Every finding on record at Stanley Total Living Center

Based on observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 3 of 3 residents reviewed for respiratory care (Residents #19, #88 and #41).The findings included:a. Resident #19 was admitted to the facility on [DATE] with the diagnosis of chronic respiratory failure with hypoxia (a condition where the body is deprived of oxygen).A review of Resident #19's physician orders dated 4/2/2025 revealed an order for oxygen to be administered as needed via nasal canula at 2 liters per minute (l/min).A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #19 was coded for receiving oxygen.Observations on 1/5/2026 at 10:54 AM, 1/5/2026 at 3:40 PM, 1/6/2026 at 8:56 AM revealed Resident #19 was in her room wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at Resident #19's room to indicate oxygen was in use during the observations.b. Resident #88 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure with hypoxia.A review of Resident #88's physician orders dated 12/5/2025 revealed an order for oxygen to be administered continuously via nasal canula at 3 l/min.A review of the admission MDS dated [DATE] indicated Resident #88 was coded for receiving oxygen.Observations on 1/5/2026 at 10:57 AM, 1/5/2026 at 3:39 PM, and 1/6/2026 at 8:58 AM revealed Resident #88 was in her room wearing a nasal cannula with oxygen being administered at 3 l/min. There was no cautionary or safety signage posted at Resident #88's room to indicate oxygen was in use during the observations.c. Resident #41 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with hypoxia.A review of Resident #41's physician orders dated 2/13/2025 revealed an order for oxygen to be administered as needed via nasal canula at 2 l/min to maintain oxygen saturations at 90% or above.A review of Resident #41's physician orders dated 8/1/2025 revealed an order for oxygen to be administered via nasal canula at bedtime to maintain oxygen saturations above 90% on at bedtime and off in AM.A review of the quarterly MDS dated [DATE] indicated Resident #41 was coded for receiving oxygen.Observations on 1/5/2026 at 10:47 AM revealed Resident #41 was in his room wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at Resident #41's room to indicate oxygen was in use during the observations. Observations on 1/5/2026 at 3:42 PM and 1/6/2026 at 8:59 AM revealed there was no cautionary or safety signage posted at Resident #41's room to indicate oxygen was in use during the observations.During an interview on 1/7/2026 at 9:53 AM NA #1 stated she had not seen oxygen in use signs posted at residents' rooms who used oxygen. During an interview on 1/7/2026 at 10:07 AM the Assistant Director of Nursing (ADON) stated the residents did not have oxygen in use signage at their rooms because the facility was a non-smoking facility and no smoking signs were present throughout the facility. During an interview on 1/7/2026 at 1:08 PM the Director of Nursing (DON) stated the facility had a policy that they did not post oxygen in use signs on resident doorways. They were posted at the entrance and exits of the facility with non-smoking signs. The DON thought since it was a non-smoking facility they were not required to have oxygen in use signs at residents' rooms.During an interview on 1/7/2026 at 1:38 PM the Administrator stated since the facility was a non-smoking facility she did not think the oxygen in use signs needed to be posted on the residents' rooms since it was posted at the entrance to the facility.

Based on observations, record review and staff interviews, the facility failed to verify and demonstrate competency for cleaning and disinfecting a shared glucometer according to the manufacturers' recommendations for using an Environmental Protection Agency (EPA) approved disinfectant cloth for 1 of 4 nursing staff reviewed for competent nurse staff. Nurse #1 was observed not disinfecting a shared glucometer after use on Resident #28 and before use on Resident #7. Failure to use an approved product and procedure to disinfect a glucometer in accordance with the manufacturer's instructions has the high likelihood to expose residents to bloodborne pathogens. Immediate jeopardy began on 10/23/24 when Nurse #1 failed to demonstrate competency in disinfecting a shared glucometer between residents. Immediate jeopardy was removed on 10/25/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Findings included: This tag is cross referred to: F 880- Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to disinfect a shared glucometer between Resident #28 and Resident #7 according to the facility's policy and the manufacturer's user guide. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer has the high likelihood to expose residents to bloodborne pathogens. None of the current residents were diagnosed with a bloodborne pathogen. This deficient practice affected 1 of 3 residents who required blood glucose levels checks (Resident #7). Review of Nurse #1's training records revealed the following: - A sign in sheet dated 1/24/24 with Nurse #1's name present was titled Proper Storage of Diabetic Supplies, walking education, completed by the pharmacy. Literature attached to the sign in sheet was titled: Proper Storage of Diabetic Supplies and read in part: Glucometer should be properly cleaned following manufacturer's guidelines. Best practice is for each patient to have their own meter. If using house meter, proper cleaning must be performed after each use. The in-service did not specify what to use to clean the meter or how to clean the meter. -A point of care testing observation had been completed for Nurse #1 by the SDC on 5/13/24 and 5/15/24. Cleaning/ disinfecting the testing meter was included on the audit form and indicated that Nurse #1 had completed the cleaning/ disinfecting of the meter correctly. -A form with Nurse #1's name, titled Nurse's Annual Skills Check had been completed on 6/2/23 and included glucometer disinfecting. -Nurse #1's online education module transcript revealed she had completed an online module entitled Professional Responsibility in Infection Prevention on 6/9/24. The module content included education on infection transmission and the reduction of the risk of infections associated with medical equipment, devices and supplies. An interview was conducted with the Staff Development Coordinator (SDC) on 10/23/24 at 12:16 PM. The SDC stated the facility educated nurses on procedures for glucometer disinfection during new hire orientation and annually. She said nurses were educated annually on glucometer disinfection through the facility's skills fair. The SDC stated the facility had held its annual skill fair at the beginning of October. The SDC explained that Nurse #1 had not attended the skills fair in October and still needed to complete her annual skills competency. The SDC said that she had a make up list for nurses who had not attended the skills fair and had planned to have them complete the skills fair makeup this week. An interview with was conducted on 10/23/24 at 7:53 AM with Nurse #1. Nurse #1 said she had worked at the facility for about 3 years. She stated she had received training on disinfecting glucometers but did not recall when exactly she had received the training. Nurse #1 said that she thought alcohol was what she was supposed to use to disinfect the glucometer. She said she could use an alcohol prep pad or could use alcohol-based hand sanitizer. Nurse #1 removed a disinfectant wipe from her medication cart and said the disinfectant wipe could also be used but that it cleaned the glucometer the same as the alcohol would. She could not state the process for disinfecting the glucometer. Nurse #1 did not say why she had not attended the skills fair. A sign in sheet titled Nurse Annual Skill Check dated 10/3/24 and 10/4/24 revealed Nurse #1's name was not on the sign in log. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 12:56 PM. The DON stated nurses should be educated during new hire orientation and annually on glucometer disinfection procedures. The DON said Nurse #1 had received education in the past on glucometer disinfection. The DON said point of testing audits for the glucometer had been completed for Nurse #1 and that Nurse #1 had disinfected the glucometer correctly on the audit. She could not say why Nurse #1 had not known the correct procedure for disinfecting the shared glucometer, except that she might have been nervous. An interview was conducted with the Administrator on 10/23/24 at 1:20 PM. The Administrator stated that education on glucometer disinfection should be completed during new hire orientation and annually for nurses. She said with the amount of education that Nurse #1 had received she did not know why she did not know the procedure for disinfecting the shared glucometer. The facility's Administrator was informed of the immediate jeopardy on 10/23/24 at 2:52 PM. The facility submitted an acceptable credible allegation of immediate jeopardy removal. The following interventions were put into place to remove the immediate jeopardy: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 10/23/24 at 7:28 am, Nurse #1 failed to properly clean and disinfect one shared blood glucose meter after use for Resident #28 and was then stopped before Resident #7 was tested during a medication pass. Nurse #1 failed to attend the skills fair that included glucose disinfection training and competency that was offered in October 2024. Both Resident #7 and Resident #28 were at risk of suffering from the deficient practice. All residents being cared for/medicated by Nurse #1 who required a blood glucose check using the shared glucometer at any time while Nurse #1 was on duty were also at risk from being affected by the deficient practice because Nurse #1 could not verbalize the correct steps to disinfect the glucometer. (12) other licensed nurses were identified as not having completed the most recent training and competency on disinfecting shared blood glucose meters. These licensed nurses received education/competency by the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters before and after each use as well as the significance of doing so for the safety/health of every resident related to the high likelihood for the spread of blood borne pathogens between 10/23/24 at 4:30 pm and 10/24/24 at 6:00 pm. Any of these licensed nurses who failed to complete this training within this time frame will not be allowed to work prior to receiving this education. Nurse #1 was terminated from employment on 10/23/24 at 4:00 pm to ensure no other residents on her assigned unit have the potential of being affected by continued deficient practice. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Between 10/23/24 at 4:30 pm and 10/24/24 at 6:00 pm, training/education was provided both in person and via Zoom meeting for all licensed nursing staff by the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters before and after each use as well as the significance of doing so for the safety/health of every resident related to the high likelihood for the spread of blood borne pathogens which included validation of competency, either in-person or through verbally providing the appropriate steps of the procedure. This training specifically included the brand of disinfectant required, the requirement for the disinfecting of the full surface area of the blood glucose meter itself, and the required length of wet contact time. No current licensed nurse will be allowed to work prior to receiving this education from the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON. This training will be included in the new hire orientation provided by the Staff Development Coordinator who will be responsible for ensuring this training and competency is completed with all licensed nurses, including any agency staff if used, during initial orientation and prior to starting their first shift .The education and competency of every licensed nurse regarding the proper cleaning and disinfecting of a multi-use blood glucose meter will be reviewed and verified by the Staff Development Coordinator at least annually via a skills fair any licensed nurse who does not attend this mandatory annual competency assessment during the scheduled time will not be allowed to work until this has been completed. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. The immediate jeopardy was removed on 10/25/24. On 10/24/24 the facility's credible allegation of immediate jeopardy removal was validated by the following: An onsite validation was completed on 10/24/24 at the facility. The validation was evidenced by nurse and administrative interviews conducted that included the required infection control practices for glucometers. Review of the facility Diabetic Management policy revealed the policy had been updated to include additional procedures for glucometer disinfection. Interviews with nurses revealed they had received education on the facility's glucometer disinfection policy/ procedures and completed glucometer disinfection competency validation. Nurses were able to state the correct process for disinfecting the facility's shared glucometers, including the correct product to use and wet contact time of two minutes. Nurses were able to verbalize glucometers needed to be disinfected before/ after each use to prevent the transmission of bloodborne pathogens. Observations were conducted and revealed nurses correctly disinfected the facility's shared glucometers according to the facility's policy/ procedures. Any current staff, agency staff, or new staff who had not received education and competency validation on glucometer disinfection would not be allowed to work by the facility until the education and competency had been completed. The immediate jeopardy removal date of 10/25/24 was validated.

Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to disinfect a shared glucometer between Resident #28 and Resident #7 according to the facility's policy and the manufacturer's user guide. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer has the high likelihood to expose residents to bloodborne pathogens. None of the current residents were diagnosed with a bloodborne pathogen. This deficient practice affected 1 of 3 residents who required blood glucose levels checks (Resident #7). Immediate jeopardy began on 10/23/24 when Nurse #1 failed to disinfect a shared glucometer between residents. Immediate jeopardy was removed on 10/25/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: The facility's policy entitled, Infection Prevention and Control Program (revised 1/9/23) included: Non-disposable equipment will be cleaned and disinfected after use (glucometers) and Equipment used by multiple residents will be properly disinfected between the use of each person. The facility's policy entitled, Diabetes Management (Revised 8/7/24) read in part: Cleaning and Disinfection Guidelines: Glucometers should be cleaned before and after use with a [brand name] disinfect wipe. Use [brand name] disinfect wipe to wipe and thoroughly wet surface area of glucometer thoroughly. Allow surface area to remain wet for two (2) minutes. Let air dry. The manufacturer's user guide for the glucometer used at the facility included cleaning and disinfecting guidelines. These instructions noted, in part, It is policy to advise health care professionals to clean and disinfect meters between each patient test to avoid cross contamination issues. A list of products approved for disinfecting the glucometer was provided by the manufacturer and included the [brand name] disinfectant wipe used by the facility. The manufacturer list of products approved for disinfecting the glucometer did not include alcohol. The manufacturer instructions for using the [brand name] disinfect wipe stated to follow the product label instructions to disinfect the meter. A [brand name] disinfectant wipe was available for use at the facility to disinfect shared glucometers. The [brand name] disinfect wipe was observed on 10/23/24 at 7:28 AM on the 100 back hall medication cart. The [brand name] disinfectant wipe was a germicidal disinfectant wipe listed as an approved product by the manufacturer of the glucometer for cleaning/disinfecting the facility's [brand name] glucometer. The disinfectant wipe product label listed the product as effective against human immunodeficiency virus (HIV-1), hepatitis B virus (HBV) and hepatitis C virus (HCV). The product label instructions stated, To Disinfect and deodorize hard, nonporous surfaces: If present, use a wipe to remove visible soil prior to disinfecting. Unfold wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry. A continuous observation was conducted of Nurse #1 and the 100 back hall medication cart during the morning medication pass on 10/23/24 from 7:28 AM to 7:52 AM. Nurse #1 collected supplies (a vial of test strips, a lancet, and an alcohol wipe) and obtained a glucometer from the medication cart in preparation to conduct a blood glucose check for Resident #28. The glucometer was not labeled with a resident's name. Nurse #1 removed an alcohol prep pad from the top drawer of her medication cart. She used the alcohol prep pad and wiped the surface around the test strip insertion site of the glucometer. Nurse #1 was accompanied as she carried the glucometer and supplies to Resident #28's room. While wearing gloves, the nurse wiped the resident's finger with an alcohol pad, used a lancet to obtain a drop of blood from her finger and applied the blood to the test strip inserted into the glucometer. Once the blood glucose results were obtained, Nurse #1 returned to the medication cart with the glucometer and discarded the trash and lancet. Nurse #1 removed an alcohol prep pad from the top drawer of her medication cart. She opened the alcohol prep pad and wiped the surface around the test strip insertion site of the glucometer. Nurse #1 then placed the glucometer on the top of her medication cart. Nurse #1 left the medication cart to administer medications to Resident #28 and returned to the medication cart at 7:41 AM. At 7:44 AM Nurse #1 was observed as she collected supplies (a vial of test strips, a lancet, and an alcohol wipe) in preparation to conduct a blood glucose check for Resident #7. Nurse #1 obtained an alcohol prep pad from the top drawer of her medication cart. She picked up the glucometer that was sitting on the top of her medication cart that had been used to conduct Resident #28's blood glucose check. She opened the alcohol prep pad and wiped the surface around the test strip insertion site of the glucometer. Nurse #1 was accompanied as she carried the glucometer and supplies into Resident #7's room. While wearing gloves, Nurse #1 approached Resident #7 with the glucometer and supplies to check her blood glucose. Nurse #1 was stopped by the surveyor and asked to return to the medication cart. On 10/23/24 an interview was conducted with Nurse #1 at 7:53 AM. Nurse #1 said she had used an alcohol prep pad to clean the glucometer because that was what she thought she was supposed to use. Nurse #1 said an alcohol prep pad or hand sanitizer could be used to clean the glucometer. Nurse #1 removed an individually packaged [brand name] disinfect wipe from the top drawer of the medication cart and stated that it could also be used to clean the glucometer but that it cleaned the glucometer the same as the alcohol prep pad or hand sanitizer would. Nurse #1 said the glucometer was supposed to be cleaned before and after each use to prevent transmission of infection. She explained she had only cleaned the glucometer around the test strip insertion site with the alcohol prep pad, because that was where the blood sample was inserted. Nurse #1 was unable to specify how she would disinfect the glucometer using the [brand name] disinfecting wipe. On 10/23/24 at 7:57 AM the Risk Management Nurse approached the medication cart during the interview with Nurse #1. The Risk Management Nurse was notified that Nurse #1 had used an alcohol prep pad and cleaned around the test strip insertion site of the glucometer but had not used a disinfectant wipe to disinfect the shared glucometer between resident use. An interview was conducted with the Risk Management Nurse on 10/23/24 at 7:57 AM at the 100 back hall medication cart with Nurse #1. The Risk Management Nurse said an alcohol prep pad could not be used to disinfect the glucometer, and that the entire surface of the glucometer needed to be disinfected not just the area around the test strip insertion site. He stated glucometers were supposed to be disinfected before and after each use. The Risk Management Nurse said the [brand name] disinfectant wipe located on the medication cart was supposed to be used to disinfect the glucometer. He explained the process to disinfect the glucometer was to use the [brand name] disinfectant wipe to wet all the surfaces of the glucometer, let it remain wet for 2 minutes, and then let it air dry. He said the purpose of disinfecting the glucometer was to prevent the transmission of bloodborne pathogens. After the Risk Management Nurse verbalized the process for disinfecting the glucometer, Nurse #1 stated she should have used the [brand name] disinfectant wipe to disinfect the glucometer. An observation was conducted on 10/23/24 at 8:00 AM of Nurse #1 disinfecting the shared glucometer. Nurse #1 obtained a [brand name] disinfectant wipe from the top drawer of the medication cart. She unfolded the disinfectant wipe and used it to wipe all the surfaces of the glucometer keeping it wet for 2 minutes. She then placed the glucometer on a paper to let it air dry. An interview was conducted with the Nurse Practitioner (NP) on 10/24/24 at 12:13 PM. The NP stated that the facility should follow its policy for disinfecting glucometers to prevent transmission of bloodborne pathogens. She stated she was not aware of any resident at the facility who had a bloodborne pathogen diagnosis. An interview was conducted with the Infection Preventionist (IP) on 10/23/24 at 12:36 PM. She said that glucometers were supposed to be disinfected before and after each use. She said the [brand name] disinfectant wipe was located on the medication cart to disinfect the glucometer. She said glucometers should be disinfected to prevent transmission of bloodborne pathogens because the facility's glucometers were shared. The IP did not know why Nurse #1 did not know how to disinfect the glucometer or had thought it was okay to use an alcohol prep pad to disinfect the glucometer. The IP stated she conducted point of care testing audits for glucometers. She said when she had audited Nurse #1 in September 2024, she had disinfected the glucometer correctly. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 12:56 PM. The DON said the facility's glucometers were shared and stored on the medication cart. She said glucometers needed to be disinfected before and after each use to prevent the transmission of bloodborne pathogens. The DON said the [brand name] disinfectant wipe should be used to disinfect the glucometer not an alcohol prep pad. She said she did not know why Nurse #1 had not disinfected the glucometer and had used an alcohol prep pad instead of a disinfect wipe, except that Nurse #1 might have been nervous. An interview was conducted with the Administrator on 10/23/24 at 1:20 PM. The Administrator said the facility's glucometers were shared and needed to be disinfected before and after each use. She said the [brand name] disinfectant wipe, not an alcohol prep pad should be used to disinfect the glucometers. The Administrator said the purpose of disinfecting the glucometer was to prevent the transmission of bloodborne pathogens. The Administrator said she did not know why Nurse #1 had not disinfected the glucometer after using it. A review of the medical diagnoses for current residents at the facility was conducted. There were no residents identified as having diagnoses which included a bloodborne pathogen. The facility's Administrator was informed of the immediate jeopardy on 10/23/24 at 2:52 PM. The facility submitted an acceptable credible allegation of immediate jeopardy removal. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 10/23/24 at 7:28 am, Nurse #1 failed to properly clean and disinfect one shared blood glucose meter after use for Resident #28 and was then stopped before Resident #7 was tested during a medication pass. Both Resident #7 and Resident #28 were at risk of suffering from the deficient practice. All residents being care for/medicated by Nurse #1 who required a blood glucose check using a shared glucometer at any time while Nurse #1 was on duty were also at risk from being affected by the deficient practice because Nurse #1 could not verbalize the correct steps to disinfect the glucometer. The blood glucose meter used by Nurse #1 was properly cleaned and disinfected by the Director of Nursing when she became aware of the initial concern on 10/23/24 at 1:00 pm. The Director of Nursing reviewed all resident diagnoses to ensure no resident currently has an active diagnosis of any blood borne pathogen on 10/23/24 at 2:09 pm. Nurse #1 was terminated from employment on 10/23/24 at 4:00 pm to ensure no other residents on her assigned unit have the potential of being affected by continued deficient practice. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The current policy and procedures for Diabetes Management was reviewed by the Director of Nursing, ADON/Case Management Coordinator, Staff Development Coordinator, Infection Control Preventionist, and Administrator at 3:30 pm to ensure accuracy of procedures following manufacturer's directions. Between 10/23/24 at 4:30 pm and 10/24/24 at 6:00 pm, training/education was provided to all licensed nursing staff by the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters before and after each use as well as the significance of doing so for the safety/health of every resident related to the high likelihood for the spread of blood borne pathogens. This training specifically included the brand of disinfectant required, the requirement for the disinfecting of the full surface area of the blood glucose meter itself, and the required length of wet contact time. No current licensed nurse will be allowed to work prior to receiving this education from the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON. This training will also be included in the new hire orientation training provided by the Staff Development Coordinator who will be responsible for ensuring this training is completed with all licensed nurses, including any agency staff if used, during initial orientation and prior to starting their first shift. The MD/Medical Director and Nurse Practitioner were both verbally notified of the breach by the Director of Nursing on 10/23/24 at 3:45 pm. The Gaston County Health Department was notified via email by the Director of Nursing on 10/23/24 at 6:45 pm of the breach. The Responsible Party of resident #28 was notified of the breach by the Director of Nursing on 10/23/24 at 7:00 pm. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. The immediate jeopardy was removed on 10/25/24. On 10/24/24 the facility's credible allegation of immediate jeopardy removal was validated by the following: An onsite validation was completed on 10/24/24 at the facility. The validation was evidenced by nurse and administrative interviews conducted that included the required infection control practices for glucometers. Interviews with nurses revealed they had received education on the facility's glucometer disinfection policy/ procedures. Nurses were able to state the correct process for disinfecting the facility's shared glucometers, including the correct product to use and wet contact time of two minutes. Nurses were able to verbalize glucometers needed to be disinfected before/ after each use to prevent the transmission of bloodborne pathogens. Observations were conducted and revealed nurses were correctly disinfecting the facility's shared glucometers according to the facility's policy/ procedures. Any current staff, agency staff, or new staff who had not received education and competency validation on glucometer disinfection would not be allowed to work by the facility until the education and competency had been completed. The immediate jeopardy removal date of 10/25/24 was validated.

Based on observations, record reviews, and staff interviews, the facility failed to provide care in a safe manner, which resulted in the resident falling from her bed, striking her head on the corner of the bedside table, which resulted in a laceration to her scalp which required 5 sutures. This was for 1 of 3 residents reviewed for the prevention of accidents (Resident #139). The findings included: A review of Resident #139's quarterly Minimum Data Set assessment dated [DATE] revealed severely impaired cognition with no delusions, behaviors, rejection of care, or instances of wandering. Resident #139 was coded as requiring total assistance with bed mobility and transfers. She was also dependent on staff for upper and lower body dressing. Resident #139 was always incontinent of bowel and bladder and was coded as not having had a fall since her last assessment. A review of Resident #139's care plan last updated on 07/03/24 revealed a care plan area for Falls: At risk for falls due to impaired safety awareness, poor balance, and psychotropic medication use that was initiated on 01/08/23. Interventions included to keep the bed in low position when not performing care for safety and to place a fall mat to the left side of the bed for safety. A review of facility provided incident and accident logs revealed Resident #139 had an unwitnessed fall on 05/28/24. Per the incident/accident report and analysis, Nurse Aide (NA) #4 reported to Nurse #4 that she had found Resident #139 on the floor of her room. NA #4 stated she was walking by Resident #139's room when she heard a noise and went into the room to investigate where she found Resident #139 face down on the floor. Nurse #4 reported Resident #139 was observed lying face down with blood around her head. Nurse #4 surmised that Resident #139 hit her head on the corner of her bedside table which resulted in the injury to Resident #139's head. Nurse #4 reported in the incident report that Resident #139's bed was in a high position and that there was a fall mat in the room but not on the floor by the bed. Review of the facility's investigation into Resident #139's fall, dated 05/28/24 revealed the facility determined that NA #3, who was assigned to Resident #139 at the time she fell , failed to implement Resident #139's care plan interventions for fall prevention that included a fall mat to her bedside and to keep her bed in a low position. During an interview with NA #3 on 10/24/24 at 9:21 AM, she verified she was assigned to Resident #139 on 05/28/24 and remembered the fall. She reported she was new to the facility and had just been released from training. She continued, stating she was unaware that Resident #139 was a fall risk and reported she did not see a fall mat in Resident #139's room. NA #3 reported she had initially entered Resident #139's room to get her up and ready for the dinner meal. She insisted that she did not touch Resident #139's bed or remove the fall mat. NA #3 stated once she got Resident #139 ready for the dinner meal, she left Resident #139 in the bed to go find another nurse aide or nurse to help her transfer Resident #139 from the bed to her wheelchair. NA #3 stated when she returned with Nurse #6, she saw Resident #139 in the floor and called for help. She insisted that there were no other staff members in the room when she found Resident #139 in the floor, the bed was in a high position, and there was no fall mat in the room. A review of Resident #139's hospital records dated 05/28/24, revealed Resident #139 was seen in the emergency room after suffering a fall at the facility. Per the records, Resident #139 was treated for a laceration on her forehead that was cleaned and sealed with 5 sutures and released back to the facility. An interview with NA #4 on 10/24/24 at 9:46 AM revealed she remembered Resident #139 and the fall she suffered on 05/28/24. NA #4 reported Resident #139 was confused and needed total assistance with 2 people assisting for transfers. She stated on 05/28/24 NA #3 was assigned to Resident #139 but that she and other nurse aides would assist if needed. She stated before the dinner meal, she had taken some trash out of the building and put it in the dumpster and when she returned into the building, as she walked past Resident #139 room, she heard a noise that she described as a moan come from Resident #139's room. She stated she immediately went into Resident #139's room and noted Resident #139 was lying face down in the floor with a pool of blood around her. NA #4 stated she called for help and that Nurse #4 came to assist. She reported NA #5 came running to the room as well. NA #4 indicated that Nurse #4 assessed Resident #139 and then she and NA #5 assisted in putting Resident #139 back into her bed until Emergency Medical Services (EMS) arrived to take Resident #139 to the hospital for evaluation and treatment. NA #4 stated while she assisted Resident #139, she noted that her bed was so high that even with the mechanical lift elevated to its highest point, she still had to lower her bed to safely get her back into bed. NA #4 stated she did not see NA #3 until after Nurse #4 had assessed Resident #139 and she and NA #5 were putting Resident #139 back into bed. An interview with NA #5 on 10/24/24 at 11:03 AM revealed she remembered Resident #139's fall on 05/28/24. She stated she assisted Resident #139 back into her bed after the fall. She reported that Resident #139's bed was in a high position and that her fall mat was leaning against the wall in her room. An interview with Nurse #4 on 10/23/24 at 2:02 PM revealed she remembered the incident and Resident #139. She reported she was assigned to Resident #139 as her nurse on 05/28/24 and that Resident #139 was confused and totally dependent on others for transfers. She verified that NA #3 was assigned to Resident #139 on 05/28/24 and that she was in another resident's room with Nurse #5 providing care when she was alerted that Resident #139 was in the floor and injured by NA #4. Nurse #4 stated she immediately left the resident in the care of Nurse #5 and went to attend to Resident #139. She stated when she entered the room, she observed Resident #139 lying face down with blood around her head. She stated she went to Resident #139 and assessed her and placed a towel to a laceration on Resident #139's head. She stated after she assessed Resident #139 and had NA #4 and NA #5 assist Resident #139 back into her bed until EMS could arrive. Nurse #4 stated she was aware Resident #139 was a fall risk and she did not know why her bed was in a high position and her fall mat was not by her bedside with no one in the room. She reported she did not see NA #3 until after Resident #139 was back into bed and NA #3 reported to her that she had left Resident #139 to get assistance in transferring her from her bed to her wheelchair for dinner. An interview with Nurse #6 on 10/21/24 at 10:18 AM revealed she had no interaction with Resident #139's fall. She stated she did observe the aftermath and that before the fall occurred she observed NA #3 walk by her while she was charting at the 100 hall's nurses station. Nurse #6 reported about 5-10 minutes later, NA #3 walked back past the nurses station and looked confused. At that time, Nurse #6 reportedly asked NA #3 if she needed help and NA #3 responded she was looking for someone to help her transfer Resident #139. Nurse #6 stated she thought it was odd that NA #3 was all the way on the other side of the facility from where Resident #139 was located looking for someone to assist her when Nurse #6 knew there were at least 2 nurses and several other nurse aides assigned to the unit where Resident #139 was located. Nurse #6 reportedly told NA #3 she would be happy to assist her and walked with NA #3 back to Resident #139's room. She stated when they arrived at the room, she observed Nurse #4 and 2 nurse aides in the room attending to Resident #139 who was face down on the floor. During an interview with the Director of Nursing on 10/24/24 at 1:53 PM, she reported she remembered Resident #139 and stated she was a confused resident who was a fall risk due to poor safety awareness but had not been identified as a frequent faller. She reported Resident #139 had a fall prevention care plan in place on 05/28/24 and that the interventions included to keep her bed in a low position while she was in bed and to place a fall mat to the left side of her bed. The Director of Nursing stated when Resident #139 fell on [DATE] and the facility completed the investigation, it was determined that NA #3 had not followed Resident #139's care plan for fall prevention and was terminated. The Director of Nursing reported when she questioned NA #3, she informed her that she had left Resident #139 to go find someone to assist with transferring Resident #139 from the bed. She stated NA #3 had been thoroughly educated and should have been familiar with Resident #139 and her care needs. She indicated if NA #3 had to go find someone to assist her with transferring a resident, she should have lowered the bed to a low position and replaced the floor mat. She stated after the fall, the facility provided education to all of the staff, completed audits, and placed the fall into the facility quality assurance program. During an interview with the Administrator on 10/24/24 at 2:01 PM, she stated she was aware of the incident and that it was determined that NA #3 had not implemented and followed Resident #139's fall prevention care plan, which resulted in Resident #139 falling and injuring herself and was sent out to the hospital for treatment. The Administrator stated she was made aware of the fall when Nurse #4 called her and told her Resident #139 had fallen and injured herself. She stated during this telephone call, Nurse #4 also reported concerns as to the way she found the room when she attended to Resident #139. The Administrator reported Nurse #4 informed her that Resident #139's bed was in a high position and that her fall mat was leaning up against the wall. The Administrator stated she immediately suspended NA #3 and had her go home and began her investigation. She stated when she interviewed NA #3, NA #3 reported she did not know Resident #139 was a fall risk and was unaware of any fall interventions that were in place. When the Administrator questioned why she was not looking at the fall risk binder located at the nurses station NA #3 reportedly told her that she was never informed of the binder. The Administrator stated she reviewed NA #3's training and determined she had signed off on being trained about the location of the fall risk binder. The Administrator revealed she ultimately terminated NA #3 from the facility. She stated she placed the fall into the facility's quality assurance program, reeducated all the staff on fall prevention and care plans, and completed audits on the residents in the facility. She reported she expected her staff to be aware of all care plans and interventions or how to find them and to implement the interventions to keep the residents safe. The facility provided the following corrective action plan with a compliance date of 07/12/24: Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice: Upon finding Resident #139 lying on the floor of her room on 5/28/24 at 5:15pm, she was sent to the hospital for immediate medical care by the licensed nurse on duty. Due to concerns for failure to follow the written care plan for resident fall safety noted by the licensed nurse on duty at the time of the fall, the CNA (NA #3) responsible for the provision of care for Resident #139 on 5/28/24 from 7am - 7pm was placed on suspension at 5:52pm pending further investigation by the Administrator. Address how the facility identified other residents having the potential to be affected by the same deficient practice: On 5/28/24 between 5:52pm - 6:15pm, the licensed nurse on duty assigned nursing assistants to conduct safety rounds on all residents assigned to the same CNA responsible for providing care to Resident #139 (NA #3) to determine if there were any other residents affected by the deficient practice of this specific nursing assistant to address any immediate safety concerns. During these rounds, three residents specifically were found in bed with the bed in the highest position, putting them at risk of falling out of bed with injury. Assigned nursing assistants provided the necessary care to each of these residents immediately, including getting them up for dinner and placing all beds in the lower position for safety. On 5/28/24 between 6:00pm - 6:30pm, the licensed nurses on the unit conducted rounds on all other residents as well to ensure there were no other concerns or residents affected by deficient practice-there were no other concerns for resident safety with all devices in place as ordered and beds in the lowest position at that time. Address what measures were put in place or what systemic changes were made to ensure that the deficient practice will not recur: Based on the findings of the facility investigation by the Administrator, the CNA (NA #3) was terminated on 6/3/24 for failure to follow the safety care plan as written for Resident #139. Between 5/29/24 - 6/3/24, the Staff Development Coordinator provided re-education to all nursing staff on their responsibility to ensure that all safety rounds are completed and all nursing interventions are in place for all residents assigned to them at all times including fall mats and the appropriate position of the bed for each particular resident. Staff who did not attend one of the training sessions after 6/3/24 due to vacation, PRN status, or FMLA were not allowed to work until this training was completed. This training is included in new hire orientation and will also be completed at least annually for all nursing staff. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Based on findings of the investigation, the Administrator assigned audits to be conducted daily x 8 days on each unit for both day and evening shifts by the Director of Nursing, Assistant Director of Nursing, and Infection Control Preventionist to ensure all safety interventions currently ordered were in place for all residents as well as education for nursing staff on duty of the importance of making safety rounds during their shift with successful demonstration on where to locate resident care plans including safety devices ordered due to fall risk. There were no concerns noted during each audit conducted. Following the completion of daily audits x 8 days, the Administrator assigned audits to be conducted weekly by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator x 6 weeks between 6/4/24 - 7/12/24 to ensure all safety interventions currently ordered were in place for all residents as well as education for nursing staff on duty of the importance of making safety rounds during their shift with successful demonstration on where to locate resident care plans including safety devices ordered due to fall risk. There were no concerns noted during each audit conducted. The Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator decided on 07/12/24 to take the plan to the next QAPI Committee meeting scheduled for 7/19/24 for further review and continue to monitor for compliance. Date of Compliance: 7/12/24 The corrective action plan was validated on 10/24/24. Review of the facility provided monitoring tools revealed the facility had ongoing monitoring to ensure fall care plan interventions including keeping beds in low position and fall mats in place while residents were in bed were in place. Observations made of residents with fall interventions revealed care plan interventions to be in place. There was evidence of in-services with sign-in sheets, audits, and other interventions that were mentioned in the corrective action plan. Interviews with staff revealed they were able to verbalize the education regarding fall interventions and procedures, notification of a fall, and what to do if they notice a fall intervention not in place. The completion date of 07/12/24 was validated.

