation Director stated R13 had significant bilateral hand/arm contractures since her admission to the facility and was treated several times by the rehabilitation team. She said the palm protectors were used to prevent R13's fingers from digging into the palm of her hand to prevent skin damage and prevent further deformity. The Rehabilitation Director stated in October 2023, on some days, R13 appeared to not tolerate the application of the palm protector. She stated on those days, rolled wash cloths were placed in R13's hands, which were tolerated well. The Rehabilitation Director stated on 10/19/23, the Occupational Therapist educated the staff to use palm protectors to R13's hands and if she was not able to tolerate the palm protectors, they were to use rolled washcloths when R13 did not receive OT. She stated she provided a copy of the education to the Director of Nursing (DON) and Unit Manager, who was no longer employed at the facility. The Director of Rehabilitation stated 11/09/23 was the last day of R13's occupational therapy and nursing was to assume the daily application of the palm protectors or washcloths to her hands. During an interview on 01/24/23 at 7:29 AM, CNA9 stated R13 had some type of device on her hands when treated by the therapist. She stated some of the time, she observed a rolled washcloth in R13's hands. CNA9 stated she had not seen any type of device or washcloth in R13's hands in several weeks and had received no education to apply anything to R13's hands. During an interview on 01/24/24 at 10:10 AM, CNA8 stated she was not aware R13 was to have palm protectors as tolerated or washcloths placed in her hands. During an interview on 01/24/24 at 9:55 AM, Licensed Practical Nurse (LPN)2 stated R13 wore boots daily and a rolled towel was placed between her arms and her chest to prevent friction per the Family Member request. LPN2 stated at one time, R13 wore palm protectors when she received therapy but said she had not seen them in her hands in several months. She stated when therapy was completed, the therapist educated the nurses and CNAs regarding the plan for the resident. LPN2 stated she was never educated by the therapist that nursing was to use palm protectors if tolerated or rolled washcloths in R13's hand during the day. LPN2 stated the information would be placed in the resident's Treatment Administration Record (TAR) to alert the staff regarding the treatment. She stated the application of R13's palm protectors or washcloths to her hands was not transcribed to the TAR. LPN2 acknowledged she was not aware the staff were to place palm protectors or washcloths in R13's hand and therefore, did not ensure she or her staff placed palm protectors or washcloths in her hands. LPN2 stated late in the day on 01/23/24, she was told R13 was to have washcloths in her hands. She stated on 01/24/24 she placed washcloths in R13's hands and a few hours later, she observed carrots in R13's hands. LPN2 stated she did not know who placed the carrots in R13's hands and how often or how long the carrots were to remain in her hands. Review of R13's November 2023, December 2023, and January 2024 TAR located in the EMR under the Orders Tab revealed they did not document any information related to placing palm protectors or washcloths to R13's hands. There was no documentation in the EMR that palm protectors or washcloths were placed in R13's hands. During an interview on 01/24/23 at 3:45 PM, the DON stated she did not receive any education from therapy in October that the therapists were using wash cloths in R13's hands if she was not able to tolerate the palm protectors. She stated she was not aware the nursing staff was to continue that treatment once R13 was discharged from therapy. The DON confirmed the information was not transcribed to the TAR, and confirmed there was no evidence in the EMR that the staff were applying palm protectors or washcloths to R13's hands. She stated the staff that were educated may have applied palm protectors or wash cloths to R13's hands on the days they were assigned to R13 and acknowledged not all the staff were aware of the plan.

Based on facility policy, observations, record review, and staff interviews, the facility failed to adequately implement care plan interventions for one resident (R) 6 out of 3 reviewed for accidents. Specifically, R6 had an unwitnessed fall, sustained a facial fracture, which required sutures, and was readmitted to the facility with interventions related to falls. The failure to ensure the interventions in place were properly recorded and monitored by staff, placed the resident at risk for avoidable reoccurring injuries. Findings include: Review of the facility's policy titled Care Planning, effective July 2017, revealed I. Purpose- The purpose of the Care Planning policy is to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care and resident desires .II. Definitions 1. Interventions- actions, treatments, procedures, or activities designed to meet an objective .3. Objective- a statement describing the results to be achieved to meet the resident's goals. On 05/09/22 at 10:00 AM, 1:39 PM, and 3:48 PM, observations were made of R6 in bed. A suture was noted above R6's left eye. Several attempts to interview R6 were unsuccessful. An interview on 05/09/22 at 10:05 AM with Certified Nursing Assistant (CNA)3 revealed she was responsible for conducting one to one/15-minute observations on R6 during her shift. CNA3 stated she is unaware when the one to one started, but has been documenting R6's behaviors, care provided, and activities during the shift. CNA3 stated her shift varies each day but confirmed today (05/09/22), she was responsible for R6's observations from 7:00 AM through 3:15 PM. CNA3 stated R6 has been sleeping most of the morning and has not been out of bed. CNA3 further stated that nursing aides are required to fill out the observation sheets on each shift and the completed sheets are given to the nurse. On 05/09/22 at 10:35 AM, review of R6's Face Sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/09/22 at 10:49 AM, review of Minimum Data Set (MDS) with an Assessment Reference Date of 05/02/22 revealed R6 had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was rarely understood and an interview could not be conducted. Further review of the MDS revealed R6 is totally dependent on staff (2-person assistance) for activities of daily living (ADLs). On 05/09/22 at 11:11 AM, review of the Resident Incident Report, dated 04/25/22 at 5:00 PM, revealed nurse was performing wound care at the time of incident, nurse was notified by CNA1 that resident was observed on the floor, resident was assessed by Registered Nurse (RN) and decision was made to send resident to hospital for further evaluation and treatment. Blood was present on floor where resident fell . Further review of the report revealed medical risk factors possibly related to incident as fall history, inability to understand directions, confusion/disorientation, and incontinency. On 05/09/22 at 11:23 AM, review of the Hospital Discharge Summary dated 04/27/22 at 1:13 PM revealed R6 was a trauma transfer after an unwitnessed fall at her facility. She presented with a laceration over her left eyebrow and was repaired with staples prior to her transfer. R6 sustained nonoperative facial fractures and received consultations with follow-up visit for neurosurgery (surgery of the nervous system), ophthalmology, and plastic surgery (removal of the sutures). Further review of the hospital discharge summary concluded R6's injuries resulted in orbital fracture, zygomatic arch fracture, and subdural hematoma. On 05/09/22 at 11:37 AM, review of the R6's Progress Notes stated, Resident was a re-admit on 04/27/2022. Resident has a left eyebrow laceration repair. Discoloration of left side of face with swollen with facial fracture none operative. Resident has a follow up appointment 5/12/2022 at 11:30 am for suture removal. Resident has a six week follow-up appointment for repeat CT scan. Resident skin is warm and dry to touch. Resident is very thin with bony premises. Resident is alert with confusion noted. Resident skin is warm and dry to touch. Resident has discoloration to arms from blood draw from hospital. Resident is being readmitted to lighthouse hospice and they will be coming out to visit resident. Resident is on a soft diet with thin liquids. Resident is at risk for falls, all fall precaution are in place fall mats, bed to lowest position, and Perimeter Mattress provided by hospice. Resident is doing well at this time no signs or symptoms of pain. Further review revealed the progress note was completed by Licensed Practical Nurse (LPN) 1. On 05/09/22 at 11:49 AM, review of R6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/09/22 at 12:00 PM, review of the R6's 15-minute observation sheets revealed the following: 05/06/22- 11:15 PM through 6:45 AM were blank. 