Based on record reviews and staff interviews, the facility failed to develop a baseline care plan that addressed a resident's anticoagulant (blood thinner) medications for 1 of 3 resident reviewed for anticoagulant therapy (Resident #45). Resident #45 was admitted to the facility on [DATE] with diagnosis that included fracture of unspecified part of neck of right femur. Resident #45's care plan dated 10/1/24 did not include goals and interventions for the use of anticoagulant therapy. Record review revealed Resident #45 had an admission order for Enoxaparin Sodium Injection 40 milligram subcutaneously one time a day due to right hip fracture until 10/22/24. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #45 was cognitively intact. A Review of Resident #45's Medication Administration Record (MAR) for October 2024 revealed Resident #45 received Enoxaparin Sodium injection 40mg/0.4 ml daily from 10/2/24 through 10/22/24. During an interview on 10/23/24 at 11:40am the MDS Nurse stated she received new orders daily and updated the care plan as needed. MDS Nurse stated the nurses would have to look at the care plan to see anticoagulant therapy goals and interventions and it was also located on the Kardex. The MDS nurse stated she normally entered anticoagulant therapy to the care plan under skin to monitor for abnormal bruising. During an interview on 10/23/24 at 12:13pm the NP stated residents on anticoagulants should be monitored for hematuria and bleeding in addition to bruising. NP stated labs would be done admission then up to NP for further follow up lab work. During an interview on 10/24/24 at 11:42am Nurse #2 stated residents that received blood thinners were monitored for bruising, signs of bleeding, skin color, and blood work would be monitored. Nurse #2 did not know if it was included in the resident's care plan. During an interview on 10/23/24 1:54pm the Director of Nursing (DON) stated nurses should know the risk of anticoagulants and monitor for increased signs of bleeding, bruising, blood in urine. DON stated that care plans were completed by the MDS nurse and anticoagulants were normally added under skin unless specifically care planned. During an interview on 10/24/24 at 3:44pm the Administrator stated nurses should know what to monitor for when a resident is on anticoagulant therapy. The Administrator was not aware that anticoagulant therapy was not in the care plan for reviewed residents. The Administrator stated she didn't know that a specific care plan was required for anticoagulant therapy since nurses should know what to monitor.

Based on observations, record reviews, and staff interviews, the facility failed to develop and implement a person-centered care plan for residents on anticoagulants for 2 of 3 residents reviewed for development and implementation of a comprehensive care plan (Resident #19 and Resident #34). Findings included: 1) Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included right hip fracture from recent fall, Open Reduction Internal Fixation (ORIF) right hip. Record review revealed Resident #19 had an admission order dated 10/2/24 for Enoxaparin Sodium (blood thinner) injection 40mg/0.4 ml subcutaneously one time a day for post-surgery for 21 days. Resident #19's care plan dated 10/3/24 did not include goals and interventions for the use of anticoagulant therapy (received blood thinner medication). A review of Resident #19's Medication Administration Record (MAR) for October 2024 revealed Resident #19 received Enoxaparin Sodium injection 40mg/0.4 ml daily from 10/3/24 through 10/23/24. Record review revealed a progress note by NP dated 10/9/24 that read Resident #19 had a history of Gastrointestinal (GI) bleed. During an interview on 10/23/24 at 11:40am the MDS Nurse stated she received new orders daily and updated the care plan as needed. MDS Nurse stated the nurses would have to look at the care plan to see anticoagulant therapy goals and interventions and it was also located on the Kardex. The MDS nurse stated she normally entered anticoagulant therapy to the care plan under skin to monitor for abnormal bruising. During an interview on 10/23/24 at 12:13pm the NP stated residents on anticoagulants should be monitored for hematuria and bleeding in addition to bruising. NP stated labs would be done admission then up to NP for follow up lab work. During an interview on 10/24/24 at 11:42am Nurse #2 stated residents that received blood thinners were monitored for bruising, signs of bleeding, skin color, and blood work would be monitored. Nurse #2 did not know if it was included in the resident's care plan. Nurse #2 stated if a resident had a history of GI bleed, then the resident's bowel movements would be monitored closely for signs blood. During an interview on 10/23/24 1:54pm the Director of Nursing (DON) stated nurses should know the risk of anticoagulants and monitor for increased signs of bleeding, bruising, blood in urine. DON stated that care plans were completed by the MDS nurse and anticoagulants were normally added under skin unless specifically care planned. During an interview on 10/24/24 at 3:44pm the Administrator stated nurses should know what to monitor for when a resident is on anticoagulant therapy. The Administrator was not aware that anticoagulant therapy was not in the care plan for reviewed residents. The Administrator stated she didn't know that a specific care plan was required for anticoagulant therapy since nurses should know what to monitor. 2) Resident #34 was admitted to the facility on [DATE] with diagnosis that included paroxysmal atrial fibrillation. Record review revealed Resident #34 had an active order dated 6/3/24 for Apixaban (blood thinner) give 1 tablet orally two times a day. Resident #34's care plan dated 6/11/24 did not include goals and interventions for the use of anticoagulant therapy. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #34 was cognitively intact and recieved an anticoagulant during the assesment reference period. A Review of Resident #34's Medication Administration Record (MAR) Apixaban 5mg was administered twice daily 6/3/24 through 10/23/24. During an interview on 10/23/24 at 11:40am the MDS Nurse stated she received new orders daily and updated the care plan as needed. MDS Nurse stated the nurses would have to look at the care plan to see anticoagulant therapy goals and interventions and it was also located on the Kardex. The MDS nurse stated she normally entered anticoagulant therapy to the care plan under skin to monitor for abnormal bruising. During an interview on 10/23/24 at 12:13pm the NP stated residents on anticoagulants should be monitored for hematuria and bleeding in addition to bruising. NP stated labs would be done admission then up to NP for further follow up lab work. During an interview on 10/24/24 at 11:42am Nurse #2 stated residents that received blood thinners were monitored for bruising, signs of bleeding, skin color, and blood work would be monitored. Nurse #2 did not know if it was included in the resident's care plan. During an interview on 10/23/24 1:54pm the Director of Nursing (DON) stated nurses should know the risk of anticoagulants and monitor for increased signs of bleeding, bruising, blood in urine. DON stated that care plans were completed by the MDS nurse and anticoagulants were normally added under skin unless specifically care planned. During an interview on 10/24/24 at 3:44pm the Administrator stated nurses should know what to monitor for when a resident is on anticoagulant therapy. The Administrator was not aware that anticoagulant therapy was not in the care plan for reviewed residents. The Administrator stated she didn't know that a specific care plan was required for anticoagulant therapy since nurses should know what to monitor.

Based on record review, and interviews with staff and the Nurse Practitioner, the facility failed to limit the duration of a psychotropic medication (medication that may affect brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days for 1 of 3 residents reviewed for unnecessary medications (Resident #19). Finding included: Resident #19 was admitted to the facility on [DATE] with diagnosis that included generalized anxiety disorder, unspecified dementia with anxiety, unspecified dementia with mood disturbance. An admission order dated 8/30/2024 for busPIRone HCl (psychotropic medication) oral tablet 5 milligrams (mg) Give 1 tablet by mouth every 24 hours as needed (PRN) for anxiety. The order had no stop date. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #19 was moderately cognitively impaired. The admission MDS indicated Resident #19 was taking an antidepressant, but did not indicate antianxiety medication was being taken. Review of Resident #19's care plan dated 10/3/2024 revealed Resident #19 had been care planned for psychotropic/antipsychotic medication use. The care plan interventions included: -Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness. A review of Resident #19's electronic Medication Administration Record (eMAR) for August, September and October 2024 revealed Resident #19 received no busPIRone HCl in August or September of 2024 and one dose on 10/6/2024. During an interview on 10/23/2024 at 12:13pm the Nurse Practitioner (NP) stated PRN psychotropic/antipsychotic medication orders were to be written for 14 days and then reviewed and rewritten as needed. If a medication was found to be effective after review, the order could be written for a longer, specific number of days. The NP did not know why Resident #19's busPIRone HCL order did not have a 14 day stop date. The NP stated that the resident's admission orders should be reviewed on admission. During an interview with Nurse #1 on 10/24/2024 10:16am Nurse #1 stated PRN psychotropic orders could only be written for a set number of days, not indefinite. An interview was completed with Nurse #2 on 10/24/2024 at 11:42am, Nurse #2 stated PRN psychotropic meds could be written for 14 days, then would be reviewed with the NP to see if a new order was needed. Nurse #2 stated when a resident was admitted a medication reconciliation was completed with the NP, if a psychotropic PRN order did not have a stop date the nurse should let NP know and have the order changed to 14 days of duration. Nurse #2 said the busPIRone HCl order for Resident #19 must have been missed during the medication reconciliation. During an interview on 10/23/2024 at 1:54pm the Director of Nursing (DON) stated PRN psychotropic/antipsychotic medication orders were to be written for 14 days and then reviewed and rewritten as needed. The DON was not aware Resident #19 had a PRN psychotropic order with no stop date. During an interview on 10/24/2024 at 3:44pm the Administrator stated PRN psychotropic/antipsychotic medication orders were to be written for 14 days and then reviewed and rewritten as needed. The Administrator was not aware Resident #19 had a PRN order for busPIRone HCl with no stop date.

Based on record review, observations, staff, Psychiatric Nurse Practitioner, Consulting Pharmacist and Nurse Practitioner interviews the facility failed to notify the Physician and the Psychiatric Nurse Practitioner of Resident #17 ' s sexual behaviors towards two female residents (Resident #52 and Resident #11) on 4/4/2023 when Resident #17 touched the breast of Resident #52 and then grabbed his crotch and asked her if she wanted some of this and later the same day, Resident #17 touched the breast of Resident #11. On 4/10/2023, when Housekeeper #1 observed Resident #17 to put his hand on the leg of a female resident (Resident #11) and moved his hand up her leg towards her vaginal area. This failure to notify the Physician and the Psychiatric Nurse Practitioner placed all residents that resided on the memory impaired unit at high likelihood of suffering serious physical and psychosocial harm enacted by Resident #17. Immediate Jeopardy began on 4/4/2023 when the facility staff failed to notify the Physician and the Psychiatric Nurse Practitioner of Resident #17 ' s sexual behaviors towards two female residents (Resident #52 and Resident #11) thereby placing all Residents on the memory impaired unit at risk for sexual abuse from Resident #17. The immediate jeopardy was removed on 5/19/2023 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems put in place are effective. The findings included: Resident #17 was admitted to the facility on [DATE]. His diagnoses included Alzheimer ' s disease, dementia with moderate mood disturbance and behavioral disturbance. A review of Resident #17 ' s minimum data set (MDS), a quarterly assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and required extensive assistance with activities of daily living (ADL). A nursing progress note dated 4/4/2023 at 6:26 PM by Nurse #1 stated, multiple times this shift had to remove resident (Resident #17) and ask him to stop sexually touching other residents and staff, made offensive comments when redirected, resident inappropriately touched this nurse while administering medications. When asked to stop he made an inappropriate response. An interview was conducted with Nurse #1 on 5/16/2023 at 3:10 PM and a follow-up interview on 5/17/2023 at 11:56 AM. Nurse #1 stated she normally worked 7:00 AM-7:00 PM on the memory impaired unit. She stated she remembered the incident on 4/4/2023 with Resident #17 inappropriately touching two female residents (Resident # 52 and Resident #11) on their breasts. Nurse #1 indicated that there were two separate incidents the first one occurred in the morning of 4/4/2023 with Resident #52 and then the second incident occurred in the afternoon with Resident #11. She had separated the residents and then put a nursing note in the electronic record of Resident #17 and stated she had reported the incidents to the oncoming shift and placed another note on the nursing 24-hour shift report (a report of importance issues that occurred during the shift). Nurse #1 stated she did not notify the Physician, Psychiatric Nurse Practitioner, or the Nurse Practitioner when Resident #17 exhibited sexual behaviors toward two female residents (Resident #52 and Resident #11) because she did not think at the time of the incidents that Resident #17 ' s inappropriate sexual behaviors were considered abuse. A telephone interview was conducted with the Consulting Pharmacist on 5/17/2023 at 8:28 AM. She stated on 4/28/2023 she was at the facility conducting her monthly chart reviews. She revealed that when she reviewed Resident #17 ' s electronic medical record she found a note dated 4/4/2023, written by Nurse #1, that he had some inappropriate sexual behavior. The Consulting Pharmacist stated she went to the Risk Management Nurse on 4/28/2023 and reported what she had observed in Resident #17 ' s electronic medical record and then left and went back to reviewing medical records. She was not aware of what happened after that, she just wanted to make sure that someone from Administration was aware of the note and his behaviors. An interview was conducted with Risk Management Nurse on 5/16/2023 at 3:29 PM. He revealed on 4/28/2023 the Consulting Pharmacist came to him and advised him that she had read a note in Resident #17 ' s electronic medical record where he had displayed some inappropriate behaviors. He stated that he went back to his office and revealed Resident #17 ' s medical record and then called and reported the incident to the Director of Nursing. The Psychiatric Nurse Practitioner saw him on Tuesday, 5/2/2023 and the 1:1 observation was stopped. He revealed that when the Consulting Pharmacist reported to him, he was not aware that the behaviors were sexual, just that he had inappropriate behaviors. He stated that he was not aware that Resident #17 had any sexual behaviors on 4/10/2023, he would have reported the incident to the Director of Nursing. An interview was conducted with the Psychiatric Nurse Practitioner (NP) on 5/16/2023 at 5:10 PM. She stated she was familiar with Resident #17, and she had been seeing him for about 6 months. She revealed when she first started seeing him, he had been calm and cooperative and about 6-8 weeks later he started to become agitated and that turned into him being aggressive towards staff. Psychiatric NP stated that staff try to redirect him when he becomes agitated or aggressive but that did not always work. She revealed that she had been notified about 2 weeks ago that he had been sexual towards a nursing staff member, but today (5/16/2023) was the first time she had been notified that he had sexual behavior towards other residents. Psychiatric NP stated if she had been notified of his sexual behaviors towards female residents, she more than likely would have put interventions into place and would have appreciated being advised of these sexual behaviors, especially the incident with Resident #11, when he put his hand up her dress. She had put a notebook at every nursing station for nursing staff to put messages in for her about residents, their behaviors, or any concerns about a resident. Psychiatric NP stated she was at the facility every Tuesday to see residents. She revealed she was concerned about the other residents on the memory impaired unit being affected by Resident #17 ' s sexual behaviors, they might start having issues, especially if the residents had a history of sexual abuse. She indicated that Resident #17 had a higher level of functioning dementia and that he was able to wait to approach residents when he knew no staff member was watching him. An interview was conducted with the Nurse Practitioner (NP) on 5/17/23 at 10:52 AM. She stated she was familiar with Resident #17 and that he had vascular dementia. To her knowledge he had behaviors of being combative with care and did not have any sexual behaviors before 4/4/2023. NP revealed she was notified on 4/28/2023 about Resident #17 ' s sexual behavior when the Administration found out about the incidents that had occurred on 4/4/2023. She stated he had already been prescribed Ativan and an antidepressant prior to 4/4/2023. NP did go and assess Resident #17 after she was notified of his sexual behaviors and reviewed his medications, she did not make any changes to his medications. She revealed that Resident #17 was already being seen by the Psychiatric NP and she was the one that prescribed any psychiatric medications. She stated the facility was very good about telling her about issues that had occurred with residents, and she had a notebook at every nursing station for staff to report any concerns or issues that they might have about a resident. She did not report the incidents to the Medical Director. A telephone interview was conducted with the Medical Director on 5/16/2023 at 5:39 PM. The Medical Director revealed he was familiar with Resident #17. He stated he was not aware of any sexual behavior for Resident #17. He indicated that staff would normally contact the NP first for any issues and then if the NP needed help, she would contact him for advice. He revealed that when he came to the facility on Friday, 5/19/2023, he would assess Resident #17, but as far as any medications are concerned, he would review it and see if medication was appropriate for his behaviors, such as hormone-based medications. He revealed he had no concerns about how the facility conducted investigations or how the staff reported issues to him or the NP. An interview was conducted with the Director of Nursing (DON) on 5/17/2023 at 3:50 PM. The DON revealed she was familiar with Resident #17, Resident #52, and Resident #11 and all were cognitively impaired. She stated she was notified about Resident #17 touching female residents by the Risk Management Nurse on 4/28/2023 after he had reviewed a note in Resident #17 ' s nursing notes. The DON stated she and Nurse #1 discussed why it was not ok for him to touch female residents, she gave re-education on abuse, what was abuse, and that it did not matter if the residents involved had dementia, who to report to and when to report. All staff had been re-educated on abuse, types of abuse, when and who to report abuse too after the incidents. DON revealed she was not aware of a sexual behavior that occurred on 4/10/2023 between Resident #17 and Resident #11 and if it had occurred the incident should have been reported to administration at that time so an investigation could have been initiated. DON stated all staff received abuse training on hire, annually and anytime an incident occurred, and they are going to increase the training to quarterly after these incidents. She indicated that the Psychiatric Nurse Practitioner and Nurse Practitioner should have been notified by Nurse #1. The DON stated that part of the re-education was for staff to notify the medical provider as soon as possible after any sexual behavior occurred. An interview was conducted with the Administrator on 5/17/2023 at 4:21 PM. She revealed she was notified of Resident #17 ' s sexual behaviors after the pharmacy consultant read about it in the chart and the pharmacist reported to the Risk Management Nurse on 4/28/2023. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. The Nurse Practitioner was notified the next time she came into the facility, on 5/1/2023, and she was at the facility on Mondays, Wednesdays, and Fridays. She stated the Psychiatric Nurse Practitioner was notified about the sexual behaviors of Resident #17 was on 5/16/2023 and indicated that she was not aware why she was not notified on 4/28/2023 when the facility was made aware of Resident #17 ' s sexual behaviors. She was not sure if the NP saw Resident #17 on the day she was notified, and she did not personally notify the Medical Director. The Administrator revealed that when Nurse #1 was initially interviewed on 4/28/2023, she did not think the sexual behavior was abuse, since the residents were demented, but she now understands after extensive training that the sexual behaviors were abusive. The families of Resident #17, Resident #52, and Resident #11 were notified of the sexual behaviors, and they did not have concerns. The Administrator was notified of immediate jeopardy on 5/17/2023 at 4:40 PM. The facility provided the following immediate jeopardy removal plan on 5/23/2023: On 4/4/23, the facility failed to notify the Psychiatric Nurse Practitioner when Resident #17 was observed touching Resident #11 and Resident #52 in a sexual manner as reported by Nurse #1. On 4/10/23, the facility failed to notify the Psychiatric Nurse Practitioner when Resident #17 was observed touching Resident #52 in a sexual manner as reported by the unit housekeeper. Both Resident #11 and Resident #52 were/are at risk of suffering from the deficient practice. All residents on the same unit (secure memory care unit) are also at risk from suffering from deficient practice. Between 4/28/23 - 5/2/23, all staff working on the secure memory care unit completed a written questionnaire provided by the Administrator to determine if any other resident on the secure memory care unit may have been affected and if they had observed and not reported any behaviors of a sexual nature including inappropriate touching exhibited by Resident #17. No concerns with any other residents were reported by any staff. A message was sent via Voice Friend (direct messenger) to all staff on 5/18/23 at 9:51am to determine if there have been any other instances that were not previously identified as resident abuse and not reported to the Psychiatric NP. This message instructed staff to immediately contact the Administrator via phone upon receipt with no concerns reported. The Psychiatric Nurse Practitioner was notified that Resident #17 was observed touching Resident #11 and Resident #52 in a sexual manner on 5/2/23 in which she assessed Resident #17 in person at that time with a medication adjustment. The Psychiatric Nurse Practitioner has since seen Resident #17 twice in person on 5/9/23 and 5/16/23 for continued monitoring of any concerns related to inappropriate sexual behaviors towards others. The Psychiatric NP reviewed the medication regimen for Resident #17 on 5/16/23 and made a change in an ordered medication related to inappropriate sexual behaviors. Between 5/17/23 @ 6:30pm and 5/18/23 @ 5:00pm, the Staff Development Coordinator and Director of Human Resources provided staff with education on timely/appropriate notification to the Physician and/or Psychiatric Nurse Practitioner. This training specifically included the need to report sexual abuse to the Physician and/or Psychiatric Nurse Practitioner immediately. No current staff member will be allowed to work prior to receiving this education from the Staff Development Coordinator. This education will also be included in the new hire orientation training provided by the Director of Human Resources who will be responsible for ensuring this abuse education is completed with all staff (including agency staff if used) during initial orientation and prior to starting their first shift. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. Alleged IJ removal date is 5/19/23 On 5/23/2023, Resident #17 was observed on 1:1 observation and the facility credible allegation for immediate jeopardy removal of 5/19/2023 was verified through on-site verification. Staff interviews revealed they had received education and training on resident abuse. This information included immediately reporting any sexual behavior to the Supervisor, Physician and Psychiatric Nurse Practitioner. The facility ' s immediate jeopardy removal plan was validated to be completed as of 5/19/2023.