05/03/22- 11:30 PM through 6:45 AM were blank. 05/02/22- 11:15 PM through 6:45 AM was blank. 04/30/22- 7:15 PM through 6:45 AM was blank 04/29/22- 3:00 PM through 6:45 PM was blank. There were no observation sheets provided by facility staff for 04/28/22 and 05/01/22. LPN1 confirmed, during a later interview, R6 had a fall on 04/25/22 and the nursing aides were to monitor R6 (1 to 1 observation) and document observations every 15 minutes on each shift. During an interview on 05/09/22 at 12:37 PM, LPN1 stated on 04/25/22 around 5:00 PM, CNA 1 notified her that R6 had fell and was on the floor. LPN1 stated she went to the room and observed a significant amount of blood of the floor. LPN1 revealed R6 was in front of the restroom door (approximately 3-5 feet away from her bed). LPN1 stated that she did not move R6, due to not knowing the extent of her injuries, and notified the RN on duty. LPN1 stated the RN did an assessment of the resident and determined R6 needed to be transported to the hospital for treatment. LPN1 stated she notified R6's physician and representative of the incident. LPN1 stated she is unaware of how R6 fell however, she is familiar with R6 and revealed she needs constant supervision due to her diagnosis (dementia). During an interview on 05/09/22 at 2:03 PM, LPN2 stated on 04/25/22, he was the nurse on duty when R6 fell . LPN2 stated he was conducting wound care when he was notified by CNA1 that R6 had fell and was on the floor. LPN2 stated when he arrived to R6's room, he observed her face down on the floor in front of the restroom. LPN2 stated there was blood on the floor where R6 was laying. LPN2 stated R6 was assessed by the RN on duty and a decision was made to send resident out to the hospital for treatment. LPN2 stated he was not in the facility when R6 was readmitted on [DATE] however, once he returned to work, he noticed R6 was put on a 1 to 1. LPN2 revealed 1 to 1's are in place to ensure residents are monitored to reduce injuries related to falls and wandering. LPN2 revealed R6 did have a history of falls, however he stated he was unsure if R6 was on a 1 to 1 prior to her fall on 04/25/22. LPN2 further stated R6 has a few follow up appointments regarding the fall, but revealed the only appointment he is aware of is with a plastic surgeon to remove the sutures. On 05/09/22 at 3:05 PM, an interview and record review with Regional Nurse Consultant (RNC) revealed R6 had fall risk assessments conducted on 04/30/22 and 05/04/22. The RNC stated both assessments (Morse Fall Risk Assessments) concluded the resident was high risk for falls and staff should implement high risk fall prevention interventions. The RNC was asked did the facility staff conduct a fall risk assessment when R6 was readmitted from the hospital on 04/27/22? The RNC provided a copy of R6's fall risk profile dated 04/02/22 and confirmed she was high risk for falls, and a fall risk care plan was in place and updated as needed. The RNC revealed nurses are to complete the Morse Fall Risk Assessment and a new fall risk assessment should be conducted upon admission, readmission, and significant changes. On 05/09/22 at 3:11 PM, Regional MDS Nurse provided a copy of R6's Comprehensive Care Plan. Review of R6's Comprehensive Care Plan with a start date of 11/27/19 revealed R6 was at risk for falls r/t (related to) dementia with poor safety awareness. Under the section titled Care Plan Goal revealed resident will have no fall-related injury thru the next review that would require hospital interventions. The following falls interventions were recorded: 1. Send out to ER for eval and treatment- start date 11/24/21 2. Place resident in open area to maximize supervision- start date 04/02/22 3. Perimeter bolsters to bed to alert resident of bed parameters- start date 04/14/22 4. Keep at or close to nurse station or common area when OOB (out of bed)- start date 04/06/22 5. Fall mats to bedside- start date 04/25/22 6. Assess fall potential on admit, quarterly and with change of condition- start date 11/29/19 7. One on one supervision as ordered- start date 04/27/22 8. Monitor positioning in bed- start date 02/18/22 9. Assist resident, remain in high traffic areas increase observation during awake hours- start date 08/31/20 10. Resident repositioned; check frequently while awake- start date 02/24/22 During an interview on 05/09/22 at 3:24 PM, CNA2 stated he was conducting care at end of the 100 hall on 04/25/22 when R6 was found on the floor. CNA2 stated he did not witness R6 fall nor did he respond to the room with other staff. CNA2 revealed he usually does not provide care for R6, however he stated he is aware the resident needs close supervision and is on a 1 to 1. CNA2 further revealed he is unaware if resident was on 1 to 1 prior to incident. During an interview on 05/09/22 at 3:40 PM, CNA4 revealed she monitors and records R6's behaviors when she relieves the primary 1 to 1 nursing aide. CNA4 stated she was not the primary aide for the current shift, however she is responsible for documenting on the sheet every 15 minutes. CNA4 stated she was unaware if R6 was on 1 to 1 observation prior to the incident. During an interview on 05/09/22 at 3:53 PM with the MDS/Care Plan Coordinator (CPC) revealed R6's care plan had been updated to reflect her change in status. The MDS/CPC stated she was aware R6 sustained a facial fracture due to a fall. The MDS/CPC stated it was her job to complete baseline care plans within 7 days upon admission, update comprehensive care plans as needed, and attend Interdisciplinary Team (IDT) meetings to discuss residents plan of care. The MDS/CPC stated IDT members consist of is not limited to, resident, resident family or representative, Administrator, Director of Nursing, Physician, Unit Manager, LPNs, CNAs, Dietary, Physical Therapy, Social Worker (SW) and any other pertinent members who are involved with resident's care. The MDS/CPC stated the SW will coordinate with family and invite them to attend care conference meetings. MDS/CPC provided a copy of R6's last care conference and confirmed it was on 04/14/22. On 05/09/22, several attempts via telephone were made to contact CNA1 with no success.

Based on facility policy, observations, record review, and staff interviews, the facility failed to ensure 1 resident, (R)6 out of 3 reviewed for falls, did not sustain a major injury. Specifically, R6 had an unwitnessed fall, was transferred, and admitted to a local hospital which resulted in a facial fracture. The lack of adequate supervision placed the resident at risk for physical and or psychosocial harm. Additionally, R6 was readmitted to the facility on [DATE] and staff did not ensure proper interventions were being recorded and monitored per the resident's needs. This failure placed the resident at risk for avoidable reoccurrences of physical and or psychosocial harm. (Cross Refer- F657) Findings include: Review of the facility's policy titled, Fall Mitigation Program, last revised February 2021, revealed III. Policy- Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . IV. Procedure. 1. Assessment- a. A fall risk assessment is completed on each resident on admission, quarterly, upon change of condition, and immediately following a fall. On 05/09/22 at 10:00 AM, 1:39 PM, and 3:48 PM, observations were made of R6 in bed. A suture was above R6's left eye. Several attempts to interview R6 were unsuccessful. An interview on 05/09/22 at 10:05 AM with Certified Nursing Assistant (CNA)3 revealed she was responsible for conducting a one to one/15-minute observations on R6 during her shift. CNA3 stated she is unaware when the one to one started but has been documenting R6's behaviors, care provided, and activities during the shift. CNA3 stated her shift varies each day but confirmed today (05/09/22) she was responsible for R6's observations from 7:00 AM through 3:15 PM. CNA3 stated she R6 has been sleeping most of the morning and has not been out of bed. CNA3 further stated that nursing aides are required to fill out the observation sheets on each shift and the completed sheets are given to the nurse. On 05/09/22 at 10:35 AM, review of R6's Face Sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, dementia without behavioral disturbance, anxiety disorder, major depressive disorder, muscle weakness, and difficulty in walking. On 05/09/22 at 10:49 AM, review of Minimum Data Set (MDS) with an Assessment Reference Date of 05/02/22 revealed R6 had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was rarely understood and an interview could not be conducted. Further review of the MDS revealed R6 is totally dependent on staff (2-person assistance) for activities of daily living (ADLs). On 05/09/22 at 11:11 AM, review of the Resident Incident Report, dated 04/25/22 at 5:00 PM, revealed nurse was performing wound care at the time of incident, nurse was notified by CNA1 that resident was observed on the floor, resident was assessed by Registered Nurse (RN) and decision was made to send resident to hospital for further evaluation and treatment. Blood was present on floor where resident fell . Further review of the report revealed medical risk factors possibly related to incident as fall history, inability to understand directions, confusion/disorientation, and incontinency. On 05/09/22 at 11:23 AM, review of the Hospital Discharge Summary dated 04/27/22 at 1:13 PM revealed R6 was a trauma transfer after an unwitnessed fall at her facility. She presented with a laceration over her left eyebrow and was repaired with staples prior to her transfer. R6 sustained nonoperative facial fractures and received consultations with follow-up visit for neurosurgery (surgery of the nervous system), ophthalmology, and plastic surgery (removal of the sutures). Further review of the hospital discharge summary concluded R6's injuries resulted in orbital fracture, zygomatic arch fracture, and subdural hematoma. On 05/09/22 at 11:37 AM, review of the R6's Progress Notes stated, Resident was a re-admit on 04/27/2022. Resident has a left eyebrow laceration repair. Discoloration of left side of face with swollen with facial fracture none operative. Resident has a follow up appointment 5/12/2022 at 11:30am for suture removal. Resident has a six week follow-up appointment for repeat CT scan. Resident skin is warm and dry to touch. Resident is very thin with bony premises. Resident is alert with confusion noted. Resident skin is warm and dry to touch. Resident has discoloration to arms from blood draw from hospital. Resident is being readmitted to lighthouse hospice and they will be coming out to visit resident. Resident is on a soft diet with thin liquids. Resident is at risk for falls, all fall precaution are in place fall mats, bed to lowest position, and Perimeter Mattress provided by hospice. Resident is doing well at this time no signs or symptoms of pain. Further review revealed the progress note was completed by Licensed Practical Nurse (LPN) 1. On 05/09/22 at 11:49 AM, review of R6's Physician Orders dated 05/04/22 revealed Monitor for Laceration of (L) eyebrow and notify MD of any adverse changes. On 05/09/22 at 12:00 PM, review of the R6's 15-minute observation sheets revealed the following: 05/06/22- 11:15 PM through 6:45 AM were blank. 05/03/22- 11:30 PM through 6:45 AM were blank. 05/02/22- 11:15 PM through 6:45 AM was blank. 04/30/22- 7:15 PM through 6:45 AM was blank 04/29/22- 3:00 PM through 6:45 PM was blank. There were no observation sheets provided by facility staff for 04/28/22 and 05/01/22. LPN1 confirmed, during a later interview, R6 had a fall on 04/25/22 and the nursing aides were to monitor R6 (1 to 1 observation) and document observations every 15 minutes on each shift. During an interview on 05/09/22 at 12:37 PM, LPN1 stated on 04/25/22 around 5:00 PM, CNA1 notified her that R6 had fell and was on the floor. LPN1 stated she went to the room and observed a significant amount of blood of the floor. LPN1 revealed R6 was in front of the restroom door (approximately 3-5 feet away from her bed). LPN1 stated that she did not move R6, due to not knowing the extent of her injuries, and notified the RN on duty. LPN1 stated the RN did an assessment of the resident and determined R6 needed to be transported to the hospital for treatment. LPN1 stated she notified R6's physician and representative of the incident. LPN1 stated she is unaware of how R6 fell however, she is familiar with R6 and revealed she needs constant supervision due to her diagnosis (dementia). During an interview on 05/09/22 at 2:03 PM, LPN2 stated on 04/25/22 he was the nurse on duty when R6 fell . LPN2 stated he was conducting wound care when he was notified by CNA1 that R6 had fell and was on the floor. LPN2 stated when he arrived to R6's room, he observed her face down on the floor in front of the restroom. LPN2 stated there was blood on the floor where R6 was laying. LPN2 stated R6 was assessed by the RN on duty and a decision was made to send resident out to the hospital for treatment. LPN2 stated he was not in the facility when R6 was readmitted on [DATE] however, once he returned to work, he noticed R6 was put on a 1 to 1. LPN2 revealed 1 to 1's are in place to ensure residents are monitored to reduce injuries related to falls and wandering. LPN2 revealed R6 did have a history of falls, however he stated he was unsure if R6 was on a 1 to 1 prior to her fall on 04/25/22. LPN2 further stated R6 has a few follow up appointments regarding the fall but revealed the only appointment he is aware of is with a plastic surgeon to remove the sutures. On 05/09/22 at 3:05 PM, an interview and record review with Regional Nurse Consultant (RNC) revealed R6 had fall risk assessments conducted on 04/30/22 and 05/04/22. The RNC stated both assessments (Morse Fall Risk Assessments) concluded the resident was high risk for falls and staff should implement high risk fall prevention interventions. The RNC was asked did the facility staff conduct a fall risk assessment when R6 was readmitted from the hospital on 04/27/22? The RNC provided a copy of R6's fall risk profile dated 04/02/22 and confirmed she was high risk for falls, and a fall risk care plan was in place and updated as needed. The RNC revealed nurses are to complete the Morse Fall Risk Assessment and a new fall risk assessment should be conducted upon admission, readmission, and significant changes. On 05/09/22 at 3:11 PM, Regional MDS Nurse provided a copy of R6's Comprehensive Care Plan. Review of R6's Comprehensive Care Plan with a start date of 11/27/19 revealed R6 was at risk for falls r/t (related to) dementia with poor safety awareness. Under the section titled Care Plan Goal revealed resident will have no fall-related injury thru the next review that would require hospital interventions. The following falls interventions were recorded: 1. Send out to ER for eval and treatment- start date 11/24/21 2. Place resident in open area to maximize supervision- start date 04/02/22 3. Perimeter bolsters to bed to alert resident of bed parameters- start date 04/14/22 4. Keep at or close to nurse station or common area when OOB (out of bed)- start date 04/06/22 5. Fall mats to bedside- start date 04/25/22 6. Assess fall potential on admit, quarterly and with change of condition- start date 11/29/19 7. One on one supervision as ordered- start date 04/27/22 8. Monitor positioning in bed- start date 02/18/22 9. Assist resident, remain in high traffic areas increase observation during awake hours- start date 08/31/20 10. Resident repositioned; check frequently while awake- start date 02/24/22 During an interview on 05/09/22 at 3:24 PM, CNA2 stated he was conducting care at end of the 100 hall on 04/25/22 when R6 was found on the floor. CNA2 stated he did not witness R6 fall nor did he respond to the room with other staff. CNA2 revealed he usually does not provide care for R6, however he stated he is aware the resident needs close supervision and is on a 1 to 1. CNA2 further revealed he is unaware if resident was on 1 to 1 prior to incident. During an interview on 05/09/22 at 3:40 PM, CNA4 revealed she monitors and records R6's behaviors when she relieves the primary 1 to 1 nursing aide. CNA4 stated she was not the primary aide for the current shift however she is responsible for documenting on the sheet every 15 minutes. CNA4 stated she was unaware is resident was on 1 to 1 observation prior to the incident. During an interview on 05/09/22 at 3:53 PM with the MDS/Care Plan Coordinator (CPC) revealed R6's care plan had been updated to reflect her change in status. The MDS/CPC stated she was aware R6 sustained a facial fracture due to a fall. The MDS/CPC stated it was her job to complete baseline care plans within 7 days upon admission, update comprehensive care plans as needed, and attend Interdisciplinary Team (IDT) meetings to discuss residents plan of care. The MDS/CPC stated IDT members consist of is not limited to, resident, resident family or representative, Administrator, Director of Nursing, Physician, Unit Manager, LPNs, CNAs, Dietary, Physical Therapy, Social Worker (SW) and any other pertinent members who are involved with resident's care. The MDS/CPC stated the SW will coordinate with family and invite them to attend care conference meetings. MDS/CPC provided a copy of R6's last care conference and confirmed it was on 04/14/22. On 05/09/22, several attempts via telephone were made to contact CNA1 with no success.