Based on record review, observation and interviews with staff, Consulting Pharmacist, Nurse Practitioner, Medical Director and the Psychiatric Nurse Practitioner (NP), the facility failed to protect the right of two severely cognitively impaired residents (Resident #52 and Resident #11) to be free of sexual abuse from Resident #17. Nurse #1 observed Resident #17 touch Resident #52 on the breast and then grab his crotch area and asked Resident #52, Do you want some of this? Nurse #1 also observed Resident #17 touch Resident #11 ' s breast. Housekeeper #1 observed Resident #17 put his hand up Resident #11 ' s dress. The Surveyor observed Resident #17 offering a female resident pudding and telling her to lick it and then roll by another female resident and make kissy faces at the resident. Staff admitted that they did not regard the above incidences as abuse because all the residents had cognitive impairment. Resident #52 and Resident #11 ' s cognitive impairment prevented them from expressing an adverse outcome. A reasonable person would have been traumatized by being sexually abused by another resident in their home environment. The deficient practice affected 2 of 3 residents reviewed for abuse and put other residents on the unit at risk for abuse by Resident #17. Immediate Jeopardy began on 4/4/2023 when Nurse #1 observed Resident #17 sexually abuse Resident #52. The Immediate Jeopardy was removed on 5/19/2023 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #17 was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, dementia with moderate mood disturbance and behavioral disturbance. Resident #17's Minimum Data Set (ADL) quarterly assessment dated [DATE] revealed he was severely cognitively impaired and required and required extensive assistance with activities of daily living (ADL). He used a wheelchair to propel around the memory impaired unit. He was coded for moods (anxiety), behaviors (combative with care) and wandering. Resident #17's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and required extensive assistance with activities of daily living (ADL). He used a wheelchair to propel around the memory impaired unit. He was coded for moods, behaviors and wandering. Resident #52 was admitted to the facility on [DATE]. Her diagnoses included vascular dementia with mood disturbance and behavioral disturbance. Resident #52's MDS, a quarterly assessment, dated 3/13/2023 revealed Resident #52 was severely cognitively impaired and required extensive assistance for ADL. Resident #52's care plan dated 7/20/2022 revealed a care plan in place for: Behaviors of being combative, verbally abusive, and socially inappropriate. She refused care at times. Resident # 11 was admitted to the facility on [DATE]. Her diagnoses included vascular dementia with mood and behavioral disturbance, pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder) and emotional lability (rapid, often exaggerated changes in mood, where strong emotions or feelings such as uncontrollable laughing or crying or heightened irritability or temper occur). Resident #11's MDS annual assessment, dated 2/17/2023 revealed Resident #11 was severely cognitively impaired and required extensive assistance with ADL. Resident #11 ' s care plan revealed a plan in place for: Behaviors of being combative, socially inappropriate, refused care and wandered. A nursing progress note dated 4/4/2023 at 6:26 PM by Nurse #1 stated, multiple times this shift had to remove resident (Resident #17) and ask him to stop sexually touching other residents and staff, made offensive comments when redirected, resident inappropriately touched this nurse while administering medications. When asked to stop he made an inappropriate response. An interview was conducted with Nurse #1 on 5/16/2023 at 3:10 PM and a follow-up interview on 5/17/2023 at 11:56 AM. Nurse #1 stated she normally worked 7:00 AM-7:00 PM on the memory impaired unit. She stated she remembered the incident on 4/4/2023 when Resident #17 inappropriately touched two female residents (Resident #52 and Resident #11) on their breasts. She indicated that there were two separate incidents. The first one occurred in the morning of 4/4/2023 with Resident #52 and then the second incident occurred in the afternoon with Resident #11 in the afternoon of 4/4/2023. She separated the residents and then put a nursing note in the electronic record of Resident #17 and stated she had reported the incidents to the oncoming shift and placed another note on the nursing 24-hour report. Nurse #1 stated she did not initially report the incidents to the Administrator because she did not feel the incidents were considered abuse since all three of the residents involved were not cognitively intact. Nurse #1 revealed she did report the incidents to the Director of Nursing on 4/28/2023 after the Risk Management Nurse came to her and asked her about the nursing entry on 4/4/2023. The Risk Management Nurse told her that he had read the note in the chart. She stated on 4/4/2023 she had observed Resident #17 approach Resident #52 touch Resident #52 on her breasts, through her clothes, and then he reached down and grabbed his crotch and said to Resident #52, Do you want some of this? Resident #52 laughed when she separated them. She stated that later in the afternoon of 4/4/2023 she observed Resident #17 touch Resident #11 ' s breasts through her clothes. Resident #11 did not respond. She separated the residents. Nurse #1 stated she did not notice if Resident #17 had an erection when he was touching the female residents. She revealed he had a penile pump, and his penis pump would need to be pumped up by the resident for it to be erect. Nurse #1 stated she kept Resident #17 separated from the female residents on the memory impaired unit on 4/4/2023. She indicated that when the Risk Management Nurse approached her on 4/28/2023, he asked her what had happened. Nurse #1 stated she received re-education after the incident on abuse, what types of abuse and that included sexual abuse, intervention, when and whom to report the incident. Nurse #1 stated at the time of the incidents on 4/4/2023 she did not feel like the incidents were abusive, but after she received re-education, she realized that the incidents were abusive. She stated Resident #17 was placed on 1:1 observation on 4/28/2023. Nurse #1 revealed she did not remember Housekeeper #1 telling her about Resident #17 touching Resident #11 ' s leg, with his hand up her dress moving toward her vaginal area. She indicated that if the Housekeeper #1 stated she had told Nurse #1 then it had to be true. An interview was conducted with Housekeeper #1 on 5/16/2023 at 2:24 PM with a follow-up interview on 5/17/2023 at 12:38 PM. She indicated she knew Resident #17 as she was normally assigned to clean the memory impaired unit. She stated she observed Resident #17 approach Resident #11 on 4/10/2023 where she observed him put his hand up Resident #11 ' s dress with his hand moving up toward Resident #11 ' s vaginal area. Resident # 17 was at this point sitting right next to Resident #11. She stated that Resident #11 did not react, and she separated them. She stated she placed Resident #17 close to the activity room. Housekeeper #1 stated the incident happened in the morning. She revealed she reported immediately to Nurse #1 what she had witnessed and that she had separated the residents. Nurse #1 advised her to and watch Resident #17 to make sure he didn ' t touch anyone or try to put his hand up anyone ' s dress. She stated she did not notice if Resident #17 had an erection when he was touching Resident #11. Housekeeper #1 stated that before the incident on 4/10/2023 she was not aware Resident #17 had any sexual behaviors. She added Resident #17 was placed on 1:1 observation for a couple of days on 4/28/2023. An interview was conducted with the Risk Management Nurse on 5/16/2023 at 3:29 PM. He revealed on 4/28/2023 the Consulting Pharmacist came to him and advised him that she had read a note in Resident #17 ' s electronic medical record where he had displayed some inappropriate behavior. He stated that he went back to his office and reviewed Resident #17 ' s medial record and then called and reported the incident to the Director of Nursing. He stated that staff re-education on abuse started on 4/28/2023 and Resident #17 was placed on 1:1 observation for the rest of the weekend. The Psychiatric Nurse Practitioner saw him Tuesday, 5/2/2023 and the 1:1 observation was stopped. A telephone interview was conducted with the Consulting Pharmacist on 5/17/2023 at 8:28 AM. She stated on 4/28/2023 she was at the facility conducting her monthly chart reviews. She revealed that when she reviewed Resident #17 ' s electronic medical record she found a note dated 4/4/2023, written by Nurse #1, that he had some inappropriate sexual behaviors. The Consulting Pharmacist stated she went to the Risk Management Nurse on 4/28/2023 and reported what she had observed in Resident #17 ' s electronic medical record and then left and went back to reviewing medical records. She was not aware of what happened after that, she just wanted to make sure that someone from Administration was aware of the note and his behaviors. The MDS Nurse updated Resident #17 ' s care plan on 4/28/2023 by the MDS Nurse. It stated Resident exhibited inappropriate sexual behaviors toward female residents. Interventions included monitor and document target behaviors, elicit family input for best approaches to resident, do not argue with resident, administer behavior medications as ordered by physician, staff monitoring will be increased, do not place near female resident unless direct supervision, follow up with Psychiatric Nurse Practitioner, keep occupied with activities as tolerated. On 5/2/2023, Divalproex Delayed Release (DR) (an antiepileptic drug used to treat manic episodes) 125 milligrams (mg) was ordered. Resident #17 was to take two by mouth twice a day. Divalproex DR 125 mg give one a day at 2 PM was also ordered. On 5/10/2023, Lorazepam (a benzodiazepine used to treat anxiety) was ordered to be given 0.5 mg by mouth twice a day for 14 days. The order was to be discontinued on 5/23/2023. A telephone interview was conducted with Nurse Aide (NA) #5 on 5/16/2023 at 9:41 PM. She stated she normally was assigned to the memory impaired unit. She revealed she was familiar with Resident #17, Resident #52, and Resident #11 and were not able to voice their needs or concerns to staff. NA #5 stated she had witnessed Resident #17 hitting staff when they tried to do personal care or toilet him in the shower room, he would become agitated when he had incontinence care or changing his clothes. She stated she witnessed Resident #17 touch a female resident ' s knee, and she separated them. She did not remember the date that happened, and she did report it to her nurse, but could not remember which nurse she reported the incident. NA #5 stated Resident #17 had touched Resident #11 ' s knee multiple times. She stated she had been re-educated on abuse, types of abuse, separate the residents and then report to her nurse, the nurse would then report to the Director of Nursing or Administrator. A telephone interview was conducted with NA #6 on 5/17/2023 at 11:00 AM. NA #6 stated she was normally assigned to work the memory impaired unit on 7PM-7AM. She revealed she was familiar with Resident #17, Resident #52, and Resident #11. NA #6 stated Resident #17 had behaviors of being combative with care, she had not witnessed any sexual behaviors. NA #6 revealed she had witnessed Resident #17 touch a female resident ' s hand or leg. She did not feel like Resident #17 meant anything by it. She stated that Resident #17 did not know what he was doing because he had dementia. She had been re-educated on abuse, types of abuse, how to intervene if you witness abuse of any kind, who and when to report abuse too. She stated she would report any inappropriate behaviors of any kind to her nurse, and the nurse would report to the Director of Nursing or Administrator. An interview was conducted with NA #1 on 5/16/2023 at 2:52 PM. She stated she was familiar with Resident #17, Resident #52, and Resident #11. She revealed she normally worked the memory impaired unit on 7AM-7PM shift. NA #1 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1, she did remember when Nurse #1 told her, and that he was not allowed to be around any female residents, and he could not be too close to female residents. She stated she did not know how close too close was. She stated she had not had to redirect Resident #17, but she had only been employed at the facility for a month. NA #1 stated she had received abuse training when she was hired, the training included what types of abuse there was, when to report abuse, who to report abuse too. She stated she was trained to report any abusive incidents she observed or heard about to her Nurse immediately and the Nurse would then report to the Administrator. An interview was conducted with NA #2 on 5/16/2023 at 3:04 PM. She stated she normally worked the memory impaired unit from 7AM-7PM. She revealed she was familiar with Resident #17, Resident #52, and Resident #11. NA #2 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1 but could not remember when Nurse #1 told her. She revealed she was told that the incident happened 2-3 weeks ago and that she really did not understand the whole situation. She was told he had sexual behaviors and he was not allowed to be around female residents. She stated staff were supposed to redirect him. NA #2 stated that prior to the incident on 4/4/2023, Resident #17 did not have any sexual behaviors before that, He was flirtatious and would [NAME] at you. She was not aware of any further incidents. NA #2 revealed she was not sure if Resident #17 was supposed to be kept away from female residents currently. She stated she received re-education on abuse, types of abuse, intervention, who and when to report abuse too, and if she heard or witnessed any resident being mistreated in any way, she would intervene and make sure the resident was safe and then report to her Nurse. An interview was conducted with NA #3 on 5/17/2023 at 10:40 AM. NA #3 stated she was familiar with Resident #17, Resident #52, and Resident #11. NA #3 normally worked the memory impaired unit. She stated that Resident #17 did cuss at staff and yell. She had never witnessed him having sexual behaviors but had heard other staff talk about it, but it was about Resident #17 grabbing a staff member in a sexual manner, she stated she had not heard of him touching any female residents. NA #3 stated she was told by the Nurses on the memory impaired unit that he was supposed to be separated from female residents and to monitor him for touching female residents. Resident #17 was allowed to sit at the table with female residents, but he had to be separated from female residents at the table. NA #3 stated she had heard that Resident #17 had grabbed a resident ' s leg ( she did not know which resident) but did not feel he was sexual. She stated she had been told to just keep an eye on him. She had received re-education on abuse, types of abuse, how, when and whom to report to. NA #3 indicated if she witnessed or heard of any abuse or mistreatment of a resident, she would separate the residents, then report to the Nurse. A telephone interview was conducted with NA #4 on 5/16/2023 at 9:37 PM. She stated she normally worked the memory impaired unit. She stated she was familiar with Resident #17, Resident #52, and Resident #11 and all 3 of them were cognitively impaired. NA #4 revealed she had observed Resident #17 have behaviors of punching staff with his fists during personal care and kicking staff in the chest with his feet, she could not remember dates. She stated she had not witnessed him having any sexual behaviors. She stated that she had heard of his inappropriate sexual behaviors but had not personally witnessed these behaviors. NA #4 indicated she had received abuse re-education and if he witnessed or heard of anyone mistreating any resident, she would report immediately to her nurse. An interview was conducted with the Psychiatric Nurse Practitioner (NP) on 5/16/2023 at 5:10 PM. She stated she was familiar with Resident #17, and she had been seeing him for about six months. She revealed when she first started seeing him, he had been calm and cooperative and about 6-8 weeks later he started to become agitated and that turned into him being aggressive towards staff. Psychiatric NP stated that staff try to redirect him when he became agitated or aggressive but that did not always work. She revealed that she had been notified about 2 weeks ago that he had been sexual towards a nursing staff member, but today (5/16/2023) was the first time she had been notified that he had sexual behaviors towards other residents. Psychiatric NP stated if she had been notified of his sexual behaviors towards female residents, she more than likely would have put interventions into place and would have appreciated being advised of these sexual behaviors, especially the incident with Resident #11, when he put his hand up her dress. She had put a notebook at every nursing station for nursing staff to put messages in for her about residents, their behaviors, or any concerns about a resident. Psychiatric NP stated she was at the facility every Tuesday to see residents. She revealed she was concerned about the other residents on the memory impaired unit being affected by Resident #17 ' s sexual behaviors, they might start having issues, especially if the residents had a history of Post-Traumatic Stress Disorder (PTSD). Psychiatric NP revealed she felt like there was a lack of education, lack of training and lack of activities at the facility. She indicated that Resident #17 had a higher level of functioning dementia and that he was able to wait to approach residents when he knew no staff member was watching him. An interview was conducted with the Nurse Practitioner (NP) on 5/17/23 at 10:52 AM. She stated she was familiar with Resident #17 and that he had vascular dementia. To her knowledge he had behaviors of being combative with care and did not have any sexual behaviors before 4/4/2023. NP revealed she was notified on 4/28/2023 about Resident #17 ' s sexual behavior when the facility found out about the incidents that had occurred on 4/4/2023. She stated he had already been prescribed Ativan and an antidepressant prior to 4/4/2023. The NP did go and assess Resident #17 after she was notified of his sexual behaviors and reviewed his medications. She did not make any changes to his medications. She revealed that Resident #17 was already being seen by the Psychiatric NP and she was the one that prescribed any psychiatric medications. She stated the facility was very good at telling her about issues that had occurred with residents, and she had a notebook at every nursing station for staff to report any concerns or issues that they might have about a resident. A telephone interview was conducted with the Medical Director on 5/16/2023 at 5:39 PM. The Medical Director revealed he was familiar with Resident #17. He stated he was not aware of any sexual behaviors for Resident #17. He indicated that staff would normally contact the NP first for any issues and then if the NP needed help, she would contact him for advice. He revealed that when he came to the facility on Friday, 5/19/2023, he would assess Resident #17, but as far as any medications are concerned, he would review it and see if medication was appropriate for his behaviors, such as hormone-based medications. Observations conducted on the memory impaired unit on 5/15/2023 at 12:27 PM revealed Resident #17 was at the dining room table sitting next to Resident #11 with one other resident in between them. Staff were observed bringing residents in and out of the dining room. No one was directly supervising Resident #17. On 5/16/2023 at 2:27 PM, Resident #17 was observed in the activity room on the memory impaired unit. He was sitting in his wheelchair approximately 1.5 feet apart from Resident #11. There was no staff in the activity room. There was a total of seven residents in the activity room to include Resident #17 and Resident #11. Resident #52 was not in the activity room but was observed sitting in her chair outside of her room, looking out a window. At 3:50 PM Resident #17 was observed sitting beside a female resident with no staff supervision. Nurse #1 came around the corner and observed Resident #17 trying to give the female resident pudding and telling her to lick it. Nurse #1 went and the female resident her own pudding. Nurse #1 was back and forth multiple times helping the NAs with care. Resident #17 left the female resident with the pudding. Next, he rolled by another female resident and made kissy faces and tried to touch the resident ' s foot and leg. Nurse #1 observed the incident and moved Resident #17 into the activity room and left the residents with no supervision. NA #1 came into the activity room and removed Resident #17 and took him to his room, he came right back out of his room and continued to roll around the memory impaired unit unsupervised. The Director of Nursing was notified and placed Resident #17 on 1:1 observation. An interview was conducted with the Director of Nursing (DON) on 5/17/2023 at 3:50 PM. The DON revealed she was familiar with Resident #17, Resident #52, and Resident #11 and all were cognitively impaired. She stated she was notified about Resident #17 touching female residents by the Risk Management Nurse on 4/28/2023 after he had reviewed a note in Resident #17 ' s nursing notes. She stated Resident #17 was placed on 1:1 observation. The DON stated she and Nurse #1 discussed why it was not ok for him to touch female residents, she gave re-education on abuse, what was abuse and that it did not matter if the residents involved had dementia. She stated that the goal for Resident #17 was that the sexual incidents did not reoccur, and that resident safety was ensured. Nurse #1 stated she understood. On 5/16/2023, Nurse #1 advised the DON that she had not observed Resident #17 make kissy faces at female residents on the memory impaired unit, after she had been advised by the DON that the behavior had been witnessed. Resident #17 was placed on 1:1 observation at 4:30 PM on 5/16/2023 and remained on 1:1 currently. All staff had been re-educated on abuse, types of abuse, when and who to report abuse to after the incidents. DON revealed she was not aware of a sexual behavior that occurred on 4/10/2023 between Resident #17 and Resident #11. DON stated all staff received abuse training on hire, annually and anytime an incident occurred. The training on hire reviewed the abuse policy and that included resident to resident abuse. An interview was conducted with the Administrator on 5/17/2023 at 4:21 PM. She revealed she was notified of Resident #17 ' s sexual behaviors after the pharmacy consultant read about it in the chart and the pharmacist reported to the Risk Management Nurse on 4/28/2023. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. The Nurse Practitioner was notified the next time she came into the facility, and she was at the facility on Mondays, Wednesdays, and Fridays. She was not sure if the NP saw Resident #17 on the day she was notified, and she did not personally notify the Medical Director. The Administrator revealed that when Nurse #1 was initially interviewed on 4/28/2023, she did not think the sexual behavior was abuse, since the residents were demented, but she now understands after extensive training that the sexual behaviors were abusive. The Administrator was notified of immediate jeopardy on 5/17/2023 at 4:40 PM. The facility provided the following immediate jeopardy removal plan on 5/23/2023: Between 4/28/23 - 5/2/23, all staff working on the secure memory care unit completed a written questionnaire provided by the Administrator to determine if any other resident on the secure memory care unit may have been affected and if they had observed and not reported any behaviors of a sexual nature including inappropriate touching exhibited by Resident #17. No concerns with any other residents were reported by any staff. Because there are no residents on the secure memory care unit with a Brief Interview of Mental Status (BIMS) of 10 or above who can report any concerns related to unwanted touching or any other interaction of a sexual nature, a thorough skin assessment was completed of all residents currently residing on the secure memory care unit by the DON, SDC, and memory care unit nurse on 5/17/2023 to determine if they have experienced any other interaction of a sexual nature. No concerns were found. A message was sent via Voice Friend (direct messenger) to all staff on 5/18/2023 at 9:51 AM to determine if there have been any other instances that were not previously identified as resident abuse and not reported to administration and/or law enforcement. This message instructed staff to immediately contact the Administrator via phone upon receipt with no concerns reported. Resident #17 was placed on 1:1 direct monitoring 24 hours/day with staff to be specifically assigned/scheduled by the Nursing Scheduler who was educated about the 1:1 requirement by the Director of Nursing on 5/16/2023 @ 4:25 PM. This 1:1 began at 4:30pm on 5/16/23 which will continue indefinitely as this resident is long-term care with no current plans for discharge. The Psychiatric NP reviewed the medication regimen for Resident #17 on 5/16/23 and made a change in an ordered medication related to inappropriate sexual behaviors. The Psychiatric NP will continue to monitor the resident in person on a weekly basis for any continued concerns related to inappropriate sexual behaviors and medication management unless otherwise needed via phone for any immediate concern as contacted by the unit nurse. Between 5/17/23 @ 6:30pm and 5/18/23 @ 5:00pm, the Staff Development Coordinator and Director of Human Resources provided all staff with a re-education on the definition of sexual abuse as well as the zero-tolerance policy for any type of resident abuse by any person. No current staff member will be allowed to work prior to receiving this education from the Staff Development Coordinator. This education will also be included in the new hire orientation training provided by the Director of Nursing (as trained by the Staff Development Coordinator on 5/17/23 at 7pm), who will be responsible for ensuring this abuse education is completed with all staff (including agency staff if used) during initial orientation and prior to starting their first shift. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. Alleged IJ removal date is 5/19/23 On 5/23/2023, the facility credible allegation for immediate jeopardy removal of 5/19/2023 was verified through on-site visit. Staff interviews revealed they had received education and training on resident abuse. This information included the facility ' s policy for prevention of abuse and neglect, how to provide care to residents with dementia and impaired cognition, what resident abuse and neglect (sexual) looks like, and the importance of reporting immediately. Interviews confirmed staff were educated on how to identify sexual abuse and intervene for resident safety and to report immediately to their supervisor. 1:1 observation documentation was verified and observed. The facility's immediate jeopardy removal plan was validated to be completed as of 5/19/2023.

Based on record review, observations, staff, Psychiatric Nurse Practitioner, and Consulting Pharmacist interviews the facility failed to follow their abuse policy and procedure in the area of protection, identification, and reporting when they failed to implement measures to ensure residents were protected from Resident #17 who had sexual behaviors that included being observed on 4/4/2023, Resident #17 touch two female residents (Resident #52 and Resident #11) on their breasts and asked one of them, Do you want some of this? On 4/10/2023 Resident #17 was observed by Housekeeper #1 to put his hand on the leg of a female resident (Resident #11) and moved his hand up her leg towards her vaginal area. This failure placed all residents that resided on the memory impaired unit at high likelihood of suffering serious physical and psychosocial harm enacted by Resident #17. Immediate Jeopardy began on 4/4/2023 when the facility failed to implement measures to ensure staff were able to identify sexual abuse and protect all residents on the memory impaired unit from sexual abuse from Resident #17. The immediate jeopardy was removed on 5/19/2023 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems put into place are effective. The findings included: A review of the facility policy and procedure titled Abuse, Neglect and Exploitation with a date of 6/6/2019 and a revision date of 11/18/2022 read in part, Every resident has the right to be free from all forms of abuse, neglect, misappropriate of property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat medical symptoms. Residents have the right to be free from mistreatment and neglect. Sexual Abuse is any non-consensual sexual contact (kissing on the mouth or touching in the bathing suit areas) with a resident and includes but is not limited to sexual harassment, sexual coercion, or sexual assault. This includes residents who are cognitively unable to give consent or who are sedated/unconscious. On page two, under examples of sexual contact: Required to report: Unwanted touching of the breasts or perineal area and other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident. Page six, paragraph 2: Crime: Sexual abuse-this would include any inappropriate touching in which the other person does not give consent for. Page 11, topic 5, Protection: Ensuring the safety, security, and support of our vulnerable population is of the upmost importance to the facility and procedures are in place to ensure the protection of the resident (s) during any investigation of abuse, neglect, or exploitation, which includes the following steps IN ORDER AS WRITTEN: Immediate removal of the resident from the suspected abusive situation by the very first staff member who witnesses or believes abuse and/or neglect has occurred. Immediate removal of the alleged perpetrator: -another resident who is being accused will be removed from the situation and placed on 1:1 with a staff member pending results of the investigation **Law Enforcement will be involved if necessary for immediate removal of any alleged perpetrator when there is emergent danger to other residents, visitors, or other employees** Page 11, topic 6, Investigation: Once the resident is safe and protected from any concerns of alleged abuse, neglect of exploitation, the following steps will occur IN ORDER AS WRITTEN (note that it is expected that these steps take place immediately following protection of the resident and often simultaneously due to required time frames for reporting and investigating): Immediate verbal reporting of suspicions, observations, or concerns of abuse and or neglect will be made by the very first staff member who witnesses or believes abuse and/or neglect has occurred to the direct supervisor on duty or any other member of management who is present-if no immediate supervisor or member of management is present-the nurse on the unit for that resident must be notified. Immediate verbal reporting of the situation that has occurred as it was initially reported as well as all actions taken to protect the resident will be made by the direct supervisor on duty or any other member of management including the unit nurse made initially aware of the situation to the Director of Nursing. **note-this identification is to occur on a 24/7/365 basis and will not be done via written note, email, or text- it MUST be regardless of the time of day or night. The Director of Nursing on receiving the verbal report will verbally notify the Administrator of all actions taken above as well as any immediate needs for assistance in the pending investigation. Page 12, topic 7, Reporting/Response: Once all steps have been taken to immediately protect the resident and to begin the initial investigation process, the Director of Nursing or his/her designee will be responsible for completing all reporting and response actions as follows: An allegation allegations of abuse, neglect, exploitation, or including injuries of unknown origin and the misappropriation of resident property to the NC Division of Health and Human Services Health Care Registry immediately but not later than: 2 hours after the allegation is made if the events that cause the allegation involve abused, result in serious injury, or are related to a reasonable suspicion of a crime. Notify Law Enforcement via phone within (2) hours if there is serious bodily injury or within (24) hours if no serious bodily injury for any reasonable suspicion of a crime. A review of the facility reported incident revealed the facility conducted an investigation that was initiated on 4/28/2023, for sexual behaviors from Resident #17 towards two female residents (Resident #52 and Resident #11) on 4/4/2023. The facility determined that none of the residents involved in the incidents on 4/4/2023 were able to be interviewed due to their impaired cognition. The Consultant Pharmacist found a note written by Nurse #1 on 4/4/2023 when she was reviewing Resident #17 ' s medical record of the incidents of sexual behaviors that occurred on 4/4/2023, she reported on 4/28/2023 the incidents to the Risk Management Nurse. The residents were assessed on 4/28/2023 for injuries and none were identified. Nurse #1 was suspended pending outcome of the investigation on 5/2/2023. Staff statements were obtained. Resident #17 was placed on 1:1 observation from 4/28/2023 through 5/2/2023 and then he was placed on every 30-minute observation until 5/5/2023. Adult Protective Services was notified, Police were not notified. All staff were re-educated on abuse on 4/28/2023, 4/29/2023, 4./30/2023 and 5/1/2023. The 24-hour report was faxed to DHSR (Division of Health Service Regulation) on 4/28/2023 by the Risk Management Nurse and the 5-day investigative report was faxed to DHSR on 5/2/2023. Resident #17 was admitted to the facility on [DATE]. His diagnoses included Alzheimer ' s disease, dementia with moderate mood disturbance and behavioral disturbance. A review of Resident #17 ' s minimum data set (MDS), a quarterly assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and required extensive assistance with activities of daily living (ADL). A review of Resident #17 ' s care plan revealed a care plan for: Resident exhibited inappropriate sexual behaviors toward female residents. Initiated on 4/28/2023. Interventions included monitor and document target behaviors, elicit family input for best approaches to resident, do not argue with resident, administer behavior medications as ordered by physician, staff monitoring will be increased, do not place near female resident unless direct supervision, follow up with Psychiatric Nurse Practitioner, keep occupied with activities as tolerated. A nursing progress note dated 4/4/2023 at 6:26 PM by Nurse #1 stated, multiple times this shift had to remove resident (Resident #17) and ask him to stop sexually touching other residents and staff, made offensive comments when redirected, resident inappropriately touched this nurse while administering medications. When asked to stop he made an inappropriate response. An interview was conducted with Nurse #1 on 5/16/2023 at 3:10 PM and a follow-up interview on 5/17/2023 at 11:56 AM. Nurse #1 stated she normally worked 7:00 AM-7:00 PM on the memory impaired unit. She stated she remembered the incident on 4/4/2023 with Resident #17 inappropriately touching two female residents (Resident # 52 and Resident #11) on their breasts. She indicated that there were two separate incidents the first one occurred in the morning of 4/4/2023 with Resident #52 and then the second incident occurred in the afternoon with Resident #11. She had separated the residents and then put a nursing note in the electronic record of Resident #17 and stated she had reported the incidents to the oncoming shift and placed another note on the nursing 24-hour shift report (a report of importance issues that occurred during the shift). Nurse #1 stated she did not initially report the incidents to the Administrator because she did not feel the incidents were considered abuse since all 3 of the residents involved were not cognitively intact. Nurse #1 revealed she did report the incidents to the Director of Nursing on 4/28/2023 after the Risk Management Nurse came to her and asked her about her nursing entry on 4/4/2023. The Risk Management Nurse told her he had read the note in the chart. She stated on 4/4/2023 she had observed Resident #17 approach Resident #52, touch Resident #52 on her breasts, through her clothes, and then he reached down and grabbed his crotch and said to Resident #52 Do you want some of this? Resident #52 laughed when she separated them. She stated that later in the afternoon of 4/4/2023 she observed Resident #17 touching Resident #11 ' s breasts through her clothes. Resident #11 did not respond. She separated the residents. Nurse #1 stated she did not notice if Resident #17 had an erection when he was touching the female residents, she revealed he had a penile pump, and his penis pump would need to be pumped up by the resident for it to be erect. Nurse #1 stated she kept Resident #17 separated from female residents on the memory impaired unit. She indicated that when the Risk Management Nurse approached her on 4/28/2023, he asked her what had happened, and then an investigation was started by the Administration. Nurse #1 stated she received re-education after the incident on abuse, what types of abuse and that included sexual abuse, intervention, when and whom to report the incident. Nurse #1 stated at the time of the incidents on 4/4/2023 she did not feel like the incidents were abusive, but after she received re-education, she realized that the incidents were abusive, and she should have reported the incidents to the Administrator immediately. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. Nurse #1 revealed that she worked on the memory impaired unit on 5/1/2023 and was called into the office to speak to the Director of Nursing and Human Resource Director and was asked to provide a written statement and then was suspended for 3 days. Nurse #1 indicated she should have reported immediately to the Administrator and that it was her mistake that she did not report immediately. Nurse #1 revealed she did not remember Housekeeper #1 telling her about Resident #17 touching Resident #11 ' s leg, with his hand up her dress moving toward her vaginal area. She indicated that if the Housekeeper #1 stated she had told Nurse #1 then it had to be true. An interview was conducted with Housekeeper #1 on 5/16/2023 at 2:24 PM with a follow-up interview on 5/17/2023 at 12:38 PM. She indicated she knew Resident #17 as she was normally assigned to clean the memory impaired unit. She stated she observed Resident #17 approach Resident #11 on 4/10/2023 where she observed him put his hand up Resident #11 ' s dress with his hand moving up towards Resident #11 ' s vaginal area. She stated that Resident #11 did not react, and she separated them. She stated she placed Resident #17 close to the activity room. Housekeeper #1 stated the incident happened in the morning. She revealed she reported immediately to Nurse #1 what she had witnessed and that she had separated the residents. Nurse #1 advised her to watch Resident #17 to make sure he didn ' t touch anyone or try to put his hand up anyone ' s dress. She stated she did not notice if Resident #17 had an erection when he was touching Resident #11. Housekeeper #1 stated that before the incident on 4/10/2023 she was not aware of any sexual behaviors that Resident #17 had, and Nurse #1 did not have her write a statement at that time. She did write a statement on 4/28/2023 and was re-educated on abuse. She stated she did not know if the facility contacted the police. Resident #17 was placed on 1:1 observation for a couple of days on 4/28/2023. A telephone interview was conducted with the Consulting Pharmacist on 5/17/2023 at 8:28 AM. She stated on 4/28/2023 she was at the facility conducting her monthly chart reviews. She revealed that when she reviewed Resident #17 ' s electronic medical record she found a note dated 4/4/2023, written by Nurse #1, that he had some inappropriate sexual behavior. The Consulting Pharmacist stated she went to the Risk Management Nurse on 4/28/2023 and reported what she had observed in Resident #17 ' s electronic medical record and then left and went back to reviewing medical records. She was not aware of what happened after that, she just wanted to make sure that someone from Administration was aware of the note and his behaviors. An interview was conducted with Risk Management Nurse on 5/16/2023 at 3:29 PM. He revealed on 4/28/2023 the Consulting Pharmacist came to him and advised him that she had read a note in Resident #17 ' s electronic medical record where he had displayed some inappropriate behaviors. He stated that he went back to his office and revealed Resident #17 ' s medical record and then called and reported the incident to the Director of Nursing. He stated he started the investigation on 4/28/2023 and submitted the initial report to DHSR (Division of Health Service Regulation) by fax. The Risk Management Nurse indicated he gathered the information and the Director of Nursing, and the Administrator conducted the investigation and submitted the 5-day investigation report to DHSR. He stated that staff re-education on abuse started on 4/28/2023 and Resident #17 was placed on 1:1 observation for the rest of the weekend. The Psychiatric Nurse Practitioner saw him on Tuesday, 5/2/2023 and the 1:1 observation was stopped. He revealed that when the Consulting Pharmacist reported to him, he was not aware that the behaviors were sexual, just that he had inappropriate behaviors. He stated that he was not aware that Resident #17 had any sexual behaviors on 4/10/2023, he would have reported the incident to the Director of Nursing. He revealed that all staff received abuse training on hire, annually and any time an incident occurred. A telephone interview was conducted with NA #5 on 5/16/2023 at 9:41 PM. She stated she normally was assigned to the memory impaired unit. She revealed she was familiar with Resident #17, Resident #52, and Resident #11 and they were not able to voice their needs or concerns to staff. NA #5 stated she had witnessed Resident #17 hitting staff when they tried to do personal care or toilet him in the shower room, he would become agitated when he had incontinence care or changing his clothes. She stated she had also witnessed Resident #17 touch a female resident ' s knee and she separated them, but she does not remember the date that happened, and she did report it to her nurse, but could not remember which nurse she reported the incident too. NA #5 stated Resident #17 had touched Resident #11 ' s knee multiple times. She stated she had been re-educated on abuse, types of abuse, separate the residents and then report to her nurse, the nurse would then report to the Director of Nursing or Administrator. A telephone interview was conducted with NA #6 on 5/17/2023 at 11:00 AM. NA #6 stated she was normally assigned to work the memory impaired unit on 7PM-7AM. She revealed she was familiar with Resident #17, Resident #52, and Resident #11. NA #6 stated Resident #17 had behaviors of being combative with care, she had not witnessed any sexual behaviors. NA #6 revealed she had witnessed Resident #17 touch a female resident ' s hand or leg but did not feel at the time she witnessed these behaviors, she did not feel like Resident #17 meant anything by it, because he does not know what he was doing, he has dementia. She had been re-educated on abuse, types of abuse, how to intervene if you witness abuse of any kind, who and when to report abuse too. She stated she would report any inappropriate behaviors of any kind to her nurse, and the nurse would report to the Director of Nursing or Administrator. An interview was conducted with Nurse Aide (NA) #1 on 5/16/2023 at 2:52 PM. She stated she was familiar with Resident #17, Resident #52, and Resident #11. She revealed she normally worked the memory impaired unit on 7AM-7PM shift. NA #1 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1 and that he was not allowed to be around any female residents, and he could not be too close to female residents. She stated she did not know how close too close was. She stated she had not had to redirect Resident #17, but she had only been employed at the facility for a month. NA #1 stated she had received abuse training when she was hired, the training included what types of abuse there was, when to report abuse, who to report abuse too. She stated she was trained to report any abusive incidents she observed or heard about to her Nurse immediately and the Nurse would then report to the Administrator. An interview was conducted with NA #2 on 5/16/2023 at 3:04 PM. She stated she normally worked the memory impaired unit from 7AM-7PM. NA #2 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1 but could not remember when Nurse #1 told her about the incidents. She revealed she was told that the incident happened 2-3 weeks ago and that she really did not understand the whole situation. She was told he had sexual behaviors and he was not allowed to be around female residents; we are supposed to redirect him. NA #2 stated that prior to the incident on 4/4/2023, Resident #17 did not have any sexual behavior before that, he was flirtatious and would [NAME] at you. She was not aware of any further incidents. NA #2 revealed she was not sure if Resident #17 was supposed to be kept away from female residents currently. She stated she received re-education on abuse, types of abuse, intervention, who and when to report abuse too, and if she heard or witnessed any resident being mistreated in any way, she would intervene and make sure the resident was safe and then report to her Nurse. An interview was conducted with NA #3 on 5/17/2023 at 10:40 AM. NA #3 stated she was familiar with Resident #17, Resident #52, and Resident #11. NA #3 normally worked the memory impaired unit. She stated that Resident #17 did cuss at staff and yell. She had never witnessed him having sexual behaviors but had heard other staff talk about it, but it was about Resident #17 grabbing a staff member in a sexual manner, she stated she had not heard of him touching any female residents. NA #3 stated she was told by the Nurses on the memory impaired unit that he was supposed to be separated from female residents and to monitor him for touching female residents, but she could not remember the date she was told. Resident #17 was allowed to sit at the table with female residents, but he had to be seated separately from female residents at the table. NA #3 stated she had heard that Resident #17 had grabbed a resident ' s leg (she did not know which resident) but did not feel he was sexual. She stated she had been told to just keep an eye on him. She had received re-education on abuse, types of abuse, how, when and whom to report to. NA #3 indicated if she witnessed or heard of any abuse or mistreatment of a resident, she would separate the residents, then report to the Nurse. A telephone interview was conducted with NA #4 on 5/16/2023 at 9:37 PM. She stated she normally worked the memory impaired unit. She stated she was familiar with Resident #17, Resident #52, and Resident #11. NA #4 revealed she had observed Resident #17 have behaviors of punching staff with his fists during personal care and kicking staff in the chest with his feet. She stated she had not witnessed him having any sexual behavior. She stated that she had heard of his inappropriate sexual behaviors but had not personally witnessed these behaviors, so she was unable to provide a date. NA #4 indicated she had received abuse re-education and if he witnessed or heard of anyone mistreating any resident, she would report immediately to her nurse. An interview was conducted with the Psychiatric Nurse Practitioner (NP) on 5/16/2023 at 5:10 PM. She stated she was familiar with Resident #17, and she had been seeing him for about 6 months. She revealed when she first started seeing him, he had been calm and cooperative and about 6-8 weeks later he started to become agitated and that turned into him being aggressive towards staff. Psychiatric NP stated that staff try to redirect him when he becomes agitated or aggressive but that did not always work. She revealed that she had been notified about 2 weeks ago that he had been sexual towards a nursing staff member, but today (5/16/2023) was the first time she had been notified that he had sexual behavior towards other residents. Psychiatric NP stated if she had been notified of his sexual behaviors towards female residents, she more than likely would have put interventions into place and would have appreciated being advised of these sexual behaviors, especially the incident with Resident #11, when he put his hand up her dress. She had put a notebook at every nursing station for nursing staff to put messages in for her about residents, their behaviors, or any concerns about a resident. Psychiatric NP stated she was at the facility every Tuesday to see residents. She revealed she was concerned about the other residents on the memory impaired unit being affected by Resident #17 ' s sexual behaviors, they might start having issues, especially if the residents had a history of sexual abuse. Psychiatric NP revealed she felt like there was a lack of education, lack of training and a lack of activities at the facility. She indicated that Resident #17 had a higher level of functioning dementia and that he was able to wait to approach residents when he knew no staff member was watching him. An interview was conducted with the Nurse Practitioner (NP) on 5/17/23 at 10:52 AM. She stated she was familiar with Resident #17 and that he had vascular dementia. To her knowledge he had behaviors of being combative with care and did not have any sexual behaviors before 4/4/2023. NP revealed she was notified on 4/28/2023 about Resident #17 ' s sexual behavior when the facility found out about the incidents that had occurred on 4/4/2023. She stated he had already been prescribed Ativan and an antidepressant prior to 4/4/2023. NP did go and assess Resident #17 after she was notified of his sexual behaviors and reviewed his medications, she did not make any changes to his medications. She revealed that Resident #17 was already being seen by the Psychiatric NP and she was the one that prescribed any psychiatric medications. She stated the facility was very good at telling her about issues that had occurred with residents, and she had a notebook at every nursing station for staff to report any concerns or issues that they might have about a resident. A telephone interview was conducted with the Medical Director on 5/16/2023 at 5:39 PM. The Medical Director revealed he was familiar with Resident #17. He stated he was not aware of any sexual behavior for Resident #17. He indicated that staff would normally contact the NP first for any issues and then if the NP needed help, she would contact him for advice. He revealed that when he came to the facility on Friday, 5/19/2023, he would assess Resident #17, but as far as any medications are concerned, he would review it and see if medication was appropriate for his behaviors, such as hormone-based medications. He revealed he had no concerns about how the facility conducted investigations or how the staff reported issues to him or the NP. Observations conducted on the memory impaired unit on 5/15/2023 at 12:27 PM revealed Resident #17 was at the dining room table sitting next to Resident #11 with one other resident in between them. Staff were observed bringing residents in and out of the dining room. No one was directly supervising Resident #17. On 5/16/2023 at 2:27 PM, Resident #17 was observed in the activity room on the memory impaired unit. He was sitting in his wheelchair approximately 1.5 feet apart from Resident #11. There was no staff in the activity room. There was a total of seven residents in the activity room to include Resident #17 and Resident #11. Resident #52 was not in the activity room but was observed sitting in her chair outside of her room, looking out a window. At 3:50 PM, Resident #17 was observed sitting beside a female resident with no staff supervision. Nurse #1 came around the corner and observed Resident #17 trying to give the female resident pudding and telling her to lick it. Nurse #1 went and got the female resident her own pudding. Nurse #1 was back and forth multiple times helping the NAs with care. Resident #17 left the female resident with the pudding. Next, he rolled by another female resident and made kissy faces and tried to touch the resident ' s foot and leg. Nurse #1 observed the incident and moved Resident #17 into the activity room and left the residents with no supervision. NA #1 came into the activity room and removed Resident #17 and took him to his room, he came right back out of his room and continued to roll around the memory impaired unit unsupervised. The Director of Nursing was notified and placed Resident #17 on 1:1 observation. An interview was conducted with the Director of Nursing (DON) on 5/17/2023 at 3:50 PM. The DON revealed she was familiar with Resident #17, Resident #52, and Resident #11 and all were cognitively impaired. She stated she was notified about Resident #17 touching female residents by the Risk Management Nurse on 4/28/2023 after he had reviewed a note in Resident #17 ' s nursing notes. She stated that the Risk Management Nurse filed and faxed a 24-hour initial report to DHSR, placed Resident #17 on 1:1 observation, and she and the Administrator did the investigation and faxed the 5-day investigation report to DHSR. She indicated that Nurse #1 was working on the memory impaired unit on 4/28/2023 and she was able to speak to her on the phone. She interviewed Nurse #1 over the phone but did not suspend her at that time pending outcome of the investigation. The DON stated she and Nurse #1 discussed why it was not ok for him to touch female residents, she gave re-education on abuse, what was abuse, and that it did not matter if the residents involved had dementia, who to report to and when to report. Nurse #1 did sign that she had read and understood the policy. Nurse #1 worked on 5/1/2023 on the memory impaired unit and on 5/2/2023 Nurse #1 was suspended pending outcome of the investigation. She stated that the goal for Resident #17 was that sexual incidents did not reoccur, and that resident safety was insured, and Nurse #1 stated to her that she understood. On 5/16/2023, Nurse #1 advised the DON that she had not observed Resident #17 make kissy faces at female residents on the memory impaired unit, after she had been advised by the DON that been witnessed. Resident #17 was placed on 1:1 observation at 4:30 PM on 5/16/2023 and remained on 1:1 currently. All staff had been re-educated on abuse, types of abuse, when and who to report abuse too after the incidents. DON revealed she was not aware of a sexual behavior that occurred on 4/10/2023 between Resident #17 and Resident #11 and if it had occurred the incident should have been reported to administration at that time so an investigation could have been initiated. DON stated all staff received abuse training on hire, annually and anytime an incident occurred, and they are going to increase the training to quarterly after these incidents. She stated they did not inform the police about the incident at the time the facility became aware of the incidents, because she thought the facility policy stated they did not have to report sexual abuse to the police. She reviewed the policy and agreed that the police should have been notified. An interview was conducted with the Administrator on 5/17/2023 at 4:21 PM. She revealed she was notified of Resident #17 ' s sexual behaviors after the pharmacy consultant read about it in the chart and the pharmacist reported to the Risk Management Nurse on 4/28/2023. She indicated after being told about Resident #17 ' s sexual behaviors, she called the nurses and did re-education on abuse and came in early the next morning to continue the education. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. The Nurse Practitioner was notified the next time she came into the facility, on 5/1/2023, and she was at the facility on Mondays, Wednesdays, and Fridays. She was not sure if the NP saw Resident #17 on the day she was notified, and she did not personally notify the Medical Director. The Administrator revealed that when Nurse #1 was initially interviewed on 4/28/2023, she did not think the sexual behavior was abuse, since the residents were demented, but she now understands after extensive training that the sexual behaviors were abusive. The families of Resident #17, Resident #52, and Resident #11 were notified of the sexual behaviors, and they did not have concerns. The Administrator stated the facility did not report the incidents to law enforcement at the time they found out about the incidents but stated she should have reported it. She revealed that her thought process at the time was that it was 20+ days later, since the incidents occurred, and he had been on 1:1 observation and that re-education would be enough. The Administrator was notified of immediate jeopardy on 5/17/2023 at 4:40 PM. The facility provided the following immediate jeopardy removal plan on 5/23/2023: Between 4/28/23 - 5/2/23, all staff working on the secure memory care unit completed a written questionnaire provided by the Administrator to determine if any other resident on the secure memory care unit may have been affected and if they had observed and not reported any behaviors of a sexual nature including inappropriate touching exhibited by Resident #17. No concerns with any other residents were reported by any staff. Nurse #1 was educated by the Director of Nursing on 4/28/23 on: the definition of sexual abuse and the need to immediately protect residents from all issues of sexual abuse followed by the immediate reporting of all issues related to sexual abuse to their supervisor who must in turn notify the Administrator or Director of Nursing immediately in person or via telephone if not present in the facility and the fact that sexual behaviors and inappropriate touching is abuse even if the abuser is cognitively impaired. On 5/17/23 @ 5:55pm, the Administrator reported the sexual abuse exhibited by Resident #17 to Resident #11 and Resident #52 to local law enforcement. A Detective with the [NAME] Police Department came to the facility on [DATE] @ 6:05pm, met with the Administrator to discuss the incident which occurred on 4/4/23 and all actions taken to prot[TRUNCATED]

Based on observations, staff interviews and record review, the facility failed to implement care plan interventions for transfer assistance for 2 of 3 residents observed for transfers (Resident #73 and #61). Both required 2 persons with gait belt for transfers but were observed to be transferred from bed to wheelchair with 1 person without use of gait belt. Findings included: 1. Resident #73 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of a document entitled Get to Know Me dated 3/29/19 revealed the type of transfer/staff assistance needed for transfers for Resident #73 was 2 persons with gait belt. Review of Transfer/Lift assessment dated [DATE] revealed Resident #73 meets all requirements for 1-person gait belt transfer but also has had recent hip and/or knee surgery or exhibits behavioral concerns related to care = 2-person gait belt transfer. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was moderately cognitively impaired. Resident #73 required extensive physical assistance of two or more persons. Review of Resident #73's care plan dated 4/15/19 revealed the resident required assistance with all Activities of Daily Living (ADL) with the goal of performing ADL as independently as possible. One of the interventions listed was Resident #73 required the assistance of 2 persons with gait belt for transfers. An observation was made on 5/31/19 at 5:48 AM of Resident #73 being transferred by Nurse Aide (NA) #1 from bed to wheelchair. NA #1 had Resident #73 wrap her arms around NA #1's neck while NA #1 stood Resident #73 up while holding on to Resident #73's torso to stand and pivot to the wheelchair. NA #1 did not use a gait belt during the transfer. An interview was conducted with NA #1 on 5/31/19 at 6:15 AM. NA #1 stated she was familiar with Resident #73 and had worked with her before. NA #1 stated she usually got Resident #73 out of bed by herself. NA #1 further stated the transfer information can be found in the Getting to Know Me book. During the interview, NA #1 looked up the transfer information from the Getting to Know Me book and revealed Resident #73 required 2 persons assistance with gait belt for transfers. NA #1 stated she forgot to look at the Getting to Know Me book before she transferred the resident because she had always transferred Resident #73 by herself. NA #1 stated she should not have transferred the resident by herself and that a gait belt should have been used. An interview conducted with Nurse #1 on 5/31/19 at 6:41 AM revealed Resident #73 required 2 persons assistance with gait belt for transfers. Nurse #1 stated NA #1 should not have transferred Resident #73 by herself. Nurse #1 said NA #1 should have gotten another staff member to help her, and that they should have used a gait belt to transfer the resident. An interview conducted with the House Supervisor on 5/31/19 at 9:35 AM revealed that it was her expectation that the nurse aides follow the transfer/lift status indicated in the Get to Know Me book. The House Supervisor stated NA #1 should have gotten another staff member to help her with the transfer of Resident #73 from bed to wheelchair. An interview was conducted with the Director of Nursing (DON) on 5/31/19 at 10:00 AM. The DON stated she expected the nurse aides to follow the care plan as to what had been deemed the safest assistance for transfers. The DON further stated it was the facility's policy that disciplinary action and re-education be given to any staff member observed not following the lift status because they considered this a serious issue. An interview conducted with the Administrator on 5/31/19 at 10:16 AM revealed it was her expectation that staff follow the care plan and the transfer/lift policy. 2. Resident #61 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #61's care plan dated 4/1/19 revealed the resident required assistance for all Activities of Daily Living (ADL) with the goal of performing ADL as independently as possible. One of the interventions listed was Resident #61 required extensive assistance of 2 persons with gait belt for transfers. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was severely cognitively impaired. Resident #61 required extensive physical assistance of two or more persons. Review of a document entitled Get to Know Me dated 4/4/19 revealed the type of transfer/staff assistance needed for transfers for Resident #61 was 2 persons with gait belt. Review of Transfer/Lift assessment dated [DATE] revealed Resident #61 meets all requirements for 1-person gait belt transfer but also has had recent hip and/or knee surgery or exhibits behavioral concerns related to care = 2-person gait belt transfer. An observation was made on 5/31/19 at 6:02 AM of Resident #61 being transferred by Nurse Aide (NA) #1 from bed to wheelchair. NA #1 had Resident #61 wrap her arms around NA #1's neck while NA #1 stood Resident #61 up while holding on to Resident #61's torso to stand and pivot to the wheelchair. During the transfer, Resident #61 was observed to have difficulty standing up and bearing weight. NA #1 did not use a gait belt during the transfer. An interview was conducted with NA #1 on 5/31/19 at 6:15 AM. NA #1 stated she thought she might be in trouble after noting Resident #61 had some difficulty standing up during the transfer. NA #1 stated she thought Resident #61 required 1-person assistance with transfers, but she was not sure. NA #1 said she was familiar with Resident #61, but she did not usually get her up out of the bed. NA #1 got Resident #61 out of the bed at that time because Resident #61 was requesting to be gotten out of the bed. NA #1 further stated the transfer information can be found in the Getting to Know Me book. During the interview, NA #1 looked up the transfer information from the Getting to Know Me book and revealed Resident #61 required 2 persons assistance with gait belt for transfers. NA #1 stated she should not have transferred the resident by herself and that a gait belt should have been used. NA #1 stated she should have looked at the Getting to Know Me book before she transferred the resident, which she forgot to do. An interview conducted with Nurse #1 on 5/31/19 at 6:41 AM revealed Resident #61 required 2 persons assistance with gait belt for transfers. Nurse #1 stated NA #1 should not have transferred Resident #61 by herself. Nurse #1 said NA #1 should have gotten another staff member to help her, and that they should have used a gait belt to transfer the resident. An interview conducted with the House Supervisor on 5/31/19 at 9:35 AM revealed that it was her expectation that the nurse aides follow the transfer/lift status indicated in the Get to Know Me book. The House Supervisor stated NA #1 should have gotten another staff member to help her with the transfer of Resident #61 from bed to wheelchair. An interview was conducted with the Director of Nursing (DON) on 5/31/19 at 10:00 AM. The DON stated she expected the nurse aides to follow the care plan as to what had been deemed the safest assistance for transfers. The DON further stated it was the facility's policy that disciplinary action and re-education be given to any staff member observed not following the lift status because they considered this a serious issue. An interview conducted with the Administrator on 5/31/19 at 10:16 AM revealed it was her expectation that staff follow the care plan and the transfer/lift policy.

Based on observations and staff interviews the facility failed to secure and label unidentified loose pills in 5 of 5 medication carts (100 back hall cart, 100 hall rehabilitation cart, 400 hall cart, 500 short hall cart, and 500 long hall cart). Findings included: 1. An observation of the 500 short hall medication cart on 06/29/18 at 10:15 AM revealed: a. 1 unidentified yellow capsule loose in the third drawer b. one half of an unidentified white tablet loose in the third drawer. An interview with the 500 short hall nurse at the time of the observation revealed she was unable to identify the medications and did not know why the pills became loose in the cart. The nurse was going to find a bag to place the loose pills in and send them back to the pharmacy. The nurse stated if she found loose pills in the cart they were placed in a bag and sent to the pharmacy. 2. An observation of the 100 back hall medication cart on 06/29/18 at 10:23 AM revealed: a. 1 loose green pill in the second drawer An interview with the 100 back hall nurse at the time of the observation revealed she thought the pill was an iron tablet. The nurse stated the pill could have been dropped accidentally during a medication pass. The nurse discarded the loose pill in the sharps container at that time. The nurse stated if she found loose pills in the medication cart she discarded them in the sharps container. 3. An observation of the 100 hall rehabilitation medication cart on 06/29/18 at 10:25 AM revealed: a. 1 purple unidentified loose pill in the second drawer An interview with the 100 hall rehabilitation nurse at the time of the observation revealed she was unable to identify the medication and did not know why the pill became loose in the cart. The nurse discarded the pill in the sharps container at that time. The nurse stated if she found loose pills in the medication cart she discarded them in the sharps container. The nurse also stated third shift checked the medication carts nightly for loose pills or expired medications. 4. An observation of the 500 long hall medication cart on 06/29/18 at 10:58 AM revealed: a. 1 orange pill loose in the third drawer b. 1 white pill loose in the third drawer An interview with the 500 long hall nurse at the time of the observation revealed she thought the orange pill was an aspirin and was unsure what the white pill was. The nurse did not know why the medications were loose in the cart and discarded the pills in the sharps container at that time. The nurse stated if she found loose pills in the medication cart she discarded them in the sharps container. 5. An observation of the 400 hall medication cart on 06/29/18 at 11:17 AM revealed: a. 1 pink unidentified loose pill in the third drawer. An interview with the 400 hall nurse at the time of the observation revealed she was unable to identify the medication and did not know why the pill became loose in the cart. The nurse discarded the pill in the sharps container at that time. The nurse stated if she found loose pills in the medication cart she discarded them in the sharps container. The nurse also stated pharmacy checked the medication carts monthly for loose pills or expired medications. An interview with the Assistant Director of Nursing (ADON) on 06/29/18 at 10:18 AM revealed the third shift supervisor checked medication carts nightly for loose medication. The Staff Development Coordinator (SDC) and the Risk Assessment Nurse also audited the medication carts periodically for loose pills or expired medication. An interview with the Director of Nursing (DON) on 06/29/18 at 10:46 AM revealed her expectation of nurses was to discard loose pills in the sharps container. The DON also stated pharmacy checked medication carts monthly for loose pills or expired medications. A subsequent interview with the DON on 06/29/18 at 5:30 PM revealed it was her expectation that medication carts be clean and in order.

Based on observations, staff interviews and review of facility records, the facility failed to store bananas per vendor recommendations to prevent the growth of bacteria (60 - 65 degrees Fahrenheit), discard expired produce (sweet potatoes and bananas) and store frozen biscuits in a secured container with a date of opening for 3 of 5 storage units observed. The findings included: 1a. An observation of the walk-in refrigerator occurred on 7/10/17 at 11:06 AM. A long 2 inch stainless steel pan was observed covered with aluminum foil and contained 18 sweet potatoes. The label on the pan recorded a use by date of 7/6/17. Further observation revealed 8 of the 18 sweet potatoes had white fuzzy growth on the exterior of the sweet potatoes. An interview on 7/10/17 at 11:06 AM with the food service director (FSD) revealed dietary staff received produce on Tuesdays/Fridays and should remove any expired foods when new stock was received. The FSD stated the sweet potatoes should have been discarded on Friday, 7/7/17 when new produce was received. 1b. A review of vendor recommendations for storage of bananas included instructions to store them at a room temperature 60 - 65 degrees Fahrenheit (F). An observation of the dry storage room occurred on 7/10/17 at 11:25 AM. A case of ripe bananas was observed stored with 12 of the bananas observed dark brown and soft to touch. The temperature of the dry storage room was observed at 74 degrees F. An interview on 7/10/17 at 11:25 AM with the FSD revealed that the dark brown bananas should be discarded and that it was the facility's routine practice to store bananas in the dry storage room. During the interview, the FSD provided written vendor recommendations to store bananas at room temperature (60 - 65 degrees F). The FSD stated that it was not their practice to monitor the temperature of the dry storage room to ensure a temperature range of 60 - 65 degrees F. She further stated that the dry storage room could be kept as cool as 67 degrees F, but that was the coolest the room would get. 1c. An observation of the freezer occurred on 7/10/17 at 11:18 AM. The freezer was observed with a plastic bag secured by being tied into a knot. The FSD identified the bag contained frozen biscuits. The bag was observed with a hole in it, there were 10 biscuits observed with ice crystals and there was no label to include a date of storage. An interview on 7/10/17 at 11:18 AM with the FSD revealed that anytime any items were opened, a label should be placed to include the name of item, the date of storage and the date of expiration.

Based on observations, record reviews, and staff and resident interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and to monitor these interventions that the committee put into place in [DATE] on a recertification survey. The deficiencies were in the areas of dietary services for food procurement, storage and sanitation and resident assessment accuracy and were originally cited in [DATE] and again on the present recertification survey. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. Findings included: This tag is cross referenced to: 1a. F 278 Accurate Assessment: Based on staff interviews and medical record review, the facility failed to accurately code an annual Minimum Data Set (MDS) to include active [DIAGNOSES REDACTED].#47) for 2 of 19 sampled MDS reviewed. On a federal recertification survey in [DATE] the facility failed to accurately code the admission Minimum Data Set (MDS) correctly to reflect a resident had been evaluated by Level II PASSR (Preadmission Screening and Review) and failed to code a significant change on the MDS to reflect dental status. On the present survey the facility continued to fail to accurately code a MDS. 1b. F371 Food Storage: Based on observations, staff interviews and review of the facility records, the facility failed to store bananas per vendor recommendations to prevent growth of bacteria (,[DATE] degrees Farenheit), produce to prevent the growth of bacteria (bananas), discard expired produce (sweet potatoes) and bananas) and store frozen biscuits in a secured container with a date of opening for 3 of 5 storage units observed. On a federal recertification survey in [DATE] the facility failed to provide sanitary conditions for distribution of food to residents in 1 or 3 areas where food was served. The facility did not have a cleaning process in place. Again on the present survey the facility continued to fail to store procedure correctly, discard expired produce, and frozen products in secure containers with the date of opening. During an interview on [DATE] at 2:22 PM with the Administrator stated they did performance improvement plans. The department heads came up their plan and work with committees on the issue. The committees came up with a corrective action plan and their information came to the Quality Assurance committee for final review. Last year the issue was an MDS coding issue. The MDS Coordinator was to check the social worker's and food service's work. This year it is an MDS Coordinator's error. Last year it was a dirty fan, but falls under the same rule area and this year it was a food storage issue. We will develop a new plan to correct the problem. It is my expectation that the MDS' will be coded accurately and all food will be stored properly.

Based on staff interviews and medical record review, the facility failed to accurately code an annual Minimum Data Set (MDS) to include all active [DIAGNOSES REDACTED].#47) for 2 of 19 sampled MDS reviewed. The findings included: 1. Resident #107 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] did not include the [DIAGNOSES REDACTED]. Review of Resident #107's cumulative physician's orders [REDACTED]. Review of the December 2016 Medication Administration Record [REDACTED]. An interview on 7/13/17 at 11:50 AM with MDS Coordinator #1 revealed she reviewed the medical record (hospital records, physician's progress notes, nurse's notes and MAR) when completing the active [DIAGNOSES REDACTED]. MDS coordinator #1 further stated that when she completed Resident #107's annual MDS, she did not refer to the MAR, but that she had been recently reminded to refer to the MAR indicated [REDACTED]. She stated, If the MAR indicated [REDACTED]. MDS Coordinator #1 stated that the [DIAGNOSES REDACTED].#107. An interview on 7/13/17 at 2:20 PM with the director of nursing (DON) revealed she expected MDS staff to refer to the signed physician's orders [REDACTED]. The DON verified that [MEDICAL CONDITION] was an active [DIAGNOSES REDACTED].#107 when the annual MDS was completed. 2. Resident #47 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] assessed Resident #47 with occasional bladder incontinence, or less than 7 occurrences of bladder incontinence during the assessment period of 3/2/17 through 3/8/17. Review of a Voiding Pattern record (nurse aide documentation of continence) dated 3/2/17 through 3/8/17 revealed 21 documented occurrences of bladder incontinence for Resident #47. An interview on 7/13/17 at 11:41 AM with MDS Coordinator #1 revealed she used the Voiding Pattern record and interviewed staff to assess bladder continence when she completed the MDS. MDS coordinator #1 verified 21 documented occurrences of bladder incontinence from 3/2/17 to 3/8/17 by review of the Voiding Pattern record for Resident #47 and stated that a data entry error occurred when she completed the MDS. She stated that she should have assessed Resident #47 as having frequent occurrences of bladder incontinence. An interview on 7/13/17 at 2:20 PM with the director of nursing revealed she expected MDS staff to review nurse aide documentation when assessing bladder continence for the MDS and that a coding error occurred for the admission MDS for Resident #47 regarding bladder continence.

Based on observations, record review, resident, and staff interviews the facility failed to develop a care plan that accurately reflected visual information for 1 of 3 residents sampled for vision (Resident #102). The findings included: Resident #102 was admitted to the facility on [DATE]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #102 had impaired vision (sees large print, but not regular print in newspapers/books) with no corrective lenses used. The MDS also indicated Resident #102 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS further indicated Resident #102 needed extensive assistance with most activities of daily living. The most recent care plan update that was dated 07/07/17 indicated the resident has impaired vision with glasses with approaches that included ensure that eyeglasses are in place/being worn by resident and provide assistance to resident with maintaining cleanliness of glasses. A review of Social Services department notes for 2017 indicated the comment he has impaired vision with no glasses was included in information written about Resident #102 on 01/23/17, 04/07/17, and 07/03/17. During an observation on 07/12/17 at 9:56 AM, Resident #102 was observed in his room and he was not wearing glasses. During an observation on 07/12/17 at 11:15 AM, Resident #102 was observed in his room and he was not wearing glasses. During an observation on 07/13/17 at 10:02 AM, Resident #102 was observed in his room and he was not wearing glasses. During an interview conducted on 07/13/17 with the Nurse Assistant (NA) #1 at 10:14 AM, NA #1 stated she was very familiar with Resident #102 and the care he required. NA #1 also stated that Resident #102 had dentures and hearing aids, but did not have glasses. NA #1 further stated she had never put glasses on Resident #102 and she had never seen Resident #102 wearing glasses. During an interview conducted on 07/13/17 with the Minimum Data Set Coordinator (MDSC) #1 at 12:38 PM, MDSC #1 stated the section on the MDS for vision is completed by Social Services and they are also responsible for writing the care plans for their areas that triggered. During an interview conducted on 07/13/17 with the Social Services Assistant (SSA) at 12:53 PM, SSA stated he created a care plan for the resident if they had vision issues that triggered and he had just recently updated the care plan for Resident #102. The SSA reviewed the care plan dated for 07/07/17 and acknowledged it was incorrect and should have stated Resident #102 did not have glasses. The SSA also acknowledged approaches for Resident #102 would be incorrect as staff did not need to assist him to do something with an appliance that he didn't have. During an interview conducted on 07/13/17 with the Director of Nursing (DON) at 1:29 PM, DON stated she expected care plans to accurately reflect information about the resident.

Based on record review, staff interview, and physician interview the facility failed to follow the physician/practitioner signed note titled Consultant Pharmacist Communication to Physician from the pharmacist regarding a Gradual Dose Reduction (GDR) of an antidepressant medication for 1 of 5 residents (Resident #111) reviewed for unnecessary medication use. The findings included: Resident #111 was admitted to the facility on [DATE]. The annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #111 had [DIAGNOSES REDACTED]. The MDS also indicated Resident #111 had short and long term memory problems with severe impairment for daily decision making. The MDS further indicated Resident #111 required extensive to total assistance for all activities of daily living. The MDS specified Resident #111 was taking an antidepressant medication daily. Record review for the medication of Resident #111 indicated a pharmacy review of current medications is completed monthly. Record review indicated on 05/25/17 a GDR of an antidepressant taken by Resident #111 was suggested by the pharmacist. The reduction recommendation was to decrease the dose from 15 milligrams (mg) every night to 7.5 mg every night in an effort to use the lowest effective dose for Resident #111. The Consultant Pharmacist Communication to Physician indicated the physician/practitioner was in agreement to reduce the medication as indicated by the pharmacist and a note is written on the form stating order written 6/2/17. Also noted on the form is another signature of a nurse with the date 06/16/17 with no other detail. Record review of nurses' notes on 06/16/17 indicated Nurse #1 (N) wrote the following statement at 4:58 AM Consultant Pharmacist Communication to Physician reviewed by ECP with order written to reduce [MEDICATION NAME] 15 mg to 7.5 mg. Order written on 6/2/17. Review of physician's orders [REDACTED].#111. Review of the Medication Administration Record [REDACTED]. During a phone interview on 07/12/17 with N #1 at 4:41 PM, N #1 stated she could not remember where the information had been written about the medication reduction for Resident #111, but she was sure she saw it somewhere since she had written a note about it. N #1 thought it was a doctor's order but was not sure. During a phone interview on 07/12/17 with the pharmacist at 7:48 PM, he stated that sometimes the way [DIAGNOSES REDACTED]. He also stated that he looks at dementia and weight loss issues and if the weight appeared stable to him, he looks at how long it has been since the last GDR and then writes a consult communication note to the physician with his recommendations. The pharmacist further stated Resident #111 had been on this medication for a while and in his clinical judgment had no negative side effects. During a phone interview of 07/13/17 with the Medical Doctor (MD) at 12:28 PM, the MD stated the delay in decreasing the antidepressant for Resident #111 would cause no harm to the resident. During an interview on 07/13/17 with the Director of Nursing (DON) at 2:07 PM, the DON stated her expectation was for the order to have been written so it could have been implemented. The DON also stated the nurse needed to physically look at the physician's orders [REDACTED].

Based on record review, staff, pharmacist, and physician interviews the consultant pharmacist failed to identify 1 of 5 residents reviewed that did not have a recommended medication gradual dose reduction (GDR) (Resident #111). The findings included: Resident #111 was admitted to the facility on [DATE]. The annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #111 had [DIAGNOSES REDACTED]. The MDS also indicated Resident #111 had short and long term memory problems with severe impairment for daily decision making. The MDS further indicated Resident #111 required extensive to total assistance for all activities of daily living. The MDS specified Resident #111 was taking an antidepressant medication daily. Record review for the medication of Resident #111 indicated a pharmacy review of current medications is completed monthly. Record review indicated on 05/25/17 a GDR of an antidepressant taken by Resident #111 was suggested by the pharmacist. The reduction recommendation was to decrease the dose from 15 milligrams (mg) every night to 7.5 mg every night in an effort to use the lowest effective dose for Resident #111. The Consultant Pharmacist Communication to Physician indicated the physician/practitioner was in agreement to reduce the medication as indicated by the pharmacist and a note is written on the form stating order written 6/2/17. Review of physician's orders [REDACTED].#111. Review of the Medication Administration Record (MAR) for the months of June and July 2017 indicated Resident #111 continued to be given 15 milligrams of the antidepressant medication at night. During a phone interview on 07/12/17 with the pharmacist at 7:48 PM, he stated that sometimes the way [DIAGNOSES REDACTED]. He also stated that he looks at dementia and weight loss issues and if the weight appeared stable to him, he looks at how long it has been since the last GDR and then writes a consult communication note to the physician with his recommendations. The pharmacist made a note on 6/22/17 that stated MD approved Remeron GDR: follow efficacy. The pharmacist stated he must have missed the GDR not occurring when he looked at the MAR and stated I don't know why I didn't catch it, I'm actually shocked that I didn't. The pharmacist further stated he probably would have caught the mistake at his July review as he tends to look back over the orders and what needs following up on. The pharmacist further stated Resident #111 had been on this medication for a while and in his clinical judgment had no negative side effects. The pharmacist acknowledged this had been a mistake but stated it would get straightened out with the facility. During a phone interview of 07/13/17 with the Medical Doctor (MD) at 12:28 PM, the MD stated the delay in decreasing the antidepressant for Resident #111 would cause no harm to the resident. During an interview on 07/13/17 with the Director of Nursing (DON) at 2:07 PM, the DON stated her expectation was for the pharmacist to be able to physically look at the order to see that it was written. The DON also stated the pharmacy had already created their own plan of correction to deal with it on their end.

Based on observations, record review, staff interviews, manufacturer specifications, and facility policy, the facility failed to remove from use expired medications on 1 of 5 medication carts. Findings included: Manufacturer specifications for Latanoprost 0.005% eye drop storage per package insert included, Protect from light. Store unopened bottle(s) under refrigeration at 36 to 46 Fahrenheit (F). Once the bottle is opened for use, it may be stored at room temperature up to 77 F for 6 weeks. A review of the facility's Medication Storage Policy dated 01/31/17 under drug storage and expiration date guidelines indicated, Latanoprost 0.005% will be expired 42 days after opened (Refrigerated before opening). An observation of the medication cart at 500 Long Hall on 07/12/17 at 4:24 PM revealed 1 bottle of Latanoprost 0.005% 2.5 Milliliter (ml) eye drop opened on 05/10/17 was stored under the room temperature. The label contained an instruction of Discard 42 days from date opened. Review of Medication Administration Record [REDACTED]. Interview on 07/12/17 at 4:28 PM with Nurse #2 reveal that the Latanoprost eye drops was ordered for Resident #167 who had admitted to 500 Hall on 07/10/17 and she had not given Resident #167 the above expired eye drops for that day yet. Nurse #2 stated she had been checking each medications before administration and the Nurse Supervisor (NS) had checked for expired medication once weekly. Interview on 07/12/17 at 4:39 PM with Nurse #3 revealed that Resident #167 was hospitalized and readmitted to the facility from the Assisted Living section recently. The facility required all the nurses to check for expiration date each time before administration. As a NS, she had conducted random checks for expired medications once weekly. Besides, the pharmacy had sent staff to facility to check for expired medications once monthly. Nurse #3 added the expired Latanoprost eye drops was caused by human error and it should be removed from the medication cart after its expiration. In an interview conducted on 07/13/17 at 12:34 PM, the Director of Nursing (DON) stated that the facility had a system in place to check for expired medication. Part of the second shift NS job description was to check for expired medication at least once weekly. Besides, the nurses were responsible to check for expired medication each time before administration. The pharmacy staff had conducted expired medication checks once monthly. It was her expectation for all the nurses to follow facility's policy and manufacturer's recommendations to discard Latanoprost after 42 days from the date it was opened. In an interview conducted via phone on 07/13/17 at 12:51 PM, Nurse #4 stated that she had checked for expired medications before each administration. She recalled the open date of this particular expired Latanoprost was 05/10/17 but she failed to see the fine print on the label stated the eye drops had to be discarded 42 days after it was opened. Nurse #4 considered the incident as a careless human error and the expired eye drop should be removed from the medication cart after its expiration. In an interview conducted on 07/13/17 at 12:59 PM, the Administrator stated that all the nursing staff were expected to follow the facility's policy for medication storage. It was her expectation for all the medication to be checked routinely and removed from the storage once it was expired.

Based on observations, staff interviews, a physician interview and medical record review, the facility failed to follow the plan of care to safely transfer a resident with a gait belt and 2 staff persons, which resulted in a subcutaneous hematoma (a raised bruise due to a ruptured blood vessel under the skin), a wrist fracture and a blood transfusion (Resident #1) and failed to implement a bed alarm as a fall intervention, per physician order, (Resident #5) for 2 of 3 sampled residents reviewed for implementation of the plan of care. The findings included: 1. Resident #1 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set of 07/23/16, Care Area Assessment and Care Plan both of July 2016 revealed Resident #1 was assessed with [REDACTED]. Care plan interventions included the use of a gait belt with the extensive assistance of 2 staff persons with transfers. Review of a skin audit dated 08/12/16 at 5:54 PM revealed intact skin to Resident #'1 left arm and a skin tear to the right index finger. Review of the facility's Resident Incident Report and a nurse's note (NN) dated 08/12/16 written at 11:30 PM by Nurse #1 recorded that on 08/12/16 at 10:20 PM, Resident #1 presented with a 2.5 inch hematoma on her right forearm. The NN documented that a skin audit completed earlier in the shift (08/12/16 at 5:54 PM) assessed this area as normal for Resident #1. When asked what occurred, the NN documented that Resident #1 stated the hematoma occurred when a nurse aide (NA) put her to bed. A NN dated 08/13/16 written at 12:44 AM noted that Resident #1 was observed with increased swelling to her right arm from the mid bicep to her wrist. The family and physician were notified and a physician's orders [REDACTED].#1 to the Emergency Department (ED) for further evaluation. Resident #1 was admitted to the hospital. Review of the Hospital Discharge summary dated 08/14/16 recorded that Resident #1 presented to the ED on 08/13/16 with a subcutaneous hematoma to the left forearm. A left arm Xray completed in the ED revealed a nondisplaced scaphoid (wrist) fracture. The hematoma was treated by clot removal and wound closure, the Resident required one multi-donor pack of platelets, one unit of packed red blood cells and the wrist fracture could not be surgically corrected. Resident #1 was re-admitted to the facility on [DATE]. The facility's investigation included a written statement by NA #1 and a documented interview with Nurse #1 and the Director of Nursing (DON) which revealed NA #1 put Resident #1 to bed after dinner without staff assistance or a gait belt. NA #1 stated Resident #1 wore a long-sleeved shirt at the time of the transfer and the NA did not observe any changes in skin integrity to the Resident's left arm after the Resident was put to bed. The investigation also documented that NA #1 was asked why she put Resident #1 to bed without staff assistance or a gait belt and NA #1 replied that she did so because Resident #1 wanted to be put to bed and NA #1 did not want the Resident to complain of having to wait. Resident #1 was observed on 10/05/16 at the following times, 10:40 AM, from 12:20 PM to 12:32 PM and at 4:21 PM in her room, in a low bed, covered with a blanket. Staff were observed to encourage and offered to assist Resident #1 with incontinence care, to get out of bed to toilet, sit in her wheelchair and attend activities, but Resident #1 declined each offer and replied Come back later. On 10/05/16 at 4:53 PM Resident #1 agreed to transfer to her wheelchair. Two nurse aides applied a gait belt, provided extensive assistance to Resident #1 to stand from her bed, pivot and transfer to her wheelchair. The transfer occurred without incident. An interview with the Administrator and DON occurred on 10/05/16 at 1:15 PM and revealed Nurse #1 called the DON on 08/13/16 around 11:00 PM to notify of Resident #1's hematoma that resulted from the 1 person transfer. The DON stated that Nurse #1 continued to monitor Resident #1, around 12:00 AM Nurse #1 noted the Resident's hematoma was larger and Resident #1 complained of pain, the physician was called and an order obtained to send Resident #1 to the hospital for further evaluation. During an interview on 10/05/16 at 3:00 PM, Nurse #1 stated NA #2 reported to him on 08/12/16 after the end of the 3 PM - 11 PM shift, that Resident #1 was found in bed dressed in her day clothes, by NA #2 and NA #3, with a raised bruise to her left arm when they went to check the Resident for incontinence and change her clothes. Nurse #1 stated his NN dated 08/12/16 and 08/13/16 documented a hematoma to the right arm instead of the left arm in error. Nurse #1 stated he assessed Resident #1 with a raised bruise to her left arm the size of his fist. Nurse #1 stated when he interviewed staff, NA #1 stated she put Resident #1 to bed after dinner without a gait belt or staff assistance which required Resident #1 to hold onto the side rail and assist with the transfer. Nurse #1 further stated he determined that must have been when the hematoma occurred because Resident #1 required a gait belt and the extensive assistance of 2 staff persons with transfers and when he completed a skin audit around 5:30 PM on 08/12/16 the hematoma to her left arm was not there. During an interview on 10/05/16 at 3:14 PM, NA #2 stated she worked the 3PM - 11PM shift on 08/12/16 and that she was the assigned NA for Resident #1. NA #2 stated at the end of the shift on 08/12/16, she and NA #3 completed their final rounds, responded to the call light for Resident #1 who requested incontinence care and to be changed into her night clothes. NA #2 stated when she removed the Resident's shirt NA #2 noted a raised bruise to the Resident's left arm. Resident #1 reported to NA #2 that the bruise happened when a NA put her to bed earlier, but that she could not recall who put her to bed or what time. NA #2 stated she immediately reported the bruise to Nurse #1 and while at the nurse's station, NA #1 stated that she put Resident #1 to bed alone, after supper. During a telephone interview on 10/05/16 at 5:41 PM, the Medical Director (MD) stated that Resident #1 was at increased risk for fractures due to her age/comorbidities. The MD stated that the wrist fracture Resident #1 sustained could have occurred as a result of being transferred on 08/12/16 without a gait belt by 1 staff person instead of 2 staff. The MD stated Resident #1 could stand/pivot during transfers, but that her assistance was minimal, which placed the primary responsibility on the staff during transfers. The MD stated Resident #1 required 2 person extensive assistance to transfer or she would fall. The MD also stated he did not know why NA #1 chose to transfer Resident #1 alone, but that it was a mistake that had a bad outcome. The MD further stated that it was quite possible that the 1 person transfer for Resident #1 that occurred on 08/12/16 resulted in her fractured wrist. He stated to be transferred safely, Resident #1 required the extensive assistance of 2 staff persons. Attempts to interview NA #1 and NA #3 were unsuccessful. During a follow up interview on 10/06/16 at 12:30 PM, the Administrator stated as a result of the facility's investigation NA #1 was terminated for not following the plan of care for Resident #1 which resulted in injury to the Resident. The Administrator stated the facility began corrective measures in response to the 08/12/16 incident that resulted in injury for Resident #1 and monitoring was ongoing. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #5 was cognitively impaired and required extensive assistance with activities of daily living (ADLs). The MDS also revealed that Resident #5 had fallen during the month prior to admission and also 2 to 6 months prior to admission. No behaviors or rejection of care were identified. Review of a facility document entitled Get to Know Me dated 09/09/16 indicated the form had been updated on 10/03/16 to reflect the addition of the bed alarm and again on 10/05/16 to reflect the addition of the nonskid socks. Review of a care plan dated 09/22/16 read, Resident #5 was at risk for falls related to a history of falls prior to admission, impaired mobility and cognition. The goal of stated care plan was Resident #5 would have no avoidable physical harm by the next review. The interventions of stated care plan included bed and chair alarm to alert staff of unsafe movements and nonskid socks when shoes not worn for fall safety. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Observation of Resident #5 on 10/18/16 at 3:10 PM revealed she was resting in bed with eyes closed. Resident #5 was dressed in black pants and a light colored shirt and had on socks that were not nonskid. The pad to the bed alarm was present on the bed but was not connected to the alarm box hanging on the side of the bed. Observation of Resident #5 on 10/18/16 at 4:43 PM revealed she was resting in bed with eyes open and was alert and verbal. Resident #5 was dressed in black pants and a light color shirt, she had on socks that were not nonskid. The pad to the bed alarm was present on the bed but was not connected to the alarm box that was hanging on the side of the bed. Interview with Nursing Assistant (NA) #4 on 10/18/16 at 4:48 PM revealed that was taking care of Resident #5 on 2nd shift which started at 3:00 PM. NA #4 stated that when she came on shift Resident #5 was in bed and she checked to make sure her chair alarm was present but did not check her bed alarm. NA #4 did not indicate why she did not check the bed alarm to make sure it was connected and working. NA #4 stated that they were expected to check Resident #5's alarm when they came on shift and every 2 hours. NA #4 observed and confirmed that the bed alarm was not connected to the bed pad on the bed and stated that is should have been connected for her safety. NA #4 explained there was a Get to Know Me sheet for every resident and if there was a question about what fall interventions were in place they could refer to it. Interview with Director of Nursing (DON) on 10/19/16 at 3:10 PM revealed that the nonskid socks and bed and chair alarm were put into place as safety interventions for Resident #5 to prevent falls and it was his expectation that they would be in place as ordered. Interview with the Administrator on 10/19/16 at 3:10 PM revealed that she expected fall interventions to be in place as ordered.

Based on observations, staff interviews, a physician interview and medical record review, the facility failed to safely transfer a resident, with a gait belt and 2 staff persons, which resulted in a subcutaneous hematoma (a raised bruise due to a ruptured blood vessel under the skin), a wrist fracture and a blood transfusion for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1). The findings included: Resident #1 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Medical record review revealed Resident #1 received 2 antiplatelet medications daily, Aspirin 81 milligrams (mg) and Plavix 75 mg, for heart attack/stroke prevention. Side effects include increased risk for bleeding/bruising. Review of an admission Minimum Data Set of 07/23/16, Care Area Assessment and Care Plan both of July 2016 revealed Resident #1 was assessed with [REDACTED]. Care plan interventions included the use of a gait belt with the extensive assistance of 2 staff persons with transfers. A skin assessment dated [DATE] at 5:54 PM recorded by Nurse #1, assessed Resident #1 with a skin tear to her right index finger, right leg and left leg with no other skin impairment noted. Review of the facility's Resident Incident Report and a nurse's note (NN) dated 08/12/16 written at 11:30 PM by Nurse #1 recorded that on 08/12/16 at 10:20 PM, Resident #1 presented with a 2.5 inch hematoma on her right forearm. The NN documented that a skin assessment completed earlier in the shift (08/12/16 at 5:54 PM) assessed this area as normal for Resident #1. When asked what occurred, the NN documented that Resident #1 stated the hematoma occurred when a nurse aide (NA) was rough when putting her to bed. Nurse #1 notified the Administrator and Director of Nursing (DON) and initiated the facility's Abuse Protocol. A NN dated 08/13/16 written at 12:44 AM noted that Resident #1 was observed with increased swelling to her right arm from the mid bicep to her wrist. The family and physician were notified and a physician's orders [REDACTED].#1 to the Emergency Department (ED) for further evaluation. Resident #1 was admitted to the hospital. Review of the Hospital Discharge summary dated 08/14/16 recorded that Resident #1 presented to the ED on 08/13/16 with a subcutaneous hematoma to the left forearm. A left arm Xray completed in the ED revealed a nondisplaced scaphoid (wrist) fracture. The hematoma was treated by clot removal and wound closure, the Resident required one multi-donor pack of platelets, one unit of packed red blood cells and the wrist fracture could not be surgically corrected. Resident #1 was re-admitted to the facility on [DATE]. The facility's investigation included a written statement by NA #1 and a documented interview with Nurse #1 and the DON which revealed NA #1 put Resident #1 to bed after dinner without staff assistance or a gait belt. NA #1 stated Resident #1 wore a long-sleeved shirt at the time of the transfer and the NA did not observe any changes in skin integrity to the Resident's left arm after the Resident was put to bed. The investigation also documented that NA #1 was asked why she put Resident #1 to bed without staff assistance or a gait belt and NA #1 replied that she did so because Resident #1 wanted to be put to bed and NA #1 did not want the Resident to complain of having to wait. Review of written statements from NA #2 and NA #3 revealed Resident #1 was noted with a raised area to her left arm at the end of the 3PM - 11PM shift on 08/12/16 when they both went to her room to check her for incontinence and change her clothes. Resident #1 was observed on 10/05/16 at the following times, 10:40 AM, from 12:20 PM to 12:32 PM and at 4:21 PM in her room, in a low bed, covered with a blanket. Staff were observed to encourage and offered to assist Resident #1 with incontinence care, to get out of bed to toilet, sit in her wheelchair and attend activities, but Resident #1 declined each offer and replied Come back later. On 10/05/16 at 4:53 PM Resident #1 agreed to transfer to her wheelchair. Two nurse aides applied a gait belt, provided extensive assistance to Resident #1 to stand from her bed, pivot and transfer to her wheelchair. The transfer occurred without incident. Resident #1 wore a long sleeved shirt and pants, bilateral geri sleeves and non skid socks. Bruising was noted to her left arm. When asked by the surveyor if she could recall a time she was transferred by 1 staff person instead of 2 or was injured during a transfer and went to the hospital, Resident #1 stated I don't know. An interview with the Administrator and DON occurred on 10/05/16 at 1:15 PM and revealed Nurse #1 called the DON on 08/13/16 around 11:00 PM to notify of Resident #1's hematoma that resulted from the 1 person transfer and the allegation of physical abuse. The DON stated Nurse #1 immediately assessed Resident #1 and suspended NA #1, NA #2 and NA #3. The DON stated that Nurse #1 continued to monitor Resident #1, around 12:00 AM Nurse #1 noted the Resident's hematoma was larger and Resident #1 complained of pain, the physician was called and an order obtained to send Resident #1 to the hospital for further evaluation. The DON also stated that Resident #1 was transferred to the hospital on [DATE] with a hematoma that opened and was lanced during the hospital course. The DON stated upon return to the facility, Resident #1 was assessed with [REDACTED]. The Administrator stated NA #1 was interviewed as part of the investigation and asked why she chose to transfer Resident #1 without assistance. NA #1 stated that Resident #1 asked to be put to bed and NA #1 did not want to upset the Resident, so she just transferred the Resident without help because Resident #1 does not like to wait when she wants to go to bed. The Administrator further stated that once the investigation was completed, NA #1 was terminated. During an interview on 10/05/16 at 3:00 PM, Nurse #1 stated NA #2 reported to him on 08/12/16 after the end of the 3 PM - 11 PM shift, that Resident #1 was found in bed dressed in her day clothes, by NA #2 and NA #3, with a raised bruise to her left arm when they went to check the Resident for incontinence and change her clothes. Nurse #1 stated his NN dated 08/12/16 and 08/13/16 documented a hematoma to the right arm instead of the left arm in error. Nurse #1 stated he assessed Resident #1 with a raised bruise to her left arm the size of his fist. Nurse #1 stated Resident #1 denied pain, he applied a dry bandage to keep the area intact and continued to monitor. Nurse #1 stated Resident #1 alleged the hematoma occurred when she was put to bed by a NA, but she could not recall who or the specific time the incident occurred. Nurse #1 stated he immediately implemented the facility's Abuse Protocol. Nurse #1 stated when he interviewed staff, NA #1 stated she put Resident #1 to bed after dinner without a gait belt or staff assistance which required Resident #1 to hold onto the side rail and assist with the transfer. Nurse #1 further stated he determined that must have been when the hematoma occurred because Resident #1 required a gait belt and the extensive assistance of 2 staff persons with transfers and when he completed a skin audit around 5:30 PM on 08/12/16 the hematoma to her left arm was not there. Nurse #1 further stated that when he went back to check on Resident #1 he noted that her left arm had increased swelling, the bruise had spread to her left upper arm and Resident #1 complained of pain. Nurse #1 further stated he contacted the physician and obtained an order to send Resident #1 to the hospital for further evaluation. During an interview on 10/05/16 at 3:14 PM, NA #2 stated she worked the 3PM - 11PM shift on 08/12/16 and that she was the assigned NA for Resident #1. NA #2 stated at the end of the shift on 08/12/16, she and NA #3 completed their final rounds, responded to the call light for Resident #1 who requested incontinence care and to be changed into her night clothes. NA #2 stated when she removed the Resident's shirt NA #2 noted a raised bruise to the Resident's left arm. Resident #1 reported to NA #2 that the bruise happened when a NA put her to bed earlier, but that she could not recall who put her to bed or what time. NA #2 stated she immediately reported the bruise to Nurse #1 and while at the nurse's station, NA #1 stated that she put Resident #1 to bed alone, after supper. During a telephone interview on 10/05/16 at 5:41 PM, the Medical Director (MD) stated that Resident #1 was at increased risk for fractures due to her age/comorbidities. The MD stated that the wrist fracture Resident #1 sustained could have occurred as a result of being transferred on 08/12/16 without a gait belt by 1 staff person instead of 2 staff. The MD stated Resident #1 could stand/pivot during transfers, but that her assistance was minimal, which placed the primary responsibility on the staff during transfers. The MD stated Resident #1 required 2 person extensive assistance to transfer or she would fall. The MD also stated he did not know why NA #1 chose to transfer Resident #1 alone, but that it was a mistake that had a bad outcome. The MD further stated that it was quite possible that the 1 person transfer for Resident #1 that occurred on 08/12/16 resulted in her fractured wrist. He stated to be transferred safely, Resident #1 required the extensive assistance of 2 staff persons. Attempts to interview NA #1 and NA #3 were unsuccessful. During a follow up interview on 10/06/16 at 12:30 PM, the Administrator stated the facility's investigation unsubstantiated the allegation of abuse due to a lack of willful intent, but NA #1 was terminated for not following the plan of care for Resident #1 which resulted in injury to the Resident. The Administrator stated the facility began corrective measures in response to the 08/12/16 incident that resulted in injury for Resident #1 and monitoring was ongoing.

Based on observation, record reviews and staff interviews the facility failed to maintain 2 of 6 sampled residents rights to be free from verbal abuse (Resident #1 and Resident #2) and failed to maintain 1 of 6 sampled residents rights to be free from physical abuse (Resident #1). Immediate jeopardy began on [DATE] when Nursing Assistant (NA) #1 was physically and verbally abusive to Resident #1 and verbally abuse to Resident #2. Immediate jeopardy was removed on [DATE] at 7:05 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to resident rights to be free from abuse. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired with no behaviors identified. The MDS further indicated that Resident #1 required extensive assistance with activities of daily living (ADLs). Interview with NA #4 on [DATE] at 12:03 PM revealed that she had been in the dining room on Saturday [DATE] at approximately 5:30 PM when she overheard NA #1 yelling at Resident #1 to stop touching her and to leave her alone. NA #4 stated that Resident #1 would pat your leg if you were sitting beside her and she was patting NA #1's leg and NA #1 got angry and began yelling at Resident #1. Interview with NA #3 on [DATE] at 3:05 PM revealed that she was working in the dining room on the evening of [DATE] and witnessed Resident #1 patting the leg of NA #1. NA #1 then stated oh my God stop it, why do u keep patting me, stop touching me and then NA #1 leaned into the face of Resident #1 and grabbed her right hand and slammed it into the lap of Resident #1 grazing the edge of the table. NA #3 described it like scolding a child, NA #3 further stated that Resident #1 had no reaction except mumbling. NA #3 stated that she had done a staff statement as directed by her nurse. NA #3 stated that she felt like NA #1 had abused Resident #1. Review of Staff Statement for Incident/Accident NA #3 stated that she witnessed NA #1 slam Resident #1's hand and tell her to stop patting her. Another family member also witnessed the way she was talking to the resident and stated that it was inappropriate. Signed by NA #3 and dated [DATE]. Interview with NA #2 on [DATE] at 4:13 PM revealed that she was present in the dining room on [DATE] assisting with supper and witnessed NA #1 get very irritated with Resident #1 who was patting her leg and grabbed her hand and slammed it into Resident #1's lap grazing the table and heard NA #1 state to Resident #1 stop F**king patting my leg. NA #2 stated that what she witnessed between NA #1 and Resident #1 was both physical and verbal abuse because they had just had mandatory training on abuse and were educated on the different types of abuse and included examples of each type. Interview with Visitor #1 on [DATE] at 9:53 AM revealed that she was a sitter for another resident at that facility. Visitor #1 stated that on [DATE] in the dining room at supper time she witnessed Resident #1 rubbing NA #1's leg and NA #1 got so mad at Resident #1 she took her arm and forced it down onto her lap. Visitor #1 stated that NA #1 was very angry and got almost nose to nose with Resident #1 and stated I told you to stop that and keep your hand to yourself. Visitor #1 further stated that she witnessed NA #1 grab the wrist of Resident #1 and shove it into her lap at least 3 times while she was in the dining room tending to the resident she worked for. Interview with NA #1 on [DATE] at 10:27 AM confirmed that she was terminated from the facility on [DATE]. NA #1 stated that on [DATE] she was in the dining room at supper time Resident #1 was patting her leg while she was assisting her with supper and NA #1 stated she took the hand of Resident #1 and put it back in her lap and told her to stop hitting NA #1. NA #1 stated that she did this between 10 to 15 times during the course of the meal. NA #1 confirmed that Resident #1 did not understand what she was saying to her. NA #1 stated that Nurse Supervisor had come into the dining room and got her so they could talk. NA #1 stated that Nurse Supervisor stated he had received a complaint that she was rude to one of the residents but did not specify which resident. NA #1 stated that she told Nurse Supervisor that she was upset at the situation and wanted to be switched to a different unit. After the conversation NA #1 stated she was reassigned to the 400 secure memory care unit for the rest of her shift. Interview with Nurse Supervisor on [DATE] at 2:34 PM revealed that NA #2 reported to him that NA #1 was being verbally aggressive and very hateful to Resident #1, so Nurse Supervisor stated he went to the dining room and asked to speak with NA #1 and asked what was going on. NA #1 stated that Resident #1 was rubbing her leg near her private area and NA #1 stated that she had pushed Resident #1's hand away and told her not to do that. Nurse supervisor stated he asked NA #1 if she was being verbally aggressive and NA #1 stated NO and so Nurse Supervisor asked NA #1 if maybe the tone of her voice could be perceived as verbally aggressive and NA #1 relied maybe. Nurse supervisor again stated that he had reassigned NA #1 to the 400 secure memory care unit for the remained of her shift. Review of email dated [DATE] at 7:15 PM from Nurse Supervisor to Director of Nursing (DON) read in part that a visitor had witnessed NA #1 being rude to Resident #1 and shoving her arm when Resident #1 would pat NA #1 on the leg. When I questioned NA #1 about it she became upset, defensive, and with an aggressive attitude. Nurse Supervisor talked to NA #1 under the camera in the 100 medication unit so the DON could observe her body language an attitude. I moved her to the 400 secure memory care unit for the remainder of her shift. Observation of video footage of Nurse Supervisor talking to NA #1 in the medication room was reviewed on [DATE] at 6:10 PM. There was no sound to the video. Nurse Supervisor and NA #1 entered the room at 6:17 PM and NA #1 was noted to be standing with both arms crossed looking at the floor while Nurse Supervisor talked to her. At one point in the video NA #1 was observed wiping her face. NA #1 was shaking her head back and forth and using hand gestures during most of the conversation. As the conversation continued on NA #1 appeared to somewhat calm down and again wiped her face and at 6:27 PM both NA #1 and Nurse Supervisor exit the medication room and the video ended. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive admission MDS dated [DATE] revealed that Resident #2 was severely cognitively impaired and no behaviors were identified. The MDS also indicated that Resident #2 required extensive assistance with ADLs. Review of care plan dated [DATE] read in part Resident #2 had impaired thought process and was forgetful at times. The goal of stated care plan was to accept judgment of staff/significant other as appropriate and interventions included approach resident warmly and positively and in a calm manner and calmly talk with resident and offer reassurance prior to initiating care. Interview with NA #1 on [DATE] at 10:27 AM revealed that on [DATE] they were in the dining room waiting on supper and Resident #2 was trying to leave the dining room and had got his wheelchair caught on the chair she was sitting in. NA #1 stated she got up to untangle the wheelchair and the chair and Resident #2 grabbed her right arm and would not let go NA #1 stated let go of my arm and then jerked her arm away from Resident #2, then Resident #2 grabbed her left arm and was twisting NA #1's pointer finger and again NA #1 stated she jerked her arm from Resident #2 and then walked out of dining room to calm down. Interview with NA #2 on [DATE] at 5:09 PM revealed that on [DATE] at approximately 5:00 PM Resident #2 was in the dining room waiting for supper and had become anxious and uncooperative and tried to leave the dining room. NA #2 stated that she took Resident #2 to see a family member who also resided at the facility to see if that would calm Resident #2 down. NA #2 stated that after Resident #2 had visited with the family member for a few minutes he had calmed down and NA #2 was able to return Resident #2 to the dining room. NA #2 further stated that when she returned Resident #2 to the dining room NA #1 asked NA #2 what is his issue? NA #2 stated to NA #1 that Resident #2 had delusions that his daughter had been killed. NA #2 stated that NA #1 then approached Resident #2 and got down in his face and stated that was a stupid reason to hit me and you had no reason to act like way in a very aggressive and threatening tone. NA #2 also stated that NA #1 was very hateful in the way NA #1 spoke to Resident #2 that evening in the dining room. Review of email sent on [DATE] at 7:15 PM from nurse supervisor to the DON read in part on Saturday evening [DATE] NA #2 witnessed NA #1 being verbally aggressive to Resident #2 when Resident #2 had become combative. Nurse supervisor stated in the email that he had talked to NA #1 and NA #1 stated she was being picked on by everyone and had already gotten in trouble with the DON. NA #1 informed nurse supervisor that she hated working at the facility and it was the most pathetic place she had ever worked at before. NA #1 claimed that the staff did not like her because she was a Yankee. NA #1's body language and attitude was aggressive and more defensive. NA #1 stated that she had changed shifts because she could not get along with her coworkers and now she could not get along with the staff that was there on Saturday. NA #1 agreed to stay for the rest of the shift and I moved her to the 400 secure memory care unit for the remainder of her shift. Observation of video footage of Nurse Supervisor talking to NA #1 in the medication room was reviewed on [DATE] at 6:10 PM. There was no sound to the video. Nurse Supervisor and NA #1 entered the room at 6:17 PM and NA #1 was noted to be standing with both arms crossed looking at the floor while Nurse Supervisor talked to her. At one point in the video NA #1 was observed wiping her face. NA #1 was shaking her head back and forth and using hand gestures during most of the conversation. As the conversation continued on NA #1 appeared to somewhat calm down and again wiped her face and at 6:27 PM both NA #1 and Nurse Supervisor exit the medication room and the video ended. The administrator and DON were notified on [DATE] at 2:30 PM of immediate jeopardy. The administrator provided acceptable credible allegation of compliance on [DATE] at 6:45 PM. Credible Allegation of Compliance F: 223 On [DATE] at 11:00pm, Nursing Assistant (NA) #1, who physically and/or verbally abused Residents #1 and #2 on [DATE], left the facility after working her entire shift. On [DATE] at 3:23 pm, the accused CNA was suspended (she had not returned to work since leaving on [DATE] @ 11:00pm) and was ultimately terminated from employment on [DATE] at 1:20pm. On [DATE] an investigation was initiated on the abuse of Resident #2 by the Director of Nursing which resulted in termination of NA #1 on [DATE] at 1:20pm. On [DATE] the family of Resident #2 was involved in the investigation and was made aware of the investigation initiated on [DATE] as well as of the outcome of the investigation on [DATE] by the Director of Nursing. On [DATE], the Nursing Supervisor was placed on suspension pending further investigation of his role in the allegations of abuse, which occurred on [DATE], for failure to protect residents and properly report resident abuse. As of [DATE] the results of this investigation are pending and the Nursing Supervisor will remain on suspension until the investigation is complete. On [DATE] at 2:19 pm The 24 hour Health Care Personnel Registry (HCPR) abuse/neglect investigation report form for Resident #1 was completed by the Director of Nursing and faxed to HCPR for further investigation of alleged abuse. On [DATE] a head to toe skin assessment was completed on Residents #1 and #2 by the 1st and 2nd shift House Supervisors with no concerns related to potential physical abuse. On [DATE] The 100 unit Social Services Coordinator met with Residents #1 and #2. Each was interviewed regarding the physical and/or verbal abuse that occurred on [DATE] to determine any residual effects from the alleged physical/verbal abuse with no concerns noted. On [DATE] The Administrator revised the facility's Abuse/Neglect Policy and Procedures. These revisions included: Immediate removal of the resident from the abusive situation by the employee who witnesses the abuse. ·Immediate reporting of the abusive situation by the employee who witnesses the abuse to the direct supervisor or any other member of management currently on duty. ·Immediate suspension of the alleged employee by the direct supervisor or member of management. ·Immediate reporting of the abusive situation by the direct supervisor or member of management to the Director of Nursing or the Administrator. On [DATE] at 8:42 am The Responsible Party of Resident #1 was notified of the allegations of physical abuse by the Director of Nursing via phone as well as the pending investigation with results to follow. On [DATE] at 9:00 am, the Director of Nursing completed the NC Board of Nursing Complaint Evaluation Tool to determine reporting requirements for the Nursing Supervisor and obtained a score of 11 which indicated NC Board of Nursing consultation but no requirement for reporting. The Director of Nursing contacted the NC Board of Nursing for the required consultation on [DATE] at 10:00am. The Director of Nursing was given a phone appointment for further review on Monday, [DATE] at 1:30pm. On [DATE] all other residents who are alert and oriented were interviewed by the 100 unit Social Services Coordinator and MDS Coordinators to determine if there were any reports of abuse and/or neglect with no negative responses. On [DATE] head to toe skin assessments were completed on all residents to assess for possible signs of abuse by the Nursing Supervisors, MDS Coordinators, and Risk Management Coordinator. Skin assessments revealed no signs of potential abuse. Between [DATE] and [DATE] an in-service was conducted by the Administrator for all staff on duty regarding resident abuse. The in-service agenda included: 1. Revised Abuse & Neglect policy/procedure to: · Immediate removal of the resident from the abusive situation by the employee who witnesses the abuse · Immediate reporting of the abusive situation by the employee who witnesses the abuse to the direct supervisor or any other member of management currently on duty · Immediate suspension of the alleged employee by the direct supervisor or member of management · Immediate reporting of the abusive situation by the direct supervisor or member of management to the Director of Nursing or the Administrator 2. Definitions of physical and verbal abuse including tone of voice and temperament used towards any resident including scenarios of both physical and verbal abuse. 3. Definition of how to make the immediate notification of abuse allegations and the expectation that such allegations will be reported verbally. 4. Expectations for the immediate protection of any resident in which abuse/neglect are suspected. No staff member, including contract staff, will be allowed to perform any work-related duties until the in-service has been completed following the final In-service on [DATE]. All in-services were given directly by the Administrator. Any new employees hired after the final in-service on [DATE] will receive a review of the revised abuse policy/procedures by the HR Director and/or the Staff Development Coordinator before any duties are performed. Immediate jeopardy was removed on [DATE] at 7:05 PM when staff interviews with nursing staff, administrative staff, and non-nursing staff confirmed that they had received in service training on the facilities revised policy on abuse and neglect, the immediate removal of resident from the abusive situation, and the immediate reporting of the abusive situation to the direct supervisor or any other member of the management on duty.

Based on record reviews and staff interviews the facility failed to thoroughly investigate and submit 24 hour and 5 working day reports to the North Carolina Health Care Personnel Registry (state agency) for a resident with a bruise of unknown origin (Resident #6). The facility also failed to immediately stop verbal abuse when observed (Resident #1 and Resident #2) which led to witnessed physical abuse (Resident #1), failed to remove the perpetrator from resident areas, failed to immediately notify the Administrator and once notified the facility failed to report the incidents of verbal and physical abuse to the North Carolina Health Care Personnel Registry in 24 hours and the investigative findings in the 5 working day report for 3 of 6 sampled residents for abuse (Resident #6, #1 and #2). Immediate jeopardy began on [DATE] when the facility failed to report a bruise of unknown origin (Resident #6) within 24 hours to the Health Care Personnel Registry and failed to conduct a thorough investigation and report those findings in the 5 working day report. Immediate Jeopardy began on [DATE] for Residents #1 and #2 when the facility also failed to report a witnessed incident of physical abuse (Resident #1) and 2 incidents of verbal abuse (Resident #1 and Resident #2) within 24 hours to the Health Care Personnel Registry and failed to conduct a thorough investigation and report those findings in the 5 working day report. Immediate jeopardy was removed on [DATE] at 7:05 PM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective with the immediate removal of residents from abusive situation and the immediate reporting of witnessed abuse to the management staff. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #6 had short and long term memory problems and was severely impaired in cognition for daily decision making. The MDS also indicated Resident #6 was totally dependent on staff for activities of daily living and exhibited no behaviors. A review of an incident report dated [DATE] at 1:45 AM revealed Nurse Aide (NA) # 5 reported to Nurse # 2 that Resident #6 had a 5 inch x 4 inch bruise on her left upper arm. The report indicated Resident #6 was sleeping when the bruise was found during the first round on the night shift. The report further indicated the bruise was located on the upper front, inside and outside left arm and was purple in color and the possible causes were listed as unknown. Nurse #2's handwritten statement revealed NA #5 called for her to look at Resident #6 and upon assessment, there was a 5 inch x 4 inch purple bruise on Resident #6's upper left arm. Nurse #2 documented she asked Resident #6 if she was in any pain and she stated yeah and when Nurse #2 touched the bruise, Resident #6 grimaced and pulled away. A review of a handwritten witness statement by NA #5 revealed she went into Resident #6's room to check and change her. She documented Resident #6 seemed to be in a lot of pain so NA #5 checked her over and noticed Resident #6's upper left arm was very badly bruised and swollen and she notified Nurse #2. A section for an explanation and detailed circumstances surrounding the bruise revealed a bruised area covered most of Resident #6's left upper arm (5 inches x4 inches) and was swollen. The notes indicated when the bruise was touched it was hard and knotted and Resident #6 grimaced and vocalized sounds. The report further revealed NA #1 and NA #3 had been assigned to work on the hall where Resident #6 lived on second shift from 3:00 PM until 11:00 PM on [DATE]. However, when NA #5 clocked in and went to the nurse's station for report NA #1 had left without telling anyone. NA #3 gave report to NA #5 but did not report any bruising on Resident #6's left upper arm. A review of a nurse's note dated [DATE] at 7:34 AM revealed NA #5 informed Nurse #2 that Resident #6 had a huge bruise on her left upper arm. The notes indicated Nurse #2 assessed the area and Resident #6 had a bruise that was 5 inches tall and 4 inches wide and covered the entire front of Resident #6's left upper arm. The notes revealed Resident #6 was unable to state how the bruise was obtained and Nurse #2 asked Resident #6 if she was in pain, and she replied yeah and when the left upper arm was touched or moved, Resident #6 grimaced, grunted and pulled away. The notes further revealed Nurse #2 gave Resident #6 [MEDICATION NAME] for pain and left a note in the physician's communication book for review. A review of a nurse's note dated [DATE] at 10:02 AM indicated an X-ray was obtained of Resident #6's left upper arm due to bruising, swelling and was painful to touch. A review of x-ray results dated [DATE] revealed 2 views of the left humerus (upper arm bone) and the impression was mild arthrosis (wear and tear on the joints) with moderate demineralization (dissolving bone). A review of a typed document dated [DATE] and signed by the Director of Nursing (DON) indicated it was brought to his attention that Resident #6 had bruising to her left arm 5 inches x 4 inches. The document revealed this was discovered according to an incident report dated [DATE] at 1:45 AM which had been presented to the DON by the Risk Management Nurse for follow up. The document revealed the DON spoke to Resident #6's family who indicated she had a history of [REDACTED].#6's clinical record and noted she required a lift for transfers. The document revealed on [DATE] at 3:15 PM the DON observed Resident #6's lift transfer by NA #6 who was assigned to care for Resident #6 and noted Resident #6 had her arms folded across her chest during the transfer. The document revealed at that time the resident's bruise was unrelated to any staff harm and had no indications it originated from any harm caused by a staff member. The document further indicated it was not established that NA #1 had caused the injury but if at any time any new information was presented that would indicate NA #1 caused the injury, either intentionally or otherwise, a formal investigation would be opened and submitted to the licensure agency per facility policy. A review of handwritten notes on a sheet of notebook paper dated [DATE] at 3:15 PM by the DON revealed NA #1's name at the top of the page highlighted with yellow highlighter and notes revealed Resident #6 on lift properly may be of concern (NA #6 did good ), concerns related to bruises on both legs and arm on 2 lift occasions. During an interview on [DATE] at 12:08 PM the Administrator explained she expected to be notified by the DON anytime an investigation of abuse was started and if the DON had any questions then she would assist as needed. The Administrator stated with any investigation staff was expected to complete a full investigation that included interviews with all staff involved so a thorough investigation would be completed and the incidents reported to the North Carolina Health Care Personnel Registry on the initial 24 hour report and the 5 working day report. During an interview on [DATE] at 9:32 AM the Risk Management Nurse stated it was her usual routine when she came to the facility in the morning to make rounds and she picked up 24 hour reports and incident reports from the day before. She stated on [DATE] she took documents to her desk and sorted through them and found Resident #6 had a bruise on her left upper arm. She further stated it looked like a big bruise so she reviewed Resident #6's skin assessments and medications and then she went to Resident #6's room and looked at the bruise. She explained the bruise was on Resident #6's left upper arm and was very purple and looked like a new bruise. She further explained the whole upper left arm was purple and she knew Resident #6 was transferred with a lift but she did not know if staff had positioned Resident #6 in the lift correctly during transfers. She stated she was at a loss as to what had caused the bruise and recalled she had asked the DON to look into the bruise and he took it from there. She stated she did not participate in any investigation related to the bruise on Resident #6's left upper arm. During an interview on [DATE] at 11:04 AM, Nurse #2 stated she remembered the bruise on Resident 6's left upper arm at the end of [DATE]. She explained NA #1 and NA #3 were supposed to be sharing work on the evening shift from 3:00 PM until 11:00 PM on [DATE] and they were supposed to stay for report with night shift staff at 11:00 PM but NA #1 left without telling anyone and didn't stay for report. She confirmed the bruise had not been reported to her by the 3:00 PM to 11:00 PM nurse at shift change during report on [DATE]. She explained NA #5 was making her first round on the night shift on [DATE] after 1:00 AM and noticed Resident #6's gown needed to be changed. She further explained when NA #5 removed Resident #6's gown she saw the bruising and swelling on Resident #6's left upper arm and reported it to Nurse #2. She explained Resident #6 had bruising on her left upper arm and when she first saw it Resident #6's left upper arm was really swollen and further described it as huge. She stated the area was warm to touch and felt firm and hard and was purple and looked like it was a new bruise. She explained the bruise was located above Resident #6's left elbow and up in the center of her upper arm and it kind of looked like the size of a hand but she did not see any fingerprints or indentions in the area. She stated it alarmed her because of the size. She further explained Resident #6 was immobile and could not move herself in bed. She stated Resident #6 could not verbalize anything but grunted and made a frown face and she could tell it hurt her when they moved her left arm and she reported the bruising to the first shift nurse during the change of shift report around 7:00 AM on [DATE]. She explained she completed the incident report and wrote her statement on the report and passed the paperwork on when she gave report to the first shift nurse on [DATE] but no one from Administration had asked her about it and she did not know anything about an investigation. During an interview on [DATE] at 12:36 PM the DON explained he received the incident report for Resident #6's bruise on her upper left arm from the Risk Management Nurse on [DATE]. He stated he was concerned her arm might have been injured during a lift transfer and wanted to see her transferred in the lift. He explained he observed NA #6 transfer Resident #6 but he did not observe NA #1 or NA #3 transfer the resident. He stated during the lift transfer Resident #6 had her arms folded across her chest and he felt the bruise was due to the position of the resident in the lift when her arms were pressed together when the lift was raised. He explained he talked to Resident #6's family who stated she bruised easily. He confirmed he did not investigate further and did not interview staff who had provided care to Resident #6 prior to the bruise found on [DATE]. He also confirmed he did not submit a 24 hour or 5 working day report to the state agency because at the time he did not consider the bruise was caused by an injury of unknown origin. During a telephone interview on [DATE] at 3:30 PM, NA #5 explained she remembered the bruise on Resident #6's left upper arm at the end of [DATE]. She explained she received shift report from NA #3 because NA #1 had left without telling anyone. She stated NA #3 did not report anything about a bruise on Resident #6's arm but during her first round of the shift she noticed Resident #6's gown was soiled and when she changed it she saw the bruise on Resident #6's left upper arm, chest and armpit. NA #5 stated it upset her when she saw it and she wanted to know what had happened and wondered how could it have happened. She explained she immediately notified Nurse #2 who came to Resident #6's room and looked at it and the bruising went down from her left arm under her armpit and on her chest and partially around her breast and the color of the bruise was purplish. She explained Resident #6 was moaning and she could tell by Resident #6's facial expression she was in pain. She stated Nurse #2 assessed Resident #6 and wrote a statement and NA #5 stated she wrote a statement. She confirmed no one from administration called her or talked to her to ask about Resident #6's bruise or what had happened so she assumed someone took care of it. On [DATE] at 3:43 PM attempts were made to contact NA #3 by phone but there was no answer. A message was left for her to return the call however, NA #3 did not return the phone call. On [DATE] at 3:55 PM attempts were made to contact NA #7 who was assigned to care for Resident #6 on the day shift on [DATE]. There was no answer and there was no voicemail option to leave a message for her to return the call. On [DATE] at 4:23 PM an attempt to contact NA #1 who no longer worked at the facility was made by phone. There was no answer and a message was left for her to return the call however, NA #1 did not return the phone call. During a follow up interview on [DATE] at 2:00 PM the Administrator stated she was made aware of the bruise on Resident #6's left upper arm during the morning meeting but now had been further brought up to speed about the incident. She stated it was her expectation that nursing staff should assess immediately for possible causes of an injury before they handed the information off to upper management and a thorough investigation should be completed and the 24 hour and 5 working day reports should be submitted as required. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired with no behaviors identified. The MDS further indicated that Resident #1 required extensive assistance with activities of daily living (ADLs). Interview with Nursing Assistant (NA) #4 on [DATE] at 12:03 PM revealed that she had been in the dining room on Saturday [DATE] at approximately 5:30 PM when she overheard NA #1 yelling at Resident #1 to stop touching her and to leave her alone. NA #4 stated that Resident #1 would pat your leg if you were sitting beside her and she was patting NA #1's leg and NA #1 got angry and began yelling at Resident #1. NA #4 stated that when she finished feeding the resident she was assisting she had reported it to a nurse but could not recall which one. No written statement by NA #4 about this incident was available. Interview with NA #3 on [DATE] at 3:05 PM revealed that she was working in the dining room on the evening of [DATE] and witnessed Resident #1 patting the leg of NA #1. NA #3 stated that NA #1 then stated oh my God stop it, why do u keep patting me, stop touching me and then NA #1 leaned into the face of Resident #1 and grabbed her right hand and slammed it into the lap of Resident #1 grazing the edge of the table. NA #3 described it like scolding a child, NA #3 further stated that Resident #1 had no reaction except mumbling. NA #3 stated that she felt like NA #1 had abused Resident #1. NA #3 stated she had reported the incident to Nurse #1 and had wrote a statement about the incident as instructed by Nurse #1. Review of Staff Statement for Incident/Accident written by NA #3 stated that she witnessed NA #1 slam Resident #1's hand and told her to stop patting her. Another family member also witnessed the way she was talking to the resident and stated that it was inappropriate. Signed by NA #3 and dated [DATE]. Interview with NA #2 on [DATE] at 4:13 PM revealed that she was present in the dining room on [DATE] assisting with supper and witnessed NA #1 get very irritated with Resident #1 who was patting her leg and grabbed her hand and slammed it into Resident #1's lap grazing the table and heard NA #1 state to Resident #1 stop F**king patting my leg. NA #2 stated that what she witnessed between NA #1 and Resident #1 was both physical and verbal abuse because they had just had mandatory training on abuse and were educated on the different types of abuse and included examples of each type. NA #2 stated she had reported the incident to the Nurse Supervisor. No written statement by NA #2 about this incident was available. Interview with Visitor #1 on [DATE] at 9:53 AM revealed that she was a sitter for another resident at that facility. Visitor #1 stated that on [DATE] in the dining room at supper time she witnessed Resident #1 rubbing NA #1's leg and NA #1 got so mad at Resident #1 she took her arm and forced it down onto her lap. Visitor #1 stated that NA #1 was very angry and got almost nose to nose with Resident #1 and stated I told you to stop that and keep your hand to yourself. Visitor #1 further stated that she witnessed NA #1 grab the wrist of Resident #1 and shove it into her lap at least 3 times while she was in the dining room tending to the resident she worked for. Visitor #1 stated that she had reported the incident to a nurse and that later that evening the Nurse Supervisor came and thanked her for reporting the incident. No written statement by Visitor #1 about this incident was available. Interview with Nurse #1 on [DATE] at 3:20 PM revealed that NA #3 reported the incident with NA #1 and Resident #1 in the dining room on [DATE] at approximately 6:30 PM. Nurse #1 stated the Nurse supervisor was already aware. Nurse #1 thanked NA #3 for reporting the incident to him and instructed NA #3 to write a statement about what she witnessed. Nurse #1 further stated that he did nothing further because he took for granted the Nurse Supervisor was taking care of the situation. No written statement by Nurse #1 about this incident was available. Interview with Nurse Supervisor on [DATE] at 2:34 PM revealed that NA #2 reported to him that NA #1 was being verbally aggressive and very hateful to Resident #1. Nurse Supervisor stated he went to the dining room and asked to speak with NA #1 and asked what was going on. NA #1 stated that Resident #1 was rubbing her leg near her private area and NA #1 stated that she had pushed Resident #1's hand way and told her not to do that. Nurse supervisor stated he asked NA #1 if she was being verbally aggressive and NA #1 stated NO and so Nurse Supervisor asked NA #1 if maybe the tone of her voice could be perceived as verbally aggressive and NA #1 relied maybe. Nurse supervisor again stated that he had reassigned NA #1 to the 400 secure memory care unit for the remained of her shift. Nurse Supervisor confirmed that he had not spoken to the DON but had sent an email notifying him of the incidents that happened on [DATE]. Nurse Supervisor further stated that his only other action besides talking to NA #1 was to reassign her to another unit for the remainder of her shift. No written statement by Nurse Supervisor about this incident was available. Review of email dated [DATE] at 7:15 PM from Nurse Supervisor to Director of Nursing (DON) read in part that a visitor had witnessed NA #1 being rude to Resident #1 and shoving her arm when Resident #1 would pat NA #1 on the leg. When I questioned NA #1 about it she became upset, defensive, and with an aggressive attitude. Nurse Supervisor talked to NA #1 under the camera in the 100 medication unit so the DON could observe her body language an attitude. I moved her to the 400 secure memory care unit for the remainder of her shift. Interview with DON on [DATE] at 3:37 PM revealed that he was made aware of the incident on [DATE] via email from Nurse Supervisor that he received on [DATE] when he arrived at work. The DON stated that NA #1 thought the staff did not like her because she was a Yankee. NA #1 told DON that Resident #1 was putting her hand on NA #1's leg and NA #1 was placing it back on Resident #1. The DON confirmed that there was no investigation completed on the incident with Resident #1 and had not been reported to the North Carolina Health Care Personnel Registry via the initial 24 hour report or the 5 working day report. The DON further stated he had not talked to the sitter/visitor that was present in the dining room that day because he had no contact information for that sitter/visitor, and the DON confirmed that he had not spoken to the other NA's that were working that evening. The DON stated that if abuse had been reported to Nurse Supervisor the expectation is that Nurse Supervisor would contact the DON or the administrator immediately. Interview with the Administrator on [DATE] at 12:08 PM revealed that she was notified by the DON anytime an investigation of abuse was started and if the DON had any question then she would assist as needed. The administrator also stated that if abuse is reported to Nurse Supervisor he would immediately notify the DON and/or administrator. The administrator went on to say that with any investigation staff is expected to complete a full investigation that included interviews with all staff involved and the nurse supervisor was fully capable of starting the investigation which should have included the immediate suspension of NA #1 and immediately notifying the DON so a thorough investigation could be completed and the incidents reported to the Health Care Personnel Registry via the initial 24 hour report and the 5 working day report. Review of 24 hour initial report dated [DATE] was filed by DON stated that report was given to DON regarding staff member slamming resident hand off of the employee's knee and putting it back on the residents knee. On [DATE] during conversation with state surveyor it was asked if I was aware of any verbal abuse toward resident to which nothing had been reported, prompting this investigation to be opened. Signed by the DON on [DATE]. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #2 was severely cognitively impaired and no behaviors were identified. The MDS also indicated that Resident #2 required extensive assistance with ADLs. Interview with NA #2 on [DATE] at 5:09 PM revealed that on [DATE] at approximately 5:00 PM Resident #2 was in the dining room waiting for supper and had become anxious and uncooperative and tried to leave the dining room. NA #2 stated that she took Resident #2 to see a family member who also resided at the facility to see if that would calm Resident #2 down. NA #2 stated that after Resident #2 had visited with the family member for a few minutes he had calmed down and NA #2 was able to return Resident #2 to the dining room. NA #2 further stated that when she returned Resident #2 to the dining room NA #1 asked NA #2 what is his issue? NA #2 stated to NA #1 that Resident #2 had delusions that his daughter had been killed. NA #2 stated that NA #1 then approached Resident #2 and got down in his face and stated that was a stupid reason to hit me and you had no reason to act like way in a very aggressive and threatening tone. NA #2 also stated that NA #1 was very hateful in the way NA #1 spoke to Resident #2 that evening in the dining room. NA #2 stated she reported this to the Nurse Supervisor at approximately 5:15 PM. The written statement obtained from NA #2 about this incident read in part that she had help calm Resident #2 down when he became worried and combative about delusions that his daughter had been killed in a car accident. NA #2 stated she was able to calm Resident #1 down and NA #1 grew upset with Resident #2 and starting fussing at Resident #2 and stated he had no reason to treat her that way. Interview with Nurse supervisor on [DATE] at 2:34 PM stated that on [DATE] at approximately 5:15 PM NA #2 reported to him that NA #1 had been very hateful to Resident #2 and was talking very loudly, more loudly then she should have been to Resident #2 in the dining room. Nurse Supervisor confirmed that he had not spoken to the DON but had sent an email notifying him of the incidents that happened on [DATE]. Nurse Supervisor further stated that his only other action besides talking to NA #1 was to reassign her to another unit for the remainder of her shift. No written statement by Nurse Supervisor about this incident was available. Review of email sent on [DATE] at 7:15 PM from nurse supervisor to Director of Nursing (DON) read in part on Saturday evening [DATE] NA #2 witnessed NA #1 being verbally aggressive to Resident #2 when Resident #2 had become combative. Nurse supervisor stated in the email that he had talked to NA #1 and NA #1 stated she was being picked on by everyone and had already gotten in trouble with the DON. NA #1 informed nurse supervisor that she hated working at the facility and it was the most pathetic place she had ever worked at before. NA #1 claimed that the staff did not like her because she was a Yankee. NA #1's body language and attitude was aggressive and more defensive. NA #1 stated that she had changed shifts because she could not get along with her coworkers and now she could not get along with the staff that was there on Saturday. NA #1 agreed to stay for the rest of the shift and I moved her to the 400 secure memory care unit for the remainder of her shift. Interview with DON on [DATE] at 3:37 PM stated that he was not made aware of the incident until Monday [DATE] when he arrived at work and read the email from Nurse Supervisor. The DON confirmed that there was no investigation completed on Resident #2 and the incident was not reported to the North Carolina Health Care Personnel Registry via the 24 hour initial report and 5 working day report. The DON also stated he had not spoken to the NA's that where working that evening about the incident and had not obtained statements from them regarding the incident. The DON further stated that he trusted the Nurse supervisor because he was present at the time and had a better idea of what happened. The DON stated if any abuse was reported to Nurse Supervisor he should immediately notify the DON. The DON again confirmed this incident was not investigated and was not reported to the Health Care Personnel Registry. Interview with the Administrator on [DATE] at 12:08 PM revealed that she was notified by the DON anytime an investigation of abuse was started and if the DON had any question then she would assist as needed. The administrator also stated that if abuse is reported to Nurse Supervisor he would immediately notify the DON and/or administrator. The administrator went on to say that with any investigation staff is expected to complete a full investigation that included interviews with all staff involved and the nurse supervisor was fully capable of starting the investigation which should have included the immediate suspension of NA #1 and immediately notifying the DON so a thorough investigation could be started and the incidents reported to the Health Care Personnel Registry via the initial 24 hour report and the 5 working day report. The administrator and DON were notified on [DATE] at 2:30 PM of immediate jeopardy. The administrator provided acceptable credible allegation of compliance on [DATE] at 6:45 PM. Credible Allegation of Compliance F 225: (1) On [DATE], Resident #6 had a bruise of unknown origin with no 24 hour report or 5 day working report submitted to the NC Health Care Personnel Registry and a thorough investigation was not completed. On [DATE] at 11:00pm, Nursing Assistant (NA) #1, who physically and/or verbally abused Residents #1 and #2 on [DATE], left the facility after working her entire shift. On [DATE] at 3:23pm, the accused CNA was suspended (she had not returned to work since leaving on [DATE] @ 11:00pm) and was ultimately terminated from employment on [DATE] at 1:20pm. On [DATE] an investigation was initiated on the abuse of Resident #2 by the Director of Nursing which resulted in termination of NA #1 on [DATE] at 1:20pm. On [DATE] the family of Resident #2 was involved in the investigation and was made aware of the investigation initiated on [DATE] as well as of the outcome of the investigation on [DATE] by the Director of Nursing. On [DATE], the Nursing Supervisor was placed on suspension pending further investigation of his role in the allegations of abuse for Residents #1 and #2, which occurred on [DATE], for failure to protect residents and properly report resident abuse. As of [DATE]. The results of this investigation are pending and the Nursing Supervisor will remain on suspension until the investigation is complete. On [DATE] at 2:19 pm The 24 hour Health Care Personnel Registry (HCPR) abuse/neglect investigation report form for Resident #1 was completed by the Director of Nursing and faxed to HCPR for further investigation of alleged abuse. On [DATE] @ 2:19pm the 24 hour abuse/neglect investigation report form for Resident #1 was completed and faxed for further investigation of alleged abuse. On [DATE] @ 3:20pm, Nursing Assistant (NA) #2 and Nursing Assistant (NA) #3 who failed to immediately report allegations of abuse towards Resident #1 and Resident #2 were suspended pending further investigation of their actions related to the allegations. NA #2 and NA #3received written disciplinary actions for failure to immediately report allegations of abuse according to the Abuse/Neglect policy on [DATE] and will return to work as of [DATE]. On [DATE] at 9:00 am, the Director of Nursing completed the NC Board of Nursing Complaint Evaluation Tool to determine reporting requirements for the Nursing Supervisor and obtained a score of 11 which indicated NC Board of Nursing consultation but no requirement for reporting. The Director of Nursing contacted the NC Board of Nursing for the required consultation on [DATE] at 10:00am. The Director of Nursing was given a phone appointment for further review on Monday, [DATE] at 1:30pm. On [DATE] @5:19pm, the 24 hour Health Care Personnel Registry (HCPR) abuse/neglect investigation report form for Resident #6 was completed by the Director of Nursing and faxed to HCPR for further investigation of alleged abuse. (2) Residents #1, #2, and #6 were assessed by the 100 unit Social Services Coordinator on [DATE] for any residual effects from the alleged physical/verbal abuse with no concerns noted. An in-service was conducted by the Administrator for all staff on duty on [DATE] regarding resident abuse. The in-service agenda included: 1. Revised Abuse & Neglect policy/procedure to: · Immediate removal of the resident from the abusive situation by the employee who witnesses the abuse · Immediate reporting of the abusive situation by the employee who witnesses the abuse to the direct supervisor or any other member of management currently on duty · Immediate suspension of the alleged employee by the direct supervisor or member of management · Immediate reporting of the abusive situation by the direct supervisor or member of management to the Director of Nursing or the Administrator 2. Definitions of physical and verbal abuse including tone of voice and temperament used towards any resident including scenarios of both physical and verbal abuse. 3. Definition of how to make the immediate notification of abuse allegations and the expectation that such allegations will be reported verbally. 4. E

Based on record reviews and staff interviews the facility failed to operationalize policy and procedures to thoroughly investigate and submit 24 hour and 5 working day reports to the North Carolina Health Care Personnel Registry (state agency) for a resident with a bruise of unknown origin (Resident #6). The facility also failed to immediately stop verbal abuse when observed (Resident #1 and Resident #2) which led to witnessed physical abuse (Resident #1), failed to remove the perpetrator from resident areas, failed to immediately notify Administrator and once notified the facility failed to report the incidents of verbal and physical abuse to the North Carolina Health Care Personnel Registry in 24 hours and the investigative findings in the 5 working day report for 3 of 6 sampled residents for abuse (Resident #6, #1 and #2). Immediate jeopardy began on [DATE] when the facility failed to report a bruise of unknown origin (Resident #6) within 24 hours to the Health Care Personnel Registry and failed to conduct a thorough investigation and report those findings in the 5 working day report. Immediate Jeopardy began on [DATE] for Residents #1 and #2 when the facility also failed to report a witnessed incident of physical abuse (Resident #1) and 2 incidents of verbal abuse (Resident #1 and Resident #2) within 24 hours to the Health Care Personnel Registry and failed to conduct a thorough investigation and report those findings in the 5 working day report. Immediate jeopardy was removed on [DATE] at 7:05 PM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective with the immediate removal of residents from abusive situation and the immediate reporting of witnessed abuse to the management staff. Findings included: A review of a facility policy titled Abuse and Neglect with a revised date of [DATE] revealed in part the facility prohibits mistreatment, neglect, and abuse of residents and misappropriation of resident's property. It is the responsibility of all staff members to respect resident's rights by not using verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion for any resident in the facility. The facility shall ensure that all alleged violations involving mistreatment, neglect, abuse, or injuries of unknown source, and misappropriation of residents property are reported immediately to the Administrator and the state survey and certification agency. The facility shall investigate all alleged violations and will protect the resident from further potential abuse while the investigation is in progress. The results of all investigations will be reported to the Administrator and the State survey certification agency within five working days of the incident. A section labeled identification revealed a definition of abuse which is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The document indicated any staff member is expected to identify any known and/or suspected case of abuse and/or neglect and to report those suspicions to their supervisor or any other member of management immediately. This may include suspicious bruising or any occurrences, patterns, and trends that may constitute abuse. The Director of Nursing/Assistant Director of Nursing and/or the Administrator is to be notified of suspicious events or allegations of abuse/neglect immediately for the safety of all residents. A section labeled Investigation/Protection indicated if an individual employee is suspected of abuse/neglect, he or she will be placed on suspension pending the outcome of the investigation to ensure the safety of residents. If Administration is unable to determine that there is a clear suspect, all staff assigned to the resident prior to the incident/injury will be interviewed in an effort to identify who may be responsible. A section labeled Reporting indicated the Director of Nursing will be responsible for completing all steps of the investigation process, reviewing with the Administrator daily until the investigation is complete. The Director of Nursing and the Administrator will review all investigations upon completion to evaluate accuracy, timeliness, and completion of all required information prior to making the final decision and/or faxing the final report to the state agency for review. 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #6 had short and long term memory problems and was severely impaired in cognition for daily decision making. The MDS also indicated Resident #6 was totally dependent on staff for activities of daily living and exhibited no behaviors. A review of an incident report dated [DATE] at 1:45 AM revealed Nurse Aide (NA) # 5 reported to Nurse # 2 Resident #6 had a 5 inch x 4 inch bruise on her left upper arm. The report indicated Resident #6 was sleeping when the bruise was found during the first round on the night shift. The report further indicated the bruise was on the upper front, inside and outside left arm and was purple in color and the possible causes were listed as unknown. Nurse #2's handwritten statement revealed NA #5 called for her to look at Resident #6 and upon assessment, there was a 5 inch x 4 inch purple bruise on Resident #6's upper left arm. Nurse #2 documented she asked Resident #6 if she was in any pain and she stated yeah and when Nurse #2 touched the bruise, Resident #6 grimaced and pulled away. A review of a handwritten witness statement by NA #5 revealed she went into Resident #6's room to check and change her. She documented Resident #6 seemed to be in a lot of pain so NA #5 checked her over and noticed Resident #6's upper left arm was very badly bruised and swollen and she notified Nurse #2. A section for an explanation and detailed circumstances surrounding the bruise revealed a bruised area covered most of Resident #6's left upper arm (5 inches x4 inches) and was swollen. The notes indicated when the bruise was touched it was hard and knotted and Resident #6 grimaced and vocalized sounds. The report revealed NA #1 and NA #3 were assigned to work on the hall where Resident #6 lived but when NA #5 clocked in and went to the nurse's station for report NA #1 had left without telling anyone. NA #3 gave report but did not report any bruising on Resident #6's left upper arm. A review of a nurse's note dated [DATE] at 7:34 AM revealed NA #5 informed Nurse #2 that Resident #6 had a huge bruise on her left upper arm. The notes indicated Nurse #2 assessed the area and Resident #6 had a bruise that was 5 inches tall and 4 inches wide and covered the entire front of Resident #6's left upper arm. The notes revealed Resident #6 was unable to state how the bruise was obtained and Nurse #2 asked Resident if she was in pain, and she replied yeah and when the left upper arm was touched or moved, Resident #6 grimaced, grunted and pulled away. The notes further revealed Nurse #2 gave Resident #6 [MEDICATION NAME] for pain and left a note in the physician's communication book for review. A review of a nurse's note dated [DATE] at 10:02 AM indicated an X-ray was obtained of Resident #6's left upper arm due to bruising, swelling and was painful to touch. A review of x-ray results dated [DATE] revealed 2 views of the left humerus (upper arm bone) and the impression was mild arthrosis (wear and tear on the joints) with moderate demineralization (dissolving bone). A review of a typed document dated [DATE] by the Director of Nursing (DON) indicated it was brought to his attention that Resident #6 had bruising to her left arm 5 inches x 4 inches. The document revealed this was discovered according to an incident report dated [DATE] at 1:45 AM and had been presented to the DON by the Risk Management Nurse for follow up. The document revealed the DON spoke to Resident #6's family who indicated she had a history of [REDACTED].#6's clinical record and noted she required a lift for transfers. The document revealed on [DATE] at 3:15 PM the DON observed Resident #6's lift transfer by NA #6 who was assigned to care for Resident #6 and noted Resident #6 had her arms folded across her chest during the transfer. The document revealed at that time it was determined the resident bruise was unrelated to any staff harm and that the resident bruise had no indications that it originated from any harm caused by a staff member. The document further revealed it was not established that NA #1 had caused the injury but if at any time any new information was presented that would indicate NA #1 caused the injury, either intentionally or otherwise, a formal investigation would be opened and submitted to the licensure agency per facility policy. A review of handwritten notes on a sheet of notebook paper dated [DATE] at 3:15 PM by the DON revealed NA #1's name at the top of the page highlighted with yellow highlighter and notes revealed Resident #6 on lift properly may be of concern (NA #6 did good), concerns related to bruises on both legs and arm on 2 lift occasions. During an interview on [DATE] at 12:08 PM the Administrator explained she was notified by the DON anytime an investigation of abuse was started and if the DON had any question then she would assist as needed. The Administrator stated with any investigation staff was expected to complete a full investigation that included interviews with all staff involved so a thorough investigation would be completed and the incidents reported to the North Carolina Health Care Personnel Registry on the initial 24 hour report and the 5 working day report. During an interview on [DATE] at 9:32 AM the Risk Management Nurse stated on [DATE] she reviewed an incident report which indicated Resident #6 had a bruise on her left upper arm. She further stated she looked at Resident #6's skin assessments and medications and then she went to Resident #6's room and looked at the bruise. She described the bruise was on Resident #6's left upper arm which covered the whole upper arm and was very purple and looked like a new bruise. She stated she was at a loss as to what had caused the bruise and recalled she had asked the DON to look into the bruise and he took it from there. She confirmed she did not participate in any investigation related to the bruise on Resident #6's left upper arm. During an interview on [DATE] at 11:04 AM Nurse #2 stated she remembered the bruise on Resident 6's left upper arm at the end of [DATE]. She explained NA #5 was making her first round on the night shift on [DATE] after 1:00 AM and noticed Resident #6's gown needed to be changed. She further explained when NA #5 removed Resident #6's gown she saw the bruising and swelling on Resident #6's left upper arm and reported it to Nurse #2. Nurse #2 confirmed the bruise had not been reported to her by the nurse at shift change during report on [DATE]. She explained when she assessed Resident #6 she had bruising on her left upper arm and described it as huge and swollen. She stated the area was warm to touch and felt firm and hard and was purple and looked like it was a new bruise. She explained the bruise was located above Resident #6's left elbow and up in the center of her upper arm and it kind of looked like the size of a hand but she did not see any fingerprints or indentions in the area. She stated it alarmed her because of the size. She further explained Resident #6 was immobile and could not move herself in bed. She stated Resident #6 could not verbalize anything but grunted and made a frown face and she could tell it hurt her when they moved her left arm and she reported the bruising to the first shift nurse during the change of shift report around 7:00 AM on [DATE]. She explained she completed the incident report and wrote her statement on the report and passed the paperwork on when she gave report to the first shift nurse on [DATE] but no one from Administration had asked her about it and she did not know anything about an investigation. During an interview on [DATE] at 12:36 PM the DON explained he received the incident report for Resident #6's bruise on her upper left arm from the Risk Management Nurse on [DATE]. He stated he was concerned her arm might have been injured during a lift transfer and wanted to see her transferred in the lift so he observed NA #6 transfer Resident #6 with a lift. He confirmed he did not investigate further or observe NA #1 or NA #3 transfer the resident and he did not submit a 24 hour or 5 working day report to the state agency because at the time he did not consider the bruise was caused by an injury of unknown origin. During a telephone interview on [DATE] at 3:30 PM, NA #5 explained she remembered the bruise on Resident #6's left upper arm at the end of [DATE]. She stated during her first round of the shift she noticed Resident #6's gown was soiled and when she changed it she saw the bruise on Resident #6's left upper arm, chest and armpit. She explained she immediately notified Nurse #2 who came to Resident #6's room and looked at it and the bruising went down from her left arm under her armpit and on her chest and partially around her breast and the color of the bruise was purplish. She explained Resident #6 was moaning and she could tell by Resident #6's facial expression she was in pain. She stated Nurse #2 assessed Resident #6 and wrote a statement and NA #5 stated she wrote a statement. She confirmed no one from administration called her or talked to her to ask about Resident #6's bruise or what had happened so she assumed someone took care of it. On [DATE] at 3:43 PM attempts were made to contact NA #3 by phone but there was no answer and a message was left for her to return the call however, NA #3 did not return the phone call. On [DATE] at 3:55 PM attempts were made to contact NA #7 who was assigned to care for Resident #6 on the day shift on [DATE]. There was no answer and there was no voicemail option to leave a message for her to return the call. On [DATE] at 4:23 PM an attempt to contact NA #1 who no longer worked at the facility was made by phone but there was no answer and a message was left for her to return the call however, NA #1 did not return the phone call. During a follow up interview on [DATE] at 2:00 PM the Administrator stated she was made aware of the bruise on Resident #6's left upper arm during the morning meeting but now had been further brought up to speed about the incident. She stated it was her expectation for a thorough investigation to be completed and the 24 hour and 5 working day reports to be submitted as required. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired with no behaviors identified. The MDS further indicated that Resident #1 required extensive assistance with activities of daily living (ADLs). Interview with Nursing Assistant (NA) #4 on [DATE] at 12:03 PM revealed that she had been in the dining room on Saturday [DATE] at approximately 5:30 PM when she overheard NA #1 yelling at Resident #1 to stop touching her and to leave her alone. NA #4 stated that Resident #1 would pat your leg if you were sitting beside her and she was patting NA #1's leg and NA #1 got angry and began yelling at Resident #1. NA #4 stated that when she finished feeding the resident she was assisting she had reported it to a nurse but could not recall which one. No written statement by NA #4 about this incident was available. Interview with NA #3 on [DATE] at 3:05 PM revealed that she was working in the dining room on the evening of [DATE] and witnessed Resident #1 patting the leg of NA #1. NA #3 stated that NA #1 then stated oh my God stop it, why do you keep patting me, stop touching me and then NA #1 leaned into the face of Resident #1 and grabbed her right hand and slammed it into the lap of Resident #1 grazing the edge of the table. NA #3 described it like scolding a child, NA #3 further stated that Resident #1 had no reaction except mumbling. NA #3 stated that she felt like NA #1 had abused Resident #1. NA #3 stated she had reported the incident to Nurse #1 and had wrote a statement about the incident as instructed by Nurse #1. Review of Staff Statement for Incident/Accident written by NA #3 stated that she witnessed NA #1 slam Resident #1's hand and told her to stop patting her. Another family member also witnessed the way she was talking to the resident and stated that it was inappropriate. Signed by NA #3 and dated [DATE]. Interview with NA #2 on [DATE] at 4:13 PM revealed that she was present in the dining room on [DATE] assisting with supper and witnessed NA #1 get very irritated with Resident #1, who was patting her leg, and NA #1 grabbed her hand and slammed it into Resident #1's lap grazing the table and heard NA #1 state to Resident #1 stop F**king patting my leg. NA #2 stated that what she witnessed between NA #1 and Resident #1 was both physical and verbal abuse because they had just had mandatory training on abuse and were educated on the different types of abuse and included examples of each type. NA #2 stated she had reported the incident to the Nurse Supervisor. No written statement by NA #2 about this incident was available Interview with Visitor #1 on [DATE] at 9:53 AM revealed that she was a sitter for another resident at that facility. Visitor #1 stated that on [DATE] in the dining room at supper time she witnessed Resident #1 rubbing NA #1's leg and NA #1 got so mad at Resident #1 she took her arm and forced it down onto her lap. Visitor #1 stated that NA #1 was very angry and got almost nose to nose with Resident #1 and stated I told you to stop that and keep your hand to yourself. Visitor #1 further stated that she witnessed NA #1 grab the wrist of Resident #1 and shove it into her lap at least 3 times while she was in the dining room tending to the resident she worked for. Visitor #1 stated that she had reported the incident to a nurse and that later that evening the Nurse Supervisor came and thanked her for reporting the incident. No written statement by Visitor #1 about this incident was available. Interview with Nurse #1 on [DATE] at 3:20 PM revealed that NA #3 reported the incident with NA #1 and Resident #1 in the dining room on [DATE] at approximately 6:30 PM. Nurse #1 stated the Nurse supervisor was already aware. Nurse #1 thanked NA #3 for reporting the incident to him and instructed NA #3 to write a statement about what she witnessed. Nurse #1 further stated that he did nothing further because he took it for granted the Nurse Supervisor was taking care of the situation. No written statement by Nurse #1 about this incident was available. Interview with Nurse Supervisor on [DATE] at 2:34 PM revealed that NA #2 reported to him that NA #1 was being verbally aggressive and very hateful to Resident #1. Nurse Supervisor stated he went to the dining room and asked to speak with NA #1 and asked what was going on. NA #1 stated that Resident #1 was rubbing her leg near her private area and NA #1 stated that she had pushed Resident #1's hand away and told her not to do that. Nurse supervisor stated he asked NA #1 if she was being verbally aggressive and NA #1 stated NO and so Nurse Supervisor asked NA #1 if maybe the tone of her voice could be perceived as verbally aggressive and NA #1 replied maybe. Nurse supervisor again stated that he had reassigned NA #1 to the 400 secure memory care unit for the remainder of her shift. Nurse Supervisor confirmed that he had not spoken to the director of nursing (DON) but had sent an email notifying him of the incidents that happened on [DATE]. Nurse Supervisor further stated that his only other action besides talking to NA #1 was to reassign her to another unit for the remainder of her shift. No written statement by Nurse Supervisor about this incident was available. Review of email dated [DATE] at 7:15 PM from Nurse Supervisor to DON read in part that a visitor had witnessed NA #1 being rude to Resident #1 and shoving her arm when Resident #1 would pat NA #1 on the leg. When I questioned NA #1 about it she became upset, defensive, and with an aggressive attitude. Nurse Supervisor talked to NA #1 under the camera in the 100 medication unit so the DON could observe her body language an attitude. I moved her to the 400 secure memory care unit for the remainder of her shift. Interview with the DON on [DATE] at 3:37 PM revealed that he was made aware of the incident on [DATE] via email from Nurse Supervisor that he received on [DATE] when he arrived at work. NA #1 told DON that Resident #1 was putting her hand on NA #1's leg and NA #1 was placing it back on Resident #1. The DON confirmed that there was no investigation completed on the incident with Resident #1 and had not been reported to the North Carolina Health Care Personnel Registry via the initial 24 hour report or the 5 working day report. The DON further stated he had not talked to the sitter/visitor that was present in the dining room that day because he had no contact information for that sitter/visitor, and the DON confirmed that he had not spoken to the other NAs that were working that evening. The DON stated that if abuse had been reported to Nurse Supervisor the expectation is that Nurse Supervisor would contact the DON or the administrator immediately. Interview with the Administrator on [DATE] at 12:08 PM revealed that she was notified by the DON anytime an investigation of abuse was started and if the DON had any question then she would assist as needed. The Administrator confirmed that the DON had not reported the incident with NA #1 and Resident #1 to the Health Care Personnel Registry and had not completed a full investigation. The Administrator also stated that if a NA had witnessed the incident on [DATE] at supper in the dining room then an investigation should have been completed. The administrator also stated that if abuse is reported to Nurse Supervisor he would immediately notify the DON and/or administrator. The administrator went on to say that staff is expected to complete a full investigation that included interviews with all staff involved. The administrator stated that nurse supervisor was fully capable of starting the investigation which should have included the immediate suspension of NA #1. The administrator further stated nurse supervisor should have immediately notified the DON so a thorough investigation could be completed and the incidents reported to the Health Care Personnel Registry via the initial 24 hour report and the 5 working day report as stated in the facility policy. The Administrator stated, after conversations with the DON yesterday, he felt like he should have done something so he filled out and faxed the 24 hour initial report to the Health Care Personnel Registry. 3. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive admission minimum data set ((MDS) dated [DATE] revealed that Resident #2 was severely cognitively impaired and no behaviors were identified. The MDS also indicated that Resident #2 required extensive assistance with ADLs. Interview with NA #2 on [DATE] at 5:09 PM revealed that on [DATE] at approximately 5:00 PM Resident #2 was in the dining room waiting for supper and had become anxious and uncooperative and tried to leave the dining room. NA #2 stated that she took Resident #2 to see a family member who also resided at the facility to see if that would calm Resident #2 down. NA #2 stated that after Resident #2 had visited with the family member for a few minutes he had calmed down and NA #2 was able to return Resident #2 to the dining room. NA #2 further stated that when she returned Resident #2 to the dining room NA #1 asked NA #2 what is his issue? NA #2 stated to NA #1 that Resident #2 had delusions that his daughter had been killed. NA #2 stated that NA #1 then approached Resident #2 and got down in his face and stated that was a stupid reason to hit me and you had no reason to act like way in a very aggressive and threatening tone. NA #2 also stated that NA #1 was very hateful in the way NA #1 spoke to Resident #2 that evening in the dining room. NA #2 stated she reported this to the Nurse Supervisor at approximately 5:15 PM. Interview with the Nurse supervisor on [DATE] at 2:34 PM revealed that on [DATE] at approximately 5:15 PM NA #2 reported to him that NA #1 had been very hateful to Resident #2 and was talking very loudly, more loudly than she should have been to Resident #2 in the dining room. Nurse Supervisor confirmed that he had not spoken to the DON but had sent an email notifying him of the incidents that happened on [DATE]. Nurse Supervisor further stated that his only other action besides talking to NA #1 was to reassign her to another unit for the remainder of her shift. No written statement by Nurse Supervisor about this incident was available. Interview with DON on [DATE] at 3:37 PM stated that he was not made aware of the incident until Monday [DATE] when he arrived at work and read the email from Nurse Supervisor. The DON confirmed that there was no investigation completed on Resident #2 and the incident was not reported to the North Carolina Health Care Personnel Registry via the 24 hour initial report and 5 working day report. The DON also stated he had not spoken to the NAs that were working that evening about the incident and had not obtained statements from them regarding the incident. The DON further stated that he trusted the Nurse supervisor because he was present at the time and had a better idea of what happened. The DON stated if any abuse was reported to Nurse Supervisor he should immediately notify the DON. The DON again confirmed this incident was not investigated and was not reported to the Health Care Personnel Registry. Interview with the Administrator on [DATE] at 12:08 PM revealed that she was notified by the DON anytime an investigation of abuse was started and if the DON had any question then she would assist as needed. The administrator also stated that if abuse is reported to Nurse Supervisor he would immediately notify the DON and/or administrator. The administrator went on to say that staff is expected to complete a full investigation that included interviews with all staff involved. The administrator stated that nurse supervisor was fully capable of starting the investigation which should have included the immediate suspension of NA #1. The administrator further stated nurse supervisor should have immediately notified the DON so a thorough investigation could be completed and the incidents reported to the Health Care Personnel Registry via the initial 24 hour report and the 5 working day report as stated in the facility policy. The Administrator stated, after conversations with the DON yesterday, he felt like he should have done something so he filled out and faxed the 24 hour initial report to the Health Care Personnel Registry. The administrator and DON were notified on [DATE] at 2:30 PM of immediate jeopardy. The administrator provided acceptable credible allegation of compliance on [DATE] at 6:45 PM. Credible Allegation of Compliance F226 (1) On [DATE], Resident #6 had a bruise of unknown origin with no 24 hour report or 5 day working report submitted to the NC Health Care Personnel Registry and a thorough investigation was not completed. On [DATE] at 11:00pm, Nursing Assistant (NA) #1, who physically and/or verbally abused Residents #1 and #2 on [DATE], left the facility after working her entire shift. On [DATE] at 3:23pm, the accused NA was suspended (she had not returned to work since leaving on [DATE] @ 11:00pm) and was ultimately terminated from employment on [DATE] at 1:20pm. On [DATE] an investigation was initiated on the abuse of Resident #2 by the Director of Nursing which resulted in termination of NA #1 on [DATE] at 1:20pm. On [DATE] the family member of Resident #2 was involved in the investigation and was made aware of the investigation initiated on [DATE] as well as of the outcome of the investigation on [DATE] by the Director of Nursing. On [DATE], the Nursing Supervisor was placed on suspension pending further investigation of his role in the allegations of abuse for Residents #1 and #2, which occurred on [DATE], for failure to protect residents and properly report resident abuse. As of [DATE]. The results of this investigation are pending and the Nursing Supervisor will remain on suspension until the investigation is complete. On [DATE] at 2:19 pm The 24 hour Health Care Personnel Registry (HCPR) abuse/neglect investigation report form for Resident #1 was completed by the Director of Nursing and faxed to HCPR for further investigation of alleged abuse. On [DATE] at 2:19pm the 24 hour abuse/neglect investigation report form for Resident #1 was completed and faxed for further investigation of alleged abuse. On [DATE] at 3:20pm, Nursing Assistant (NA) #2 and Nursing Assistant (NA) #3 who failed to immediately report allegations of abuse towards Resident #1 and Resident #2 were suspended pending further investigation of their actions related to the allegations. NA #2 and NA #3 received written disciplinary actions for failure to immediately report allegations of abuse according to the Abuse/Neglect policy on [DATE] and will return to work as of [DATE]. On [DATE] at 9:00 am, the Director of Nursing completed the NC Board of Nursing Complaint Evaluation Tool to determine reporting requirements for the Nursing Supervisor and obtained a score of 11 which indicated NC Board of Nursing consultation but no requirement for reporting. The Director of Nursing contacted the NC Board of Nursing for the required consultation on [DATE] at 10:00am. The Director of Nursing was given a phone appointment for further review on Monday, [DATE] at 1:30pm. On [DATE] at 5:19pm, the 24 hour Health Care Personnel Registry (HCPR) abuse/neglect investigation report form for Resident #6 was completed by the Director of Nursing and faxed to HCPR for further investigation of alleged abuse. (2) Residents #1, #2, and #6 were assessed by the 100 unit Social Services Coordinator on [DATE] for any residual effects from the alleged physical/verbal abuse with no concerns noted. An in-service was conducted by the Administrator for all staff on duty on [DATE] regarding resident abuse. The in-service agenda included: 1. Revised Abuse & Neglect policy/procedure to: · Immediate removal of the resident from the abusive situation by the employee who witnesses the abuse · Immediate reporting of the abusive situation by the employee who witnesses the abuse to the direct supervisor or any other member of management currently on duty · Immediate suspension of the alleged employee by the direct supervisor or member of management · Immediate reporting of the abusive situation by the direct supervisor or member of management to the Director of Nursing or the Administrator 2. Definitions of physical and verbal abuse including tone of voice and temperament used towards any resident including scenarios of both physical and verbal abuse. 3. Definition of how to make the immediate notification of abuse allegations and the expectation

Based on staff interviews and record review the facility failed to provide care without the resident falling out of bed on 2 occasions. The resident sustained [REDACTED].#3). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] specified the resident had severly impaired cognitive skills, did not resist care but required extensive assistance of 2 persons with bed mobility was transferred with a mechanical lift and was always incontinent of bowel and bladder. The MDS also specified the resident had not fallen. Resident #3 had a care plan updated 09/03/14 that specified the resident requried assistance with activities of daily living (ADL). On 09/03/14 the nurse aides' computerized care plan assignment was also updated but did not specify the number of nurse aides required to provide care for Resident #3. Review of Resident #3's medical record revealed a nurse's entry dated 10/10/14 at 2:49 AM that read in part, nurse aide (NA) #1 called for help. Resident #3 was in the floor bleeding from her right eyebrow. Resident #3 was unresponsive but regained consciousness that was altered. Resident #3's left pupil was fixed and right pupil was sluggish to react to light. Resident #3 was sent to the Emerengcy Department for evaluation and diagnosed with [REDACTED]. Further review of Resident #3's medical record revealed a document titled "history and physical examination [REDACTED]. Resident #3 was admitted to the surgical intensive care unit for hourly neurological checks. On 10/11/14 Resident #3 returned to the facility at her usual baseline. The facility provided an "Incident Report" dated 10/11/14 that specified nurse aide (NA) #1 was providing incontinence care on 10/10/14, when she rolled the resident over that resulted in the resident rolling out of the bed, striking her head on the nightstand. Resident #3's care plan was updated on 10/14/14 and a new intervention was added that specified "2 staff members for care when in bed." A nurse's entry dated 10/20/14 at 10:00 AM read in part, nurse was called to Resident #3's room and found Resident #3 laying face on the floor with a 3 centimeter skin tear to bridge of her nose, a 5 ? inch long laceration to her forehead and a 4 centimeter by 1 ? centimeter laceration to her left eyebrow. Resident #3 was sent to the Emergency Department for evaluation. A document titled "history and physical examination [REDACTED]. The hospital "Discharge/Transfer Summary" dated 10/21/14 specified Resident #3 was admitted for observation and a CT (computerized tomography) scan revealed resolution of the left subdural hematoma. Neurologically, Resident #3 had not changed and she was released back to the facility. The facility provided an "Incident Report" dated 10/21/14 that specified on 10/20/14 NA #2 was in the room with Resident #3 and rolled the resident over in bed which resulted in Resident #3 rolling out of bed. On 10/28/14 at 10:00 AM NA #2 was interviewed and reported that she was trained to reference the facility's computerized care plan assignment system for instructions on residents' individual needs such as bed mobility and transfer status. She explained that she had cared for Resident #3 in the past and on 10/20/14 she provided care as usual. NA #2 stated that she was in the room with Resident #3 preparing the resident for a transfer with the mechanical total lift. NA #2 explained that this involved placing a lift pad underneath Resident #3. She added that she was alone at Resident #3's bedside when she rolled the resident away from her body to tuck the lift pad underneath Resident #3's backside. In doing so, Resident #3's legs fell off the bed resulting in Resident #3 rolling off the bed and striking her head. NA #2 stated she was unable to stop the resident from rolling off the bed. NA #2 added that NA #3 was in the room providing assistance to Resident #3's roommate. NA #2 stated that she was unaware changes had been made to Resident #3's computerized care plan following her 10/10/14 fall to have 2 staff when providing care in bed. NA #2 stated she could not recall if she had reviewed the computerized care plan assignment for Resident #3 on 10/20/14. On 10/28/14 at 12:00 PM NA #1 was interviewed and reported that she was providing incontinence care as usual on 10/10/14 at 1:30 AM for Resident #3. She stated she was alone in the room and Resident #3 was in bed, she rolled the Resident #3 away from her body. NA #1 explained that while Resident #3 was on her side, the resident flenched causing the resident to roll off the bed. NA #1 stated that she was unaware of how much assistance Resident #3 required because she cared for the resident at night while she slept. NA #1 stated she assumed it was okay to provide Resident #3 incontinence care alone. On 10/28/14 at 11:00 AM the MDS Coordinator was interviewed and reported that she was responsible for updating residents' care plans. She explained that when care plans were updated in the computer system the changes were reflected on the nurse aide's computerized care plan assignments. The MDS Coordinator stated that it was the responsibility of the nurse aide to review each resident's computerized care plan assignment for changes. The MDS Coordinator reported that she expected nurse aides to follow the MDS coding when providing care and in the case of Resident #3, she required 2 person assistance with bed mobility. The MDS Coordinator reported that on 10/14/14 changes were made to Resident #3's care plan that specified 2 staff members were to provide care at all times due to the resident's fall on 10/10/14 and due to her debilitated state. The MDS Coordinator reported that it was not her practice to report to nurses or nurse aides when changes had been made to residents' care plans because they were expected to review them daily before starting their assignments. On 10/28/14 at 1:15 PM the Director of Nursing (DON) was interviewed about Resident #3's falls. He stated that it was determined after the fall on 10/10/14 2 nurse aides were to be in the room to provide care for Resident #3. He also reported that nurse aides were to roll residents toward their bodies and not away. The DON stated he was unaware that NA #1 had rolled Resident #3 in the wrong direction on 10/10/14. He also reported that he conducted an investgation into Resident #3's fall on 10/20/14. He explained that in his investigation he concluded that NA #2 did not follow Resident #3's care plan for 2 staff to provide care when in bed. He added that NA #2 stated she was unaware of the change with Resident #3's care plan which resulted in the error. He stated that NA #2 should not have rolled Resident #3 away from her while in bed without another staff member to assist.

Based on observations, staff interviews and record review the facility failed to implement their policy and procedures to protect residents from 1 of 2 residents with sexually inappropriate behaviors (Resident #1). Five residents were affected by this behavior (Resident #3, #5, #8, #9 and #11). Immediate jeopardy began on 12/03/12 when staff became aware Resident #1 was exhibiting sexually inappropriate behaviors toward Resident #11. The administrator was notified of the immediate jeopardy on 12/11/12 at 5:00 PM. Immediate jeopardy was removed on 12/13/12 at 12:30 PM when the facility provided and implemented an acceptable allegation of compliance. The facility will remain out of compliance at a scope and severity level E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. The findings are: A document titled "Abuse and Neglect" revised 10/20/11 read in part, residents of this facility shall not be subjected to abuse or neglect by anyone including other residents. The document specified, "The facility will strive to prevent and protect all residents from abuse by another resident. The following measures will be taken depending upon the individual situation, type and frequency of abuse and the severity of the problem:" - The resident in question will be separated temporarily until the investigation is completed and prevention measures are in place. - Care planning measures will be identified and developed to prevent reoccurrence of abuse 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's medical record revealed a nurse's entry made by Nurse #1 dated 12/03/12 at 7:00 PM that specified Resident #1 had his hand up Resident #11's shirt and was fondling her breast and that the behavior was not consensual. No immediate intervention was specified in the nurse's entry as indicated in the facilities policy and procedures. On 12/11/12 at 1:00 PM the Director of Nursing (DON) was interviewed and explained that inappropriate behaviors were expected with demented residents especially on a secured unit. She verbalized that she had educated staff to separate and redirect the residents when inappropriate behaviors were observed. She stated she did not consider Resident #1's sexually inappropriate behaviors to be abusive because the resident was demented and unaware of what he was doing. She also explained that the residents that had been touched inappropriately by Resident #1 were demented and unable to give consent. She added that the residents had not been assessed for injury because she did not perceive the actions to be abusive. On 12/13/12 at 10:25 AM nurse #1 was interviewed and reported that she had received training on abuse and neglect and was trained to separate and protect the residents involved in an incident and report the incident to the Director of Nursing (DON). Nurse #1 stated that when she observed Resident #1 inappropriately touching Resident #11 she separated the residents and redirected Resident #1. She stated that she notified the DON on 12/03/12 via a written statement and continued to monitor Resident #1 as usual. She added that Resident #11 was not assessed for injury. On 12/13/12 at 9:40 AM the Administrator was interviewed and reported that residents on the secured unit required constant monitoring because of their dementia status and poor safety awareness. She explained that sexually inappropriate behaviors were expected to be reported immediately to either herself or the DON. She stated that the inappropriate sexual behaviors displayed by Resident #1 had not been reported immediately to the DON. The Administrator stated she would have expected immediate interventions to be put in place to prevent subsequent behaviors from Resident #1. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and severely impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with activities of daily living (ADL). Review of Resident #1's medical record revealed a nurse's entry made by nurse #1 dated 12/03/12 at 7:20 PM specified Resident #1 was licking and kissing the lips of Resident #3. Resident #1 was redirected by nurse #1 but none of the other policy and procedures were implemented. On 12/11/12 at 1:00 PM the Director of Nursing (DON) was interviewed and explained that inappropriate behaviors were expected with demented residents especially on a secured unit. She verbalized that she had educated staff to separate and redirect the residents when inappropriate behaviors were observed. She stated she did not consider Resident #1's sexually inappropriate behaviors to be abusive because the resident was demented and unaware of what he was doing. She also explained that the residents that had been touched inappropriately by Resident #1 were demented and unable to give consent. She added that the residents had not been assessed for injury because she did not perceive the actions to be abusive. On 12/13/12 at 10:25 AM nurse #1 was interviewed and reported that she had received training on abuse and neglect and was trained to separate and protect the residents involved in an incident and report the incident to the Director of Nursing (DON). Nurse #1 stated that when she observed Resident #1 inappropriately touching Resident #3 she separated the residents and redirected Resident #1. She stated that she notified the DON on 12/03/12 via a witness statement and continued to monitor Resident #1 as usual. She added that Resident #3 was not assessed for injury. On 12/13/12 at 9:40 AM the Administrator was interviewed and reported that residents on the secured unit required constant monitoring because of their dementia status and poor safety awareness. She explained that sexually inappropriate behaviors were expected to be reported immediately to either herself or the DON. She stated that the inappropriate sexual behaviors displayed by Resident #1 had not been reported immediately to the DON. The Administrator stated she would have expected immediate interventions to be put in place to prevent subsequent behaviors from Resident #1. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and severely impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with activities of daily living (ADL). Review of Resident #1's medical record revealed a nurse's entry dated 12/04/12 at 7:35 AM that specified Resident #1 was in bed with Resident #5. Resident #1 had his hand inside Resident #5's brief. Resident #1 was redirected back to his bed and the two residents remained in the same room. No further intervention was documented nor implemented per the facilities policy and procedures. A nurse's entry dated 12/04/12 specified Resident #1 was found in Resident #5's room kissing the resident. Resident was redirected and given [MEDICATION NAME] which the note specified was not effective. A nurse's entry dated 12/07/12 at 8:15 AM specified Resident #1 wearing only a t-shirt was in bed with Resident #5. The entry specified Resident #1 was redirected back to his own bed. No other interventions were documented. A nurse's entry dated 12/07/12 at 11:50 PM specified Resident #1 was found in bed with Resident #5. Resident #1 was removed from the room and taken to the activity room. A nurse's entry dated 12/11/12 at 3:00 AM specified the door to Resident #1 and Resident #5's room was closed and a fall mat had been placed behind the door. The staff member was able to get inside the room and found Resident #1 with his pants off waving his penis in the face of Resident #5. Resident #1 was redirected back to bed. No other interventions were implemented as per the facilities policy and procedures. On 12/11/12 at 1:00 PM the Director of Nursing (DON) was interviewed and explained that inappropriate behaviors were expected with demented residents especially on a secured unit. She verbalized that she had educated staff to separate and redirect the residents when inappropriate behaviors were observed. She stated she did not consider Resident #1's sexually inappropriate behaviors to be abusive because the resident was demented and unaware of what he was doing. She also explained that the residents that had been touched inappropriately by Resident #1 were demented and unable to give consent. She added that the residents had not been assessed for injury because she did not perceive the actions to be abusive. She added that Resident #5 remained in the same room with Resident #1 because no other male beds were available on the secured unit. On 12/13/12 at 9:40 AM the Administrator was interviewed and reported that residents on the secured unit required constant monitoring because of their dementia status and poor safety awareness. She explained that sexually inappropriate behaviors were expected to be reported immediately to either herself or the DON. She stated that the inappropriate sexual behaviors displayed by Resident #1 had not been reported immediately to the DON. The Administrator stated she would have expected immediate interventions to be put in place to prevent subsequent behaviors from Resident #1. 4. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident and short and long term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS also specified the resident was dependant on staff for assistance with activities of daily living (ADL). Review of Resident #1's medical record revealed a nurse's entry 12/04/12 at 10:15 PM that specified Resident #1 was kissing Resident #9 on the lips. Resident #1 was told to stop by the nurse. A nurse's entry dated 12/07/12 at 10:00 PM specified Resident #1 was kissing Resident #9 on the mouth. Resident #1 was redirected. No other interventions were implemented as per the facilities policy and procedures. On 12/11/12 at 1:00 PM the Director of Nursing (DON) was interviewed and explained that inappropriate behaviors were expected with demented residents especially on a secured unit. She verbalized that she had educated staff to separate and redirect the residents when inappropriate behaviors were observed. She stated she did not consider Resident #1's sexually inappropriate behaviors to be abusive because the resident was demented and unaware of what he was doing. She also explained that the residents that had been touched inappropriately by Resident #1 were demented and unable to give consent. She added that the residents had not been assessed for injury because she did not perceive the actions to be abusive. On 12/13/12 at 9:40 AM the Administrator was interviewed and reported that residents on the secured unit required constant monitoring because of their dementia status and poor safety awareness. She explained that sexually inappropriate behaviors were expected to be reported immediately to either herself or the DON. She stated that the inappropriate sexual behaviors displayed by Resident #1 had not been reported immediately to the DON. The Administrator stated she would have expected immediate interventions to be put in place to prevent subsequent behaviors from Resident #1. 5. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with activities of daily living (ADL). Review of Resident #1's medical record revealed a nurse's entry dated 12/04/12 that specified Resident #1 was sitting in Resident #8's bed with his pants off fondling her breast. Resident #1 was redirected and became combative. No other interventions were implemented per the facilities policy and procedures. On 12/11/12 at 1:00 PM the Director of Nursing (DON) was interviewed and explained that inappropriate behaviors were expected with demented residents especially on a secured unit. She verbalized that she had educated staff to separate and redirect the residents when inappropriate behaviors were observed. She stated she did not consider Resident #1's sexually inappropriate behaviors to be abusive because the resident was demented and unaware of what he was doing. She also explained that the residents that had been touched inappropriately by Resident #1 were demented and unable to give consent. She added that the residents had not been assessed for injury because she did not perceive the actions to be abusive. On 12/13/12 at 9:40 AM the Administrator was interviewed and reported that residents on the secured unit required constant monitoring because of their dementia status and poor safety awareness. She explained that sexually inappropriate behaviors were expected to be reported immediately to either herself or the DON. She stated that the inappropriate sexual behaviors displayed by Resident #1 had not been reported immediately to the DON. The Administrator stated she would have expected immediate interventions to be put in place to prevent subsequent behaviors from Resident #1. The administrator was notified of the immediate jeopardy on 12/11/12 at 5:00 PM. The facility provided a credible allegation of compliance on 12/12/12 at 4:45 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Credible Allegation of Compliance: All residents of the facility were immediately protected from any alleged sexual behaviors by having resident #1 provided with 1:1, 24/7 nursing aide sitter until he was involuntary committed to the hospital on [DATE] at 10:15pm. Resident #5 was assessed by the Social Work Director on 12/12/12 at 11:15am for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. Resident #3 was assessed by the Social Work Director, on 12/12/12 at 2:00pm for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. Resident #8 was assessed by the Social Work Director on 12/12/12 at 2:25pm for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. Resident #9 was assessed by the Social Work Director on 12/12/12 at 2:30pm for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. All remaining residents on the locked unit were assessed by the Social Work Director and Social Work Assistant on 12/12/12 for any history of sexual behaviors that have not been identified or addressed. An in-service was immediately developed and conducted on 12/11/12 by the SDC on reporting sexual abuse to DON or Administrator. In-service began to include all staff and completed by 12/12/12 at 12:00pm. Any full-time, part-time or PRN staff that were unavailable will not be allowed to work in the facility until they have completed the in-service. This in-service included: A) Recognizing sexual behaviors B) Identifying and reporting of sexual behaviors immediately by phone to the DON or Administrator 24 hours a day, 7 days a week. The telephone numbers are posted at each nursing station C) Staff response to include immediate separation of residents and initiating 1:1 staffing 24/7 until further notice D) Expectations of staff responsibility to ensure that resident is monitored until management receives notification of behaviors and implements appropriate safety interventions, notifying the medical provider by phone or in person of incidents E) Prevention and how to supervise residents on any unit for inappropriate sexual behaviors F) Admission process for reviewing behaviors and determining if facility can meet the needs of potential admission candidates. The abuse/neglect policy was revised under the section of prevention to include the use of a newly developed admissions tool for identifying any sexual behaviors prior to determining appropriateness for admission. This policy was also revised to include immediate separation of the residents involved in inappropriate sexual behaviors including initiation of 1:1 staffing and immediate reporting of sexual behaviors to the DON and/or Administrator 24/7 by the nurse on duty for resident protection. A daily audit will be conducted by the QA/ADON (back-up will be Nurse in Charge) Monday through Friday and the Nurse in Charge (back-up is Manager on Duty) on the weekend. This daily audit will be a review of a newly developed sexual behavior incident report to ensure compliance. During these audits, the QA/ADON and the Nursing in Charge (weekends) will also obtain verbal reports from staff of any other concerns related to sexual behaviors. These daily audits and any other staff concerns related to sexual behaviors will be reported to the Safety Committee Monday-Friday by the QA/ADON for further review. Any weekend audits or other staff concerns related to sexual behaviors will be called directly to the DON by the Nurse in Charge for further review. Reporting of the Sexual Behavior Incident Reports, auditing tools, and any interventions implemented will be reported by the Social Work Director (back-up is the Social Work Assistant) monthly to the Quality Assurance Team, any further recommendations for interventions from the Quality Assurance Team will be implemented by the Team at that time to ensure compliance.

Based on observations, staff interviews and record reviews the facility failed to protect residents from a resident with sexually inappropriate behaviors for 1 of 2 sampled residents with sexually inappropriate behaviors (Resident #1). Five residents were affected by this behavior (Resident #3, #5, #8, #9 and #11). Immediate jeopardy began on 12/03/12 when staff became aware Resident #1 acted sexually inappropriate toward Resident #11. The administrator was notified of the immediate jeopardy on 12/11/12 at 5:00 PM. Immediate jeopardy was removed on 12/13/12 at 12:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. The findings are: Resident #1 was admitted from home to the facility on [DATE] with [DIAGNOSES REDACTED]. A document titled "Long Term Care Services" (FL2) dated 11/19/12 specified Resident #1 was verbally abusive at times. The "Nursing Admission Assessment and Review" dated 11/19/12 completed by Nurse #1 specified the resident had inappropriate sexual behavior. The initial Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS also specified the resident had physical behavior symptoms directed toward others in the last 1 to 3 days (e.g. hitting, kicking, pushing, scratching, grabbing, and abusing others sexually). The MDS specified that the resident's behavior put others at risk for physical injury, intruding on the privacy of others and significantly disrupting care or living environment for others. Resident #1 was assessed by the MDS to require extensive assistance with activities of daily living (ADL) and was ambulatory. The behavior Care Area Assessment (CAA) dated 11/26/12 specified, "Resident has impaired cognition, safety awareness and daily decision making abilities. Resident has episodes of grabbing at staff in inappropriate areas on their body. Resident wanders into other residents' rooms. He is not easily redirected." Resident #1's behavior care plan dated 11/27/12 specified a problem with wandering into other residents' rooms and a history of grabbing at staff in inappropriate areas. Approaches to reduce the number of inappropriate behaviors included: - explain to resident that behavior is not acceptable - redirect resident away from other residents' rooms - redirect resident when displaying socially inappropriate behavior - provide frequent and constant supervision - 1 on 1 sitter (updated on 12/06/12) Review of Resident #1's nurses' notes revealed the following sexually inappropriate behaviors: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS also specified the resident was dependant on staff for activities of daily living (ADL). A nurse's entry dated 12/03/12 at 7:00 PM specified Resident #1 had his hand up Resident #11's shirt and was fondling her breast. No immediate intervention was specified in the nurse's entry. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and severely impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with activities of daily living (ADL). A nurse's entry dated 12/03/12 at 7:20 PM specified Resident #1 was licking and kissing the lips of Resident #3. Resident #1 was redirected. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and severely impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with activities of daily living (ADL). A nurse's entry dated 12/04/12 at 7:35 AM specified Resident #1 was found in bed with Resident #5. Resident #1 had his hand inside Resident #5's brief. Resident #1 was redirected back to his bed and the two residents remained in the same room. No further intervention was documented. A nurse's entry dated 12/04/12 specified Resident #1 was found in Resident #5's room kissing the resident. Resident was redirected and given Valium which the note specified was not effective. A nurse's entry dated 12/07/12 at 8:15 AM specified Resident #1 wearing only a t-shirt was in bed with his roommate, Resident #5. Resident #1 was redirected back to his own bed. No other interventions were specified. A nurse's entry dated 12/07/12 at 11:50 PM specified Resident #1 was found in bed with his roommate, Resident #5. Resident #1 was removed from the room and taken to the activity room. A nurse's entry dated 12/11/12 at 3:00 AM specified the door to Resident #1 and Resident #5's room was closed and a fall mat had been placed behind the door. The staff member was able to get inside the room and found Resident #1 with his pants off waving his penis in the face of Resident #5. Resident #1 was redirected back to bed 4. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident and short and long term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS also specified the resident was dependant on staff for assistance with activities of daily living (ADL). A nurse's entry 12/04/12 at 10:15 PM specified Resident #1 was kissing Resident #9 on the lips. Resident #1 was told to stop. A nurse's entry dated 12/07/12 at 10:00 PM specified Resident #1 was kissing Resident #9 on the mouth. Resident #1 was redirected. 5. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with activities of daily living (ADL). A nurse's entry dated 12/04/12 specified Resident #1 sitting on bed with his pants off fondling Resident #8's breast. Resident #1 was redirected and became combative. 6. A nurse's entry dated 12/05/12 at 9:25 PM specified Resident #1 was found standing over another resident (not identified). He had removed the resident's shirt and was kissing her and fondling her breasts. The resident asked Resident #1 to stop. The entry specified the immediate intervention was to continue to monitor Resident #1. On 12/11/12 at 9:10 AM Resident #1 was observed on the secured unit in another resident's bed unsupervised. Nurse aide (NA) #1 was interviewed during this observation and stated Resident #1 was supposed to have a sitter but added she had not seen the sitter that day. NA #1 reported she was assisting other residents and was not monitoring Resident #1. NA #1 assisted Resident #1 into the group activity and waited until a sitter arrived. On 12/11/12 at 12:15 PM the Assistant Social Worker was interviewed and stated she met with Resident #1's family on 11/19/12. She stated she had reviewed the FL2 and spoke to the family regarding Resident #1's behaviors. The Assistant Social Worker stated that the family reported to her the resident's sexually inappropriate behavior had worsened toward his wife and had caused the family to be unable to care for him at home. The Assistant Social Worker stated she did not report the concern of being sexually inappropriate to anyone after meeting with the family because the resident was going to be placed in the secured unit for behavior monitoring. The Assistant Social Worker also stated no interventions were implemented to address the resident's sexually inappropriate behavior because she didn't feel that he posed any concerns to other residents. On 12/11/12 at 1:00 PM the Director of Nursing (DON) was interviewed and reported that Resident #1 was admitted to the facility without knowledge of the resident being sexually inappropriate to women. The DON stated that after his admission to the facility Resident #1 was sexually inappropriate toward staff but added staff were trained to handle such behaviors. The DON explained that inappropriate behaviors were expected with demented residents especially on a secured unit. She verbalized that she had re-educated staff that when inappropriate behaviors were observed she expected staff to separate and redirect the residents. The DON stated she was unaware of incidents of Resident #1 acting sexually inappropriate with other residents on 12/03/12 or 12/04/12. She stated she was first made aware of Resident #1's sexual inappropriateness toward residents on 12/05/12. She added that Resident #1's physician's assistant was contacted on 12/05/12 for medication adjustments to decrease the resident's sexually inappropriate behaviors. She reported that on 12/06/12 Resident #1 was placed on 1 on 1 supervision from 7AM to 7PM after the resident had been observed again being sexually inappropriate with another resident on the secured unit. The DON explained the resident only needed 1 on 1 supervision from 7AM to 7PM because after 7PM Resident #1 was in bed and added it was an easier time of day for staff to monitor him. The DON also stated a bed pad alarm had been placed on Resident #1's bed to alert staff when the resident got out of bed. The DON provided a written statement dated 12/10/12 that specified she believed that facility was doing all they could to address Resident #1's sexually inappropriate behaviors. The statement outlined her plan for implementing interventions to decrease Resident #1's sexually inappropriate behaviors that included allowing time for the medication changes to take effect, continue to redirect him and keep him busy during the day. An interview was conducted with Nurse #1 on 12/13/12 at 10:25 AM. Nurse #1 stated she completed the admission assessment with Resident #1's family who reported that the resident was sexually inappropriate with women. Nurse #1 stated she documented on the "Nursing Admission Assessment and Review" that the resident was sexually inappropriate and notified the oncoming nurse but did not report the concern to anyone else. She explained that she did not feel the sexually inappropriate behavior needed to be reported because the resident was being admitted to a secured unit for behavior monitoring. She also stated that she was trained to immediately intervene when a resident to resident incident occurred. She added that she would separate the residents involved in a physical incident, assess for injury and them complete an incident report or if the incident was serious she would contact the Director of Nursing (DON). On 12/13/12 at 11:00 AM the Administrator was interviewed and reported that residents on the secured unit required constant monitoring because of their dementia status and poor safety awareness. She explained that sexually inappropriate behaviors were expected to be reported immediately to either herself or the DON. She stated that the inappropriate sexual behaviors displayed by Resident #1 had not been reported immediately to the DON. The Administrator stated she would have expected immediate interventions to be put in place to prevent subsequent behaviors from Resident #1. The administrator was notified of the immediate jeopardy on 12/11/12 at 5:00 PM. The facility provided a credible allegation of compliance on 12/12/12 at 4:45 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Credible Allegation of Compliance: Resident #1 was immediately assigned to a nurse aide for one on one supervision beginning on 12/11/12 at 5:00 PM for 24 hours. One on one supervision continued until 12/11/12 at 10:15 PM when Resident #1 was involuntarily committed to the hospital for evaluation and treatment. Resident #5 was assessed by the Social Work Director on 12/12/12 at 11:15 AM for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. Resident #3 was assessed by the Social Work Director, on 12/12/12 at 2:00 PM for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. Resident #8 was assessed by the Social Work Director on 12/12/12 at 2:25 PM for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. Resident #9 was assessed by the Social Work Director on 12/12/12 at 2:30 PM for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. Resident #11 was assessed by the Social Worker on 12/12/12 at 2:40 PM for any residual effects from the sexualized behaviors of Resident #1. No concerns were noted. All remaining residents on the locked unit were assessed by the Social Work Director and Social Work Assistant on 12/12/12 for any history of sexual behaviors that have not been identified or addressed. A new system of reporting, monitoring, documenting, and responding to sexually inappropriate behaviors on the secured unit was developed as a facility policy. The components of new system include the following: 1. Any new admission candidates to the secured unit will be reviewed prior to acceptance for any history of sexual behaviors to ensure facility can meet the needs of the candidate prior to admission acceptance. 2. Any staff noting inappropriate sexual behaviors, must immediately separate the residents involved, initiate 1:1 supervision 24/7, notify the medical provider and report to the nurse in charge, who will then notify the DON or the Administrator immediately either in person or by telephone. The telephone numbers are posted at each nursing station. 3. Daily audits will be conducted on the secure unit by the QA/ADON nurse (back-up will be nurse in charge) Monday-Friday. Weekend daily audits will be conducted by the Nurse in Charge (back-up is Manager on Duty). This daily audit will be a review of a newly developed sexual behavior incident report to ensure compliance that the facility is meeting the above concerns and will also include discussion with staff of any other concerns for sexual behaviors. The daily audits/staff discussions will be reported to the Safety Committee Monday-Friday by the QA/ADON and any weekend audits will be called to the DON by the Nurse in Charge for determination of any further interventions. An in-service was immediately developed and conducted on 12/11/12 by the SDC on reporting sexual abuse to DON or Administrator--this included all staff and was completed on 12/12/12 at 12:00pm-any staff that was unavailable for the in-service will not be allowed to work in the facility until they have completed it. This in-service included: ? Recognizing sexual behaviors ? Identifying and reporting of sexual behaviors immediately by phone to the DON or Administrator 24 hours a day, 7 days a week. The telephone numbers are posted at each nursing station ? Staff response to include immediate separation of residents and initiating 1:1 staffing, 24/7, until further notice ? Expectations of staff responsibility to ensure that resident is monitored until management receives notification of behaviors and implements appropriate safety interventions, notifying the medical provider by phone or in person of incidents ? Prevention and how to supervise residents on a secure unit for inappropriate sexual behaviors ? Admission process for reviewing behaviors and determining if facility can meet the needs of potential admission candidates. A daily audit will be conducted on the secure unit by the QA/ADON nurse (back-up will be nurse in charge) Monday through Friday and on weekends by the nurse in charge (back-up is Manager on Duty). This daily audit will be a review of a newly developed sexual behavior incident report to ensure compliance. During these audits staff will be interviewed by the QA/ADON nurse for any other incidents. These daily audits and any staff concerns will be reported to the Safety Committee Monday-Friday by the QA/ADON and will be called to the DON by the Nurse in charge on weekends before implementation of further interventions not already in place. Reporting of the Sexual Behavior Incident Reports, any auditing tools, and any interventions implemented will be reported by the Social Work Director (back-up is Social Work Assistant) monthly to the Quality Assurance Team. Any further recommendations for interventions from the Quality Assurance Team will be implemented by the team at that time to ensure compliance.

Based on staff interviews and record review the facility failed to implement Physician ordered fall interventions for one (1) of three (3) sampled residents who fell and sustained a fracture in the facility (Resident #4). The findings are: Resident #4 was admitted to the facility on [DATE] diagnosed with [REDACTED]. The MDS also specified the resident required extensive assistance with Activities of Daily Living (ADLs) that included transfers. Additionally, the MDS specified the resident used a wheelchair and was not steady moving from seated to standing position. Also, the MDS indicated the resident had fallen twice in the facility. Resident #4's medical record was reviewed and revealed a physician's orders [REDACTED]. A document titled "Fall Risk Assessment" dated 3/21/12 specified the resident was "high" risk for falls and recommended a bed and chair alarm. Resident #4's Fall risk care plan dated 4/3/12 specified the resident was at risk for falls related to poor balance during transitions and difficulty maintaining standing position without assistance. The care plan included interventions to prevent the resident from sustaining any trauma due to a fall that included: - chair pad alarm while in wheelchair to alert staff of unsafe movements Further review of Resident #4's medical record revealed a nurses' entry dated 4/15/12 that specified the nurse responded to the resident's cry for help and found the resident lying in the hallway on her back with her left leg bent underneath her lower torso and her right leg dislocated. The entry specified the resident was crying in pain and her vital signs were abnormal. The entry revealed licensed nurse (LN) #3 called for additional assistance and requested that 911 Emergency be called. A physician's orders [REDACTED]. The Emergency Department (ED) report dated 4/15/12 specified the resident had a fractured left femur and hip. On 5/21/12 at 11:15 a.m. LN #1 was interviewed and reported that on 4/15/12 at 7:50 p.m. she responded to Resident #4's cry for help and found her in the hallway on the floor beside her wheelchair. She stated she was the first person to respond to the resident and confirmed the resident's chair alarm was not sounding. She stated that the resident was in obvious pain as evidenced by her crying. LN #1 obtained Resident #4's vital signs that were abnormal. LN #1 reported her initial response was to call 911 Emergency because she feared the resident was going into shock. She stated she called for assistance from LN #2 and asked that he call 911 Emergency. LN #1 also reported that prior to the fall Resident #4 had been left in the hallway after the evening meal at approximately 6:30 p.m. LN #1 stated she stayed with the resident until Emergency Service Responders arrived. On 5/21/12 at 2:45 p.m. nurse aide (NA) #1 was interviewed and reported she had been assigned to care for Resident #4. She stated that Resident #4 required a chair alarm when in her wheelchair because of her frequent attempts to stand and get out of the wheelchair. She added that the resident required frequent monitoring because of her poor safety awareness and that the Resident had fallen several times in the facility. The NA also reported that Resident #4's family visited often and would at times turn the chair alarm off while they visited. NA #1 stated that she was trained to make a "safety round" first thing when reporting for her shift (3 p.m. to 11 p.m.) that included checking residents' personal alarms to ensure they were functioning properly. She added that she was also trained to check alarms periodically throughout her shift. NA #1 reported that she was assigned to care for Resident #4 on 4/15/12. She added that she did not check the resident's chair alarm for proper functioning during the "safety round" because the family was in the facility visiting the resident. The NA added that on 4/15/12 at 6:00 p.m. Resident #4's family brought the resident into the dining room for the evening meal and left. She added that she was in the dining room for the evening meal and did not check the resident's chair alarm at 6:00 p.m. to verify if it was on or off. NA #1 revealed Resident #4 was assisted to the hallway after the evening meal around 6:30 p.m. NA #1 added that following the evening meal she was assisting another resident and heard cries for help. She reported that once she finished providing care to the other resident she walked out into the hallway and observed Resident #4 lying in the floor. She added that LN #1 had responded to Resident #4's cry for help. NA #1 stated she observed the resident's chair alarm panel box and noted the alarm was turned "off." NA #1 stated she then turned the alarm panel box "on." She added that from the start of her shift at 3:00 p.m. until the time the resident fell at 7:50 p.m. she had not checked the resident s alarm to ensure it was functioning properly because the resident's family was visiting. She stated she should have checked the alarm when the family brought the resident into the dining room. On 5/21/12 at 3:30 p.m. the Director of Nursing (DON) was interviewed and reported he would expect nurse aides to check placement and functioning of personal alarms during "safety rounds." He stated that his investigation into Resident #4's fall accident revealed another resident s alarm had sounded the same time Resident #4 fell ; but he was unaware Resident #4 cried out for help. He stated he was aware Resident #4's alarm was off at the time of the fall but declined to answer if he expected it to be on. He offered no further explanation why NA #1 failed to check the resident's personal chair alarm during safety rounds or any other time during her shift.

Based on staff interviews and record review, the facility failed to supervise or use alarms to prevent falls for one (1) of sixteen (16) residents. (Resident # 1) Resident # 1 was admitted to the facility on [DATE] and was readmitted on [DATE]. [DIAGNOSES REDACTED]. On the most recent Minimum Data Set ((MDS) dated [DATE] the facility assessed Resident # 1 as having deficit with her short and long term memory and severe impairment with cognitive skills for daily decision making, and required extensive assistance with transfers. A care plan dated 03/17/10, review date 06/15/10 entitled " Falls " reads resident is at risk for falls due to wandering daily and decreased safety awareness due to impaired cognition related to dementia. Interventions listed are: personal alarm at all times, encourage resident to wear glasses, fall committee to review falls as needed, gather and assess information on past falls, keep bed at lowest level while in bed and not receiving care, observe for decrease or loss of functional status, wander guard alarm at all times on wheelchair, administer medications per MD order, keep bed at lowest position while not receiving care. A facility form entitled " Incident/Accident Report " and dated 03/17/10 revealed Resident #1 was noted to be sitting on the floor of her room with her back against her bed, no injury noted. Fall committee recommendation after the fall was to supervise Resident #1 more closely. A physical therapy screening dated 03/17/10 was reviewed and recommended nursing to closely supervise resident to decrease risk for falls. An Incident /Accident report dated 03/20/10 revealed Resident # 1 was found on the floor in her bathroom in front of her wheelchair, stated she hit her head, no other injury noted. Fall committee intervention noted on the Incident/Accident Report was to assist as needed. A physical therapy screening report dated 03/22/10 was reviewed and indicated nursing to closely supervise resident to decrease risk for falls and to use chair alarm for fall precaution. An additional Incident/Accident Report dated 04/28/10, 9:15 am, revealed Resident #1 had fallen out of her wheelchair in the feeding room and was on her left side with a purplish discoloration and pinpoint area bleeding at right outer eye. The fall committee intervention on the form was to remove resident quicker from the dining room. An additional Incident/Accident Report dated 05/05/10 indicated Resident # 1 was found sitting on the floor in the doorway of her room, no apparent injury. The fall committee recommendation on this report was to supervise Resident # 1 in common areas. The Incident /Accident Report dated 05/19/10 revealed Resident # 1 was found lying on her back beside her bed and wheelchair. The Incident/Accident Report indicated Resident #1 complained of pain to her left hip when moved. Facility records further indicated Resident # 1 was transferred to the hospital where she was evaluated and treated for [REDACTED]. On 08/17/10, 3:15 pm, the Risk management staff was interviewed and stated Resident # 1 did not have had an alarm prior to the fall on 05/19/2010. Risk Management staff indicated Resident # 1 was discussed in falls committee after each fall, and the interventions were to supervise her closely, monitor her, assist her as needed and remove her from the dining room earlier. Risk management staff indicated supervision was expected to be close monitoring of resident and to keep her in common areas where she could be observed and assisted. Risk Management staff indicated any Physical Therapy screenings after falls came to her and she then communicated the recommendations to the nursing staff. She stated she did not know why the recommendation for an alarm had not been communicated. On 08/19/2010, 10:30 am the Director of Nurses was interviewed and indicated Resident # 1 was discussed in the falls committee each time she fell and that she expected staff to supervise and monitor this resident to prevent falls. On 08/19/10 at 2:15 pm Licensed Nurse # 1 was interviewed and stated she was the nurse for Resident #1 on 05/19/10 when Resident # 1 fell . She stated a nurse assistant came to her reported Resident #1 was on the floor in her room. She further indicated that Resident # 1 was by herself when she fell , no one was supervising her and no alarms were being used at the time she fell . She further indicated during the interview that any changes such as recommendations from therapy for residents went to Risk Management and then were communicated on report to the nurses.