Based on facility policy, record review, and interviews, the facility failed to ensure one resident (R) 6 out of 3 sampled residents reviewed were free from avoidable accidents. Specifically, R6 had an unwitnessed fall with injury, that resulted in her being transferred to the hospital. This failure placed R6 at risk for avoidable pain and harm. Findings include: Review the facility policy titled, Fall Risk Management: Assessment last revised February 2021 revealed III. Policy- It is the policy of this facility to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Review of Face Sheet revealed R6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, [CONDITION(S)], other muscle spasm, pain, contracture of muscle- multiple sites, contracture of the left elbow, contracture of the right elbow, and other abnormalities of gait and mobility. Review of R6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/22 revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident could not be interviewed because she is rarely understood. Further review revealed R6 is totally dependent of staff with all activities of daily living (ADLs). Review of R6's care plan, with onset date of 11/02/20 and last revised 03/11/22, revealed pain: related to facial and nose fractures. R6 has the potential for falls r/t (related to) impaired mobility and generalized weakness. She leans to the side when up in wheelchair. Dx (diagnoses) [CONDITION(S)]. R6 will be free from any injuries r/t falls through next review. Review of R6's Morse Fall Risk assessment dated [DATE] revealed a total score of 50, indicating low fall risk, implement standard fall prevention interventions. Review of R6's Morse Fall Risk assessment dated [DATE] revealed a total score of 75, indicating resident is high risk, implement high risk fall prevention interventions. Review of R6's Physician Telephone Orders dated 02/25/22 revealed Bed Bolsters to bed daily due to fall risk. Review of R6's Physician Orders dated 03/01/22 revealed the following: 1. Check Functioning of Low Air Mattress every shift with a start date of 09/24/21 2. Low Air Loss Mattress with a start date of 09/24/21 3. Floor Mats to both sides of bed with a start date of 09/24/21 Review of R6's Morse Fall Risk assessment dated [DATE] revealed a total score of 75, indicating resident is high risk, implement high risk fall prevention interventions. Review of the facility's Resident Incident Report dated 03/10/22 at 8:56 PM revealed R6 was observed on the floor with a bruise. Resident bed noted as electric. Further review of the narrative of incident and description of injuries revealed at 8:55 PM during med pass nurse found resident laying on her left side with her face on the floor mat in front of her dresser. Resident has redness to left side of cheek and forehead. Bed found deflated causing bed bolsters to slip to the left side. Review of R6's Telephone Physician Orders dated 03/10/22 revealed STAT x-ray (L) head and shoulder r/t fall one hour prior. The order was observed not signed by a physician. Review of R6's Progress Notes, completed by Licensed Practical Nurse (LPN) 2 dated 03/11/22 at 6:05 AM revealed at 8:55 during pm med pass nurse found resident laying on left side of face on the floor mat in front of her dresser. Resident was thoroughly checked, VS (vital signs) obtained, and assisted back to bed along with two CNAs (Certified Nurse Assistants). Further review of the progress note revealed CNA stated that her last encounter with resident was at 6:45 PM for change and repositioning. Bed was found deflated causing bed bolsters to slip to the left side. An interview with R6's representative (RP) in resident's room on 04/21/22 at 12:15 PM revealed her daughter fell and that she was aware of the fall that occurred at the facility on 03/10/22. The RP stated that it was determined by staff that R6 fell out of bed due to the bed being unplugged and deflated. The RP stated no one admitted to unplugging the bed but due to a fall in November 2020, staff were supposed to be checking the air mattress during rounds and care. RP further stated that she met with the former Administrator after R6's fall and all agreed that due to the air mattress being deflated, it caused R6 to fall. A telephone interview with LPN2 on 04/21/22 at 4:34 PM revealed she was passing medications when she found R6 laying on the floor. LPN 2 stated she immediately checked on the resident and had 2 other CNAs help her get resident up and back into bed. LPN2 stated she conducted an assessment to see if anything was broken or resident sustained any bruises and noted R6 had redness to the left side of her face and forehead. LPN2 stated that she noticed the bed was deflated and checked to see if the bed had been unplugged. LPN2 stated when she observed the cord was unplugged, she immediately plugged the air mattress to the outlet closests to the bed. LPN2 stated that she did not observe R6 fall and did not know how long the resident was on the floor. LPN2 further stated that an agency CNA told her that she did rounds around 6:00 PM and the bed was not deflated. An interview with CNA3 on 04/21/22 at 5:19 PM revealed she was not caring for R6 on 03/10/22 but did assist another CNA after the resident fell from her bed. CNA3 stated that she was called to R6's room and observed the resident on the floor. CNA3 stated the agency nurse (LPN2) stated she had just got to the room and found the resident on the floor. CNA3 stated she did not witness R6 fall from bed and did not know how the resident fell . CNA3 stated she did observe R6's bed and confirmed it was deflated. An interview with LPN3 on 04/21/22 at 5:35 PM revealed she was not in the facility during the time R6 fell from her bed but stated she is the Unit Manager and was notified via telephone by LPN2. LPN3 stated LPN2 revealed the bed was unplugged and had deflated causing R6 to fall. LPN3 stated an x-ray was ordered and the Nurse Practionier (NP) confirmed an acute nasal fracture however, due to R6's history, she was sent out by Emergency Medical Services (EMS) to a local hospital to be further exanimated. A telephone interview with CNA4 on 04/21/22 at 6:00 PM revealed she was here at the facility on 03/11/22. CNA4 stated she assisted the nurse with getting R6 off the floor from an apparent fall from the bed. CNA4 stated when she arrived to the room, she observed that the bed was deflated but was unsure if that caused R6 to fall from the bed. CNA4 stated that R6 did have redness in her face and nose area, but was unsure if she sustained any significant injuries from the fall. CNA4 stated she is familiar with R6 and noted that she has an air mattress and bed bolsters in place to prevent falls. CNA4 further stated she did not observe R6 fall, but did observe the bed was deflated and the bed bolsters were not in place. A telephone interview with LPN1 on 04/21/22 at 6:29 PM revealed she did not work on 03/11/22. LPN1 stated she is familiar with R6, but has not worked with her in a long time. LPN1 did confirm that R6 has an air mattress and bed bolsters in place to prevent falls. LPN1 further stated R6 should have a fall mat at bedside.

Based on observations, record review, interviews, and review of the facility policy titled, Elopement and Wandering Residents, the facility failed to provide adequate supervision to prevent elopement. Resident (R)26 exited the facility on June 27, 2021 at 4:20 PM unassisted. A nursing staff member identified a man coming up the road with his walker toward the stop sign of [NAME] road, street frontage, as R26. On 10/28/21 at 4:07 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R) 26. R26 had a successful elopement from the facility on June 27, 2021. R26 was found walking down the street with a walker by a member of the facility staff. R26 was unharmed and did not obtain any injuries. The facility's failure to provide adequate supervision to a resident diagnosed with dementia and who ambulated independently throughout the facility has the potential for serious injury, serious harm, serious impairment, or death, constituted Immediate Jeopardy (IJ) Past Non-Compliance at F600 and F689. The immediate jeopardy existed from June 27, 2021 to June 30, 2021. The facility presented an allegation of compliance plan of correction on 10/28/21 at 5:00 PM, indicating they had identified their own deficiency and put a plan in place to remove the immediacy. Staff interviews, record review, policy review and review of training were completed during the survey to verify the immediate corrective actions taken by the facility. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the survey. Therefore, this deficient practice was cited as Past Noncompliance. The credible allegation of compliance included the following: On 6-27-21-Headcount completed by the Director of Nursing to ensure all residents were accounted for. All residents present. On 6-27-21- Door checks conducted by Maintenance Director to ensure all doors alarm accordingly when breached ensuring all residents who are assessed at risk for elopement are supervised by facility staff when exiting the facility, identifying exit seeking behaviors, and redirecting residents, reporting any observations of unsecured doors or concerns related to all aspect of resident safety immediately and directly to the NHA and DON. On 6-28-21-Audit of all residents with wander-guards conducted to ensure proper placement/function, expiration date, care plan updated and in the elopement binder. Effective 6-28-21, the Director of Social Services will review all electronic nursing notes for the last 30 days to ensure there weren't any other exit seeking behaviors. This will be completed by 6-28-21. Elopement assessment and care plans were reviewed and validated for all residents assessed at risk by MDS. Elopement notebooks were reviewed and updated as needed by the nurse managers. This will be completed by 6-28-21. On 6-28-21, elopement assessments were completed by the Unit Manager, ADON or DON for current facility residents. On 6-28-21-All doors were checked by Maintenance director to ensure proper function. Effective 6-28-21, Executive director and director of nursing will monitor incident reports, electronic nurse's note and 24-hour report to ensure there aren't any instances of exit seeking behaviors or incidents associated with exit seeking behaviors. This monitoring will occur daily (M-F) x 30 days and weekly x 8 weeks. Effective 6-28-21, Executive Director will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. Effective 6-28-21, the center Executive Director and the Director of Nursing will be ultimately responsible for ensure implementation of the credible allegation. Compliance Date: 6-30-21 Findings: Review of the facility's policy titled Elopement and Wandering Resident reads: IV. Policy The facility will strive to promote resident safety and protect the rights and dignity of the resident by preventing unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement. This facility ensures that residents who exhibit wandering behavior and/or are at risk of elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. R26 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses, including but not limited to; unspecified dementia without behavioral disturbance, adult failure to thrive, cognitive-communication deficit, muscle weakness, unsteadiness on feet, and mood disorder due to known physiological condition with depressive features. Observations during the survey revealed on 10/25/21 at 4:30 PM, R26 was sitting at the nurse's station of unit 200. S/he was among other residents. S/he appeared well-groomed and in good spirits. On 10/27/21 at approximately 12 PM, R26 was walking with his/her walker between units 100 and 200. On 10/28/21 at approximately 5:00 PM, R26 was observed walking toward unit 100. The Minimum Data Set (MDS) assessment dated [DATE] revealed that R26 scored an 8 (mildly impaired mental status) in his/her brief interview for mental status (BIMS). R26 was coded as having adequate hearing and clear speech. S/he is able to make self-understood and understand others and has no wandering behaviors coded. Progress notes reviewed on 10/28/21 at 8:30 AM revealed that on 6/27/21 at 4:15 PM, the facility became aware that R26 was seen walking with his/her walker on [NAME] road by a staff member. A Certified Nursing Assistant (CNA) got into the car of the staff member who reported seeing R26 on the road. R26 was returned to the facility unharmed. A basic assessment (BA) was completed and neurological checks started. No injuries were noted at the time. However, the resident complained of knee pain, and pain medication was provided. The Director of Nursing (DON), unit manager, and physician were notified. R26's sister was contacted by telephone to alert her of the incident. Review of the DON's notes revealed R26 stated in an interview that s/he was going home because every time s/he left the house, his/her mother and sister sell his/her cars. R26 was an auto-body repair mechanic. An internal investigation was started. DON informed the resident's daughter of the incident. 15-minute monitoring continues. Staff will continue to monitor the patient to detour any exit-seeking behavior. The facility investigation report reviewed on 10/28/21 at approximately 10:25 AM revealed Registered Nurse (RN)4 provided the facility a written statement detailing what had happened. RN4's statement revealed, Returning from lunch at 4:20 PM when I noted what appeared to be one of our residents coming up the road with his walker towards the stop sign of [NAME] Rd. I proceeded to the facility to inform the receptionist and get assistance. CNA3 got in the car with me. We pull over in a driveway and asked the resident where he was heading. He stated that he was going to the store to get economical cigarettes. Explained to him I would take him to the store. He thanked me and got in the car. Drove him to the store and bought him a pack of cigarettes and returned him to the facility and his nurse. CNA3 also gave the facility a written statement of his/her involvement in the matter. His/her statement reads, At exactly 3 PM, I observed R26 was sitting in front of the nurse's station. At approximately 4:15 PM, I was notified that R26 had left the facility. S/he had not observed resident leaving. I assisted a nurse in bringing resident back to facility. Began 15 min interval vitals checks. R26's elopement assessment dated [DATE] and reviewed on 10/28/21 at approximately 12:00 PM stated that in its conclusion that R26 was not at risk of elopement at the time. Elopement assessment dated [DATE] stated the resident exited the facility. R26's care plan reviewed on 10/28/21 at 12:45 PM revealed on 6/27/21, a care plan for exit seeking was developed on 6/27/21 with the goal that R26 will not exit the facility and will not wander outside of the building. The interventions included wander-guard as ordered, Q15 minute checks initiated, redirect, reassure, and orient resident as needed, provide diversional activities if resident is attempting to exit the building. Offer food, snacks, visit with others, group activities, individual activities, music, etc. Notify MD and resident representative. In an interview with CNA1 on 10/28/21 at 1:15 PM, s/he stated that R26 walks around the facility hallways with his/her walker. At times, s/he seems confused and wander into other residents' rooms, but is easily redirected. S/he also likes to sit at the nurse's station with other residents. CNA1 has not seen R26 attempting to exit the facility. In an interview with CNA2 on 10/28/21 at approximately 1:25 PM, s/he stated that R26 is confused at times and thinks s/he is in a relationship with some of the residents. S/he is easily redirected most time. In a phone interview with RN4 on 10/28/21 at approximately 1:45 PM, her/his statement was read back to him/her and asked if s/he verifies that the statement read to her/him was truth to the best of her knowledge, s/he stated, yes. S/he also said that s/he thinks someone was with the resident by the time s/he got back to him/her, but she was not sure and could not remember the name of the alleged person. In a phone interview with CNA3, her/his statement was read back to him/her and asked if s/he verifies that the statement read to her/him was truth to the best of her knowledge, s/he stated, yes and did not want to add anything else. In an interview with the DON and NHA, they both acknowledged that on 6/27/21, R26 exited alone the facility and was found on [NAME] Road by nursing staff. The DON added that R26 was brought back to the facility unharmed.

Based on observations, record review, interviews, and review of the facility policy titled, Elopement and Wandering Residents, the facility failed to ensure neglect did not occur by providing adequate supervision to prevent elopement. Resident (R)26 exited the facility on June 27, 2021 at 4:20 PM unassisted. A nursing staff member identified a man coming up the road with his walker toward the stop sign of [NAME] road, street frontage, as R26. On 10/28/21 at 4:07 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R) 26. R26 had a successful elopement from the facility on June 27, 2021. R26 was found walking down the street with a walker by a member of the facility staff. R26 was unharmed and did not obtain any injuries. The facility's failure to provide adequate supervision to a resident diagnosed with dementia and who ambulated independently throughout the facility has the potential for serious injury, serious harm, serious impairment, or death, constituted Immediate Jeopardy (IJ) Past Non-Compliance at F600 and F689. The immediate jeopardy existed from June 27, 2021 to June 30, 2021. The facility presented an allegation of compliance plan of correction on 10/28/21 at 5:00 PM, indicating they had identified their own deficiency and put a plan in place to remove the immediacy. Staff interviews, record review, policy review and review of training were completed during the survey to verify the immediate corrective actions taken by the facility. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the survey. Therefore, this deficient practice was cited as Past Noncompliance. The credible allegation of compliance included the following: On 6-27-21-Headcount completed by the Director of Nursing to ensure all residents were accounted for. All residents present. On 6-27-21- Door checks conducted by Maintenance Director to ensure all doors alarm accordingly when breached ensuring all residents who are assessed at risk for elopement are supervised by facility staff when exiting the facility, identifying exit seeking behaviors, and redirecting residents, reporting any observations of unsecured doors or concerns related to all aspect of resident safety immediately and directly to the NHA and DON. On 6-28-21-Audit of all residents with wander-guards conducted to ensure proper placement/function, expiration date, care plan updated and in the elopement binder. Effective 6-28-21, the Director of Social Services will review all electronic nursing notes for the last 30 days to ensure there weren't any other exit seeking behaviors. This will be completed by 6-28-21. Elopement assessment and care plans were reviewed and validated for all residents assessed at risk by MDS. Elopement notebooks were reviewed and updated as needed by the nurse managers. This will be completed by 6-28-21. On 6-28-21, elopement assessments were completed by the Unit Manager, ADON or DON for current facility residents. On 6-28-21-All doors were checked by Maintenance director to ensure proper function. Effective 6-28-21, Executive director and director of nursing will monitor incident reports, electronic nurse's note and 24-hour report to ensure there aren't any instances of exit seeking behaviors or incidents associated with exit seeking behaviors. This monitoring will occur daily (M-F) x 30 days and weekly x 8 weeks. Effective 6-28-21, Executive Director will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. Effective 6-28-21, the center Executive Director and the Director of Nursing will be ultimately responsible for ensure implementation of the credible allegation. Compliance Date: 6-30-21 Findings: Review of the facility's policy titled Elopement and Wandering Resident reads: IV. Policy The facility will strive to promote resident safety and protect the rights and dignity of the resident by preventing unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement. This facility ensures that residents who exhibit wandering behavior and/or are at risk of elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. R26 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses, including but not limited to; unspecified dementia without behavioral disturbance, adult failure to thrive, cognitive-communication deficit, muscle weakness, unsteadiness on feet, and mood disorder due to known physiological condition with depressive features. Observations during the survey revealed on 10/25/21 at 4:30 PM, R26 was sitting at the nurse's station of unit 200. S/he was among other residents. S/he appeared well-groomed and in good spirits. On 10/27/21 at approximately 12 PM, R26 was walking with his/her walker between units 100 and 200. On 10/28/21 at approximately 5:00 PM, R26 was observed walking toward unit 100. The Minimum Data Set (MDS) assessment dated [DATE] revealed that R26 scored an 8 (mildly impaired mental status) in his/her brief interview for mental status (BIMS). R26 was coded as having adequate hearing and clear speech. S/he is able to make self-understood and understand others and has no wandering behaviors coded. Progress notes reviewed on 10/28/21 at 8:30 AM revealed that on 6/27/21 at 4:15 PM, the facility became aware that R26 was seen walking with his/her walker on [NAME] road by a staff member. A Certified Nursing Assistant (CNA) got into the car of the staff member who reported seeing R26 on the road. R26 was returned to the facility unharmed. A basic assessment (BA) was completed and neurological checks started. No injuries were noted at the time. However, the resident complained of knee pain, and pain medication was provided. The Director of Nursing (DON), unit manager, and physician were notified. R26's sister was contacted by telephone to alert her of the incident. Review of the DON's notes revealed R26 stated in an interview that s/he was going home because every time s/he left the house, his/her mother and sister sell his/her cars. R26 was an auto-body repair mechanic. An internal investigation was started. DON informed the resident's daughter of the incident. 15-minute monitoring continues. Staff will continue to monitor the patient to detour any exit-seeking behavior. The facility investigation report reviewed on 10/28/21 at approximately 10:25 AM revealed Registered Nurse (RN)4 provided the facility a written statement detailing what had happened. RN4's statement revealed, Returning from lunch at 4:20 PM when I noted what appeared to be one of our residents coming up the road with his walker towards the stop sign of [NAME] Rd. I proceeded to the facility to inform the receptionist and get assistance. CNA3 got in the car with me. We pull over in a driveway and asked the resident where he was heading. He stated that he was going to the store to get economical cigarettes. Explained to him I would take him to the store. He thanked me and got in the car. Drove him to the store and bought him a pack of cigarettes and returned him to the facility and his nurse. CNA3 also gave the facility a written statement of his/her involvement in the matter. His/her statement reads, At exactly 3 PM, I observed R26 was sitting in front of the nurse's station. At approximately 4:15 PM, I was notified that R26 had left the facility. S/he had not observed resident leaving. I assisted a nurse in bringing resident back to facility. Began 15 min interval vitals checks. R26's elopement assessment dated [DATE] and reviewed on 10/28/21 at approximately 12:00 PM stated that in its conclusion that R26 was not at risk of elopement at the time. Elopement assessment dated [DATE] stated the resident exited the facility. R26's care plan reviewed on 10/28/21 at 12:45 PM revealed on 6/27/21, a care plan for exit seeking was developed on 6/27/21 with the goal that R26 will not exit the facility and will not wander outside of the building. The interventions included wander-guard as ordered, Q15 minute checks initiated, redirect, reassure, and orient resident as needed, provide diversional activities if resident is attempting to exit the building. Offer food, snacks, visit with others, group activities, individual activities, music, etc. Notify MD and resident representative. In an interview with CNA1 on 10/28/21 at 1:15 PM, s/he stated that R26 walks around the facility hallways with his/her walker. At times, s/he seems confused and wander into other residents' rooms, but is easily redirected. S/he also likes to sit at the nurse's station with other residents. CNA1 has not seen R26 attempting to exit the facility. In an interview with CNA2 on 10/28/21 at approximately 1:25 PM, s/he stated that R26 is confused at times and thinks s/he is in a relationship with some of the residents. S/he is easily redirected most time. In a phone interview with RN4 on 10/28/21 at approximately 1:45 PM, her/his statement was read back to him/her and asked if s/he verifies that the statement read to her/him was truth to the best of her knowledge, s/he stated, yes. S/he also said that s/he thinks someone was with the resident by the time s/he got back to him/her, but she was not sure and could not remember the name of the alleged person. In a phone interview with CNA3, her/his statement was read back to him/her and asked if s/he verifies that the statement read to her/him was truth to the best of her knowledge, s/he stated, yes and did not want to add anything else. In an interview with the DON and NHA, they both acknowledged that on 6/27/21, R26 exited alone the facility and was found on [NAME] Road by nursing staff. The DON added that R26 was brought back to the facility unharmed.

Based on record review and interviews, the facility failed to provide adequate assistance for one of three sampled residents (Resident #2) reviewed for accidents. Specifically, a Certified Nursing Assistant (CNA) failed to position Resident #2 with two staff during changing of linens per the care plan. The facility's failure to provide assistance/supervision led to Resident #2 falling from the bed and sustaining sutures to the forehead and a nasal fracture. Findings include. The Electronic Medical Record (EMR) revealed Resident #2's [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 08/11/20, indicated the resident had significant cognitive impairment. The MDS indicated Resident #2 was dependent for positioning with two staff members. Review of Resident #2's undated Kardex (a reference document used by direct care staff to know a resident's care needs) revealed that prior to the fall, the resident was noted to have arm contractures, paralysis or weakness on both sides, bolsters to the bed, fragile skin, and instructions to position with two staff every two hours. Review of a Nursing Progress Note dated 11/01/20 revealed that a CNA called the nurse into Resident #2's room. Resident #2 was observed on the floor on the left side of the bed with blood on the floor. The note stated Resident #2 had a laceration to the forehead and blood from the nose. Per the note, pressure was kept on the areas and the emergency medical system was called. The note stated Resident #2 had an elevated heart rate of 105, an elevated respiratory rate of 26, and an elevated blood pressure of 166/113. The note stated emergency medical technicians transported Resident #2 to the Hospital. Review of an Emergency Department (ED) Provider Note dated 11/01/20 revealed Resident #2 had a nasal bone fracture and a [MEDICATION NAME] fracture that extends from the nasal bone into the anterior wall of the bilateral maxillary sinuses, fractures of bilateral medial lateral pterygoid plates, and diffuse subcutaneous [MEDICAL CONDITION]. In addition, Resident #2 had an approximately five centimeter (cm) jagged vertical laceration to the mid forehead extending down to the bridge of the nose. Review of a Nursing Progress Note dated 11/02/20 revealed Resident #2 returned to the facility at 3:00 PM. The note stated Resident #2 had swelling of his/her face, sutures applied to the forehead, and bilateral discoloration to both eyes. Review of a written statement dated 11/02/20 revealed that CNA #5 was assigned to Resident #2 during the day shift on 11/01/20. Per CNA #5's written statement, he/she was giving Resident #2 care, and as CNA #5 was making the resident's bed with the fitted sheet, the resident moved and fell on his/her head. The statement stated the bed was in the low position. Per the statement, after the fall, the nurse came in and took care of the resident. Two attempts to interview CNA #5 by telephone at 3:15 PM on 12/07/20 and at 9:00 AM on 12/08/20 were unsuccessful, and the surveyor was unable to leave a message on CNA #5's telephone. Interview at 10:30 AM on 12/08/20 with Licensed Practical Nurse (LPN) #1 revealed that information regarding residents was located in the Kardex which was kept at the nurse's station, and the CNAs were to reference it for information regarding resident care and the amount of staff needed to provide the care. LPN #1 stated Resident #2 required two staff any time they positioned or turned the resident, related to his/her contractures and difficulty with positioning. Further interview with LPN #1 revealed that when he/she went into Resident #2's room to assess the resident on 11/01/20, he/she could not recall if the bed was in the low position. LPN #1 stated the assigned CNA had positioned Resident #2 by himself/herself while turning the resident to change the bed linens and did not follow the care plan. During interviews with CNA #1 on 12/09/20 at 11:00 AM, CNA #2 on 12/09/20 at 11:26 AM, CNA #3 on 12/9/20 at 12:00 PM, and CNA #4 on 12/08/20 at 2:22 PM, they each stated that information about the amount of staff and type of assistance each resident needed was located at the nurse's station in the Kardex. Each of the four CNAs were aware that Resident #2 had contractures and two staff were required to position Resident #2 in bed. During the interviews with CNA #1 on 12/09/20 at 11:00 AM, and CNA #3 on 12/9/20 at 12:00 PM, they stated they were assigned to Resident #2's unit during the day shift on 11/01/20. Each CNA stated that CNA #5 failed to ask them for assistance with positioning Resident #2. Interview at 2:00 PM on 12/09/20 with the Director of Health Care Services revealed that Resident #2 required two staff for positioning. The Director of Health Care Services confirmed that on 11/01/20, the CNA positioned Resident #2 on his/her side to change the bed linens without another staff member, the resident rolled off the bed onto the floor, and sustained a nose fracture and facial bruising. The facility provided an acceptable Removal Plan on 12/8/2020. The Removal Plan demonstrates the non-compliance exisited from 11/1/2020 to 11/2/2020. The facility provided evidence of Fall Policy update, staff education on falls policy and 2 person lift, and audits x 4 weeks with no deviation from the falls and 2 person lift requirments.

Based on record review and interview, the facility failed to identify underlying causes for weight changes and provide the necessary and timely nutrition to prevent an extended decline in body weight without improvement for 1 of 14 residents reviewed for alleged abuse (Resident #6). The findings included: The facility admitted Resident #6 on 3/28/12 with diagnoses, including but not limited to [MEDICAL CONDITION], Type 2 Diabetes, [MEDICAL CONDITION], Urinary Incontinence, Depressive, Dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review on 6/18/19 at 2:20 PM of the resident weight record revealed that s/he lost 36.2 lbs (18%) of body weight in three months and 17 days. Resident #6 weighed 200.2 pounds (lbs) on 7/10/18, 193 lbs on 8/7/18, 186.2 lbs on 9/7/18, 176.2 lbs on 10/10/18, 169.8 lbs on 10/17/18, and 164 lbs on 10/24/18. On 10/28/18, the resident was sent to the hospital emergency room with symptoms of lethargy. Registered dietitian's notes dated 10/17/18 and reviewed on 6/18/19 at 3:20 PM stated that Resident #6 had a significant weight loss and the resident's diet was changed to pureed/thin liquids due to swallowing difficulty. In an interview with the Certified Dietary Manager on 6/19/19 at approximately 1:30 PM, s/he stated the resident did not trigger for significant weight change until 10/10/18.

Based on record review and interview, the facility failed to ensure interventions were in place to prevent or reduce falls for 3 of 14 residents reviewed for alleged abuse (Residents #2, #4, and #10). The findings included: The facility admitted Resident #2 on 3/20/2017 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review on 6/18/2019 at approximately 8:45 AM of the medical record for Resident #2 revealed a fall on 7/1/2018, 2/2/2019, and 6/1/2019. At the time of the fall on 6/1/2019 Resident #2 obtained a lump on his/her forehead (7 cm x 6 cm), a small scratch across the bridge of the nose, and three small scratches to his/her left leg. Review on 6/18/2019 at approximately 10:05 AM of the Comprehensive Plan of Care, dated 5/17/2019, for Resident #2 stated as a Problem/Need, Increased risk for falls, has significant history of falls. Resident has decreased safety awareness and leans forward at times while up in the wheelchair. The Goal stated, Resident will have no falls through next review. Interventions included eye exam as needed, therapy screen as needed, fall assessment routinely. Interventions included to maintain an environment free of clutter and safety hazards, and to place items frequently used within easy reach and visual fields to avoid resident reaching for items. Other interventions included to provide adequate lighting, free of glare and call light within reach, fall mats, and to make sure resident has baby doll as prefers. No additional interventions were added to the plan of care to reduce or prevent further falls for Resident #2 following the fall with injuries on 6/1/2019. An interview on 6/18/2019 at approximately 10:20 PM with the Director of Nursing (DON) confirmed no additional interventions were put in place to prevent falls or to reduce further falls or to prevent Resident #2 from falling out of his/her wheelchair. The facility admitted Resident #4 on 8/9/2018, with [DIAGNOSES REDACTED]. Review on 6/19/2019 at approximately 11:04 AM of the medical record for Resident #4 revealed a history of falls. Review of an incident report dated 12/19/2018 revealed Resident #4 noted sitting on top of a floor mat in his/her room and obtaining a bruise and swelling to his/her left inner arm. Resident #4 complained of pain to the left arm and shoulder. Further review on 6/19/2019 at approximately 11:04 AM of the medical record for Resident #4 revealed a X-ray of the left shoulder and the findings indicated an acute humeral neck fracture. Review of the medical record for Resident #4 on 6/19/2019 at approximately 11:15 AM revealed falls on 12/1/2018, 12/12/2018, 12/17/2018, a second fall on 12/17/2018, the fall with injury on 12/19/2018, a fall with injury on 12/31/2018, and falls on 2/11/2019, 2/16/2019, and 3/30/2019. Review on 6/20/2019 at approximately 10:09 AM of the Comprehensive Plan of Care, dated 8/17/2018, for Resident #4 revealed that this resident was at risk for falls related to Dementia and a history of falling. The goal stated, Resident with no falls- related injury through next review. Interventions included, keep floor free of debris and clutter, keep call light within reach and encourage use, keep fluids and frequently used items within reach, Physical Therapy and Occupational Therapy evaluation as needed, and use wheelchair for transport. No other interventions were in place to reduce or prevent further falls for Resident #4. Review on 6/20/2019 at approximately 11:25 AM of a fall assessment dated [DATE] at 1:11 PM revealed a score of 43 indicating high risk for falls. An interview on 6/20/2019 approximately 12:00 noon with the DON confirmed no new interventions to reduce falls or prevent further falls were added to the plan of care for Resident #4. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Observation on 6/21/19 at 9:12 AM revealed Resident #10 was in bed sleeping with bruises under both eyes and small swelling on the forehead noted. Record review on 6/21/19 at 9:22 AM revealed that on the morning of 6/4/19 a Certified Nursing Assistant (CNA), the care provider, and two other CNAs were assisting with transfer and mobility, and observed bruises on the resident's face. The observation was immediately reported to Licensed Practical Nurse (LPN) #12. LPN #12 informed the unit manager that s/he needed to see Resident #10, who possibly had an unwitnessed fall. The unit manager observed the resident with a bruised area to the forehead, swollen eyes, darkened eyelids, and dried blood in his/her hair. The Medical doctor, DON, and resident representative were notified, and the resident was sent to the emergency room (ER). In an interview with CNA #14 on 6/21/19 at 9:55 AM, s/he stated that s/he saw the resident's bruised left eye on 6/3/19 (3-11 shift) around 9-9:15 PM and did not report it because s/he assumed the nurse already knew due to the fact that the resident had some treatment on it. CNA #14 also stated that s/he did not see the resident's swollen forehead because the resident was wearing a hair wrap covering his/her hair and part of the forehead. In a phone interview with LPN #12 on 6/21/19 at 10:33 AM, s/he stated that s/he was called to the resident's room to check the resident's face due to bruising and swelling.

Based on record review and interview, the facility failed to review and revise the Comprehensive Plan of Care with interventions to reduce or prevent falls for 2 of 14 residents reviewed for alleged abuse (Residents #2 and #4). The findings included: The facility admitted Resident #2 on 3/20/2017 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review on 6/18/2019 at approximately 8:45 AM of the medical record for Resident #2 revealed a fall on 7/1/2018, 2/2/2019, and 6/1/2019. At the time of the fall on 6/1/2019 Resident #2 obtained a lump on his/her forehead (7 cm x 6 cm), a small scratch across the bridge of the nose, and three small scratches to his/her left leg. Review on 6/18/2019 at approximately 10:05 AM of the Comprehensive Plan of Care, dated 5/17/2019, for Resident #2 stated as a Problem/Need, Increased risk for falls, has significant history of falls. Resident has decreased safety awareness and leans forward at times while up in the wheelchair. The Goal stated, Resident will have no falls through next review. Interventions included eye exam as needed, therapy screen as needed, fall assessment routinely. Interventions included to maintain an environment free of clutter and safety hazards, and to place items frequently used within easy reach and visual fields to avoid resident reaching for items. Other interventions included to provide adequate lighting, free of glare and call light within reach, fall mats, and to make sure resident has baby doll as prefers. No additional interventions were added to the plan of care to reduce or prevent further falls for Resident #2 following the fall with injuries on 6/1/2019. An interview on 6/18/2019 at approximately 10:20 PM with the Director of Nursing (DON) confirmed no additional interventions were put in place to prevent falls or to reduce further falls or to prevent Resident #2 from falling out of his/her wheelchair. The facility admitted Resident #4 on 8/9/2018, with [DIAGNOSES REDACTED]. Review on 6/19/2019 at approximately 11:04 AM of the medical record for Resident #4 revealed a history of falls. Review of an incident report dated 12/19/2018 revealed Resident #4 noted sitting on top of a floor mat in his/her room and obtaining a bruise and swelling to his/her left inner arm. Resident #4 complained of pain to the left arm and shoulder. Further review on 6/19/2019 at approximately 11:04 AM of the medical record for Resident #4 revealed a X-ray of the left shoulder and the findings indicated an acute humeral neck fracture. Review of the medical record for Resident #4 on 6/19/2019 at approximately 11:15 AM revealed falls on 12/1/2018, 12/12/2018, 12/17/2018, a second fall on 12/17/2018, the fall with injury on 12/19/2018, a fall with injury on 12/31/2018, and falls on 2/11/2019, 2/16/2019, and 3/30/2019. Review on 6/20/2019 at approximately 10:09 AM of the Comprehensive Plan of Care, dated 8/17/2018, for Resident #4 revealed that this resident was at risk for falls related to Dementia and a history of falling. The goal stated, Resident with no falls- related injury through next review. Interventions included, keep floor free of debris and clutter, keep call light within reach and encourage use, keep fluids and frequently used items within reach, Physical Therapy and Occupational Therapy evaluation as needed, and use wheelchair for transport. No other interventions were in place to reduce or prevent further falls for Resident #4. Review on 6/20/2019 at approximately 11:25 AM of a fall assessment dated [DATE] at 1:11 PM revealed a score of 43 indicating high risk for falls. An interview on 6/20/2019 approximately 12:00 noon with the DON confirmed no new interventions to reduce falls or prevent further falls were added to the plan of care for Resident #4.

Based on record review, interview, and review of the facility's abuse policy, Abuse and Neglect Prohibition Policy and Plan, the facility failed to ensure residents were free from abuse and neglect for 1 of 14 residents reviewed for alleged abuse (Resident #13). The findings included: The facility admitted Resident #7 on 9/6/18 with [DIAGNOSES REDACTED]. The facility admitted Resident #13 on 1/12/19 with [DIAGNOSES REDACTED]. Review on 6/19/19 at approximately 3:00 PM of Resident #7's nurse's notes dated 5/26/19 stated the following: the resident was verbally aggressive to another resident and noted by staff to hit resident. When approached by the nurse, the resident stated he doesn't have to do a (expletive) thing and leave him/her the (expletive) alone. Made DON (Director of Nursing) aware of the situation and was given instructions to send resident out for psych eval if the behavior continues. After speaking with DON, the nurse informed the resident if continued behavior he would be sent out. The resident calmed down and apologized. No other behaviors noted this afternoon. Review on 6/19/19 at approximately 3:10 PM of Resident #13's nurse's notes dated 5/26/19 stated the following: the resident noted on the front porch smoking. The resident was reminded about the smoking policy. The resident stated s/he apologized, and s/he was aware that s/he should not be smoking, but s/he had gotten upset, and needed a cigarette and s/he would not do it again, got into an altercation with another resident concerning cigarette lighter and was hit by the other resident in the arm. DON made aware. No injuries noted. Resident c/o (complained of) throbbing pain right arm at level 8. Pain meds were given. Medication effective. Will continue to monitor. Review on 6/20/19 at approximately 9:15 AM of the social services notes dated 5/29/19 revealed that Resident #13 expressed to the DON that s/he did not feel safe at the facility. The social worker notes indicated that the facility gave Resident #13 the option of being discharged to another nursing facility or home due to his/her concerns. On 5/29/19, the facility reported the incident that occurred on 5/26/19 between Residents #7 and #13 to the State Agency. A hospice aid witnessed the incident on 5/26/19 and provided the facility a signed handwritten statement dated 5/26/19 that stated, I .pushed Resident #13 outside to smoke. Resident #13 asked Resident #7 for his/her lighter and Resident #7 got mad and started yelling at him/her and cursing at him/her. Resident #7 told Resident #13 s/he'll beat his/her (expletive). Resident #13 said no you're not, Resident #7 then rolled over and punched Resident #13 on his/her right arm. In an interview with Licensed Practical Nurse (LPN) #11 on 6/21/19 at 9:53 AM, s/he stated that on 5/26/19 the hospice aid informed him/her of an altercation between Residents #7 and #13 that resulted in Resident #7 punching Resident #13 on the right arm. LPN #11 stated that the residents were separated, interviewed, and examined for injuries. There were no obvious injuries on either resident, but Resident #13 complained of severe pain to the right arm. Resident #7 admitted hitting Resident #13 on the right arm but denied using a closed fist. LPN #11 stated that the DON, medical doctor, and resident representative were informed. In an interview with the DON on 6/21/19 at approximately 10:30 AM, s/he did not elaborate regarding not reporting the resident to resident altercation to appropriate state agencies and state law enforcement timely. Review of the facility's policy, Abuse and Neglect Prohibition Policy and Plan, revealed it stated the facility has zero-tolerance for abuse or neglect of a resident or the misappropriation of resident